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Biomedical subjects

D Raveh

Publications and source records attributed to D Raveh.

At least 19 recordsLinked to original sources
PubMed2002

Changing epidemiology of infective endocarditis: a retrospective survey of 108 cases, 1990-1999.

The aim of this study was to report the experience with infective endocarditis over the past decade, describe the changing clinical and epidemiological features of the disease, and attempt to determine the optimal number of blood culture sets required for diagnosis. All cases diagnosed during a 10-year period were reviewed clinically and microbiologically. In addition, a retrospective assessment of blood culture data was performed. From the period 1990-1999, 108 cases that met the von Reyn or Duke's criteria were recorded. The major underlying cardiac condition was the presence of a prosthetic valve ( n=33 patients, 31%). Among patients with native valves, nonrheumatic valvular heart disease of the elderly was the most common underlying factor ( n=19 patients, 25%). Overall, 13 patients (11%) died. Predictors on admission for increased mortality were shortness of breath, age >60 years, time to defervescence, erythrocyturia, hemoglobin level <10 g/dl, and leukocytosis >15,000 (all P<0.05). Analysis of blood culture data showed that the diagnostic yield among groups from whom either only one or more than six blood culture sets were drawn was reduced compared with that among groups from whom between two and five culture sets had been taken. The outcome of endocarditis in this series from a community hospital was much more favorable compared with that reported in surveys from large tertiary centers. Moreover, obtaining more than two or three blood cultures is neither helpful nor cost-effective in the initial assessment of patients with suspected endocarditis.

Aged↗
PubMed2002

Puerperal adrenal abscess complicating chorioamnionitis.

BACKGROUND: An abscess in the adrenal gland is a rare finding described only a few times in the literature. We present a case report of chorioamnionitis complicated by a puerperal adrenal abscess diagnosed and drained percutaneously using ultrasound and computed tomography. CASE: A 22-year-old woman delivered prematurely because of chorioamnionitis. Amoxicillin clavulanate was administered, and her fever defervesced. Six days later, the patient presented with a temperature of 40C and right flank pain. Workup revealed an abscess in the right adrenal gland, which was diagnosed by computed tomography scan, and then drained percutaneously. Follow-up revealed regression of the abscess to complete recovery. CONCLUSION: Adrenal abscess has not been described in the past as a possible complication of choriamnionitis. It is important to assess the entire abdominal cavity by ultrasound or computed tomography in febrile patients who do not respond to medical therapy.

Abscess↗
PubMed2002

Poor prenatal detection rate of cardiac anomalies in Noonan syndrome.

BACKGROUND: The wide variation and nonspecific nature of many of the associated ultrasonographic findings complicate prenatal diagnosis of Noonan syndrome. The aim of the present study was to define the rate of prenatal diagnosis of heart malformations in cases diagnosed postnatally with Noonan syndrome. METHODS: English-language literature review of 29 cases of Noonan syndrome examined prenatally with confirmed postnatal diagnosis and four case reports from our center. RESULTS: Cases were evaluated for cervical spine pathologies, cardiac anomalies and other pathological findings, including hydrops fetalis and polyhydramnios. Cardiac anomalies were suspected in only nine of 33 cases; three of these were associated with cystic hygroma. Cardiac anomalies were eventually diagnosed in 31/33 cases postnatally. Polyhydramnios was diagnosed in 19/33 cases in the third trimester, and hydrops fetalis was detected in eight of 33. Cystic hygroma was present in a total of nine cases at mid-trimester. CONCLUSIONS: Noonan syndrome is characterized by late-onset and progressive pathologies, particularly the associated cardiac anomalies, which develop through the course of gestation and postnatal life. This complicates or precludes prenatal diagnosis at mid-trimester or at any time in the prenatal period, and partly explains the low rate of detection of fetal cardiac lesions in this syndrome.

Female↗
PubMed2002

The three vessels and trachea view (3VT) in fetal cardiac scanning.

OBJECTIVE: Comprehensive evaluation of the fetal heart has become a major part of targeted organ scanning to rule out fetal malformations. Evaluation of the mediastinal major vessels seems to be the most difficult and time-consuming part of fetal heart examination. Our aim was to define and evaluate the three vessels and trachea (3VT) view, a novel and simple method to examine the great vessels in the mediastinum, and its applicability in the clinical practice of fetal echocardiography, while establishing nomograms for cardiac vessel measurements obtained in this view. METHODS: The three vessels and trachea view was examined in 379 low-risk gravidae between 14+0 and 23+6 weeks' gestation. Six parameters in this plane were measured to establish nomograms. In another group of 984 mixed high- and low-risk patients we compared the time required to identify the aortic arch using the 3VT view as compared to the long-axis view. RESULTS: The 3VT view was readily and satisfactorily demonstrated in all but two of the 1363 cases examined. In 17 cases (out of a total of 982) more than 10 min were required to identify the aortic arch using the 3VT view and in 71 patients when employing the long-axis view (P < 0.001). CONCLUSION: The clinical applicability of the 3VT view to evaluate the anatomy of the major vessels in the mediastinum is demonstrated. Although a wide variation in the six parameters of the 3VT view used here precludes their use in diagnosing great vessel anomalies, some of the ratios between them have promising potential in the evaluation of great vessel malformations. Further, the 3VT view seems to be more efficient in identifying the aortic arch than does the long-axis view.

Adult↗
PubMed2002

Risk factors for nephrotoxicity in elderly patients receiving once-daily aminoglycosides.

BACKGROUND: There remain concerns about the safety of once-daily dosing of aminoglycosides (AGs) in the elderly. AIM: To assess the safety of once-daily AGs in elderly patients and evaluate possible risk factors for nephrotoxicity. DESIGN: Prospective, non-interventional surveillance study. METHODS: All patients receiving AGs were monitored over 4 months. Clinicians determined the AG dose for each patient after estimating patient weight and calculating creatinine clearance (CrCl) using the Cockcroft-Gault formula. Parallel figures were calculated by the investigators using measured weight. Clinicians obtained an AG trough level 24 h after initiation of treatment, and, if non-toxic, every 5-7 days thereafter. AG toxicity was defined as an increase in serum creatinine of > or =50%. RESULTS: In the study period, 249 consecutive patients received an AG: 116 (47%) males, mean+/-SD age 75+/-16 years. Forty-two (17%) received amikacin and 207 (83%) gentamicin. An increase of > or =50% in serum creatinine was detected in 31/249 (12.4%); maximal creatinine was < or =177 micromol/l in 16/249 (6.4%), 186-265 micromol/l in nine (3.6%), and >265 micromol/l in six (2.4%). None developed oliguric renal failure. Renal damage correlated with a high AG trough level (>1.1 microg/ml) (p<0.001); haemoglobin level <10 g/dl (p<0.05); hospital admission >7 days prior to AG treatment (p<0.005); and AG treatment > or =11 days (p<0.05). Mean CrCl based on estimated weight was 52+/-18 ml/min; that based on actual weight was 71+/-37 ml/min. Despite this, mean AG dose was 1.3+/-0.6 higher than optimal. CONCLUSIONS: Oliguric and/or lasting renal toxicity is rare in elderly patients receiving once-daily aminoglycosides for <11 days, if regular trough drug levels are monitored.

Adult↗
PubMed2001

Age as a risk factor for severe Plasmodium falciparum malaria in nonimmune patients.

In this nationwide, cross-sectional study, we evaluated the influence of age and other factors that affect clinical outcome of Plasmodium falciparum malaria in nonimmune patients. Of 135 patients with P. falciparum malaria, 84 (62%) were < 40 years old, and only 5% of the patients in this age group developed severe malaria, compared with 18% of the subjects who were > or =40 years of age (odds ratio, 4.29); moreover, all deaths occurred in the latter group. Male subjects did not differ from female subjects with regard to severity of disease.

Adult↗
PubMed2001

Diagnostic value of the D-dimer test in deep vein thrombosis: improved results by a new assay method and by using discriminate levels.

Previous studies have suggested that D-dimer testing reliably selects patients for whom duplex sonography should be performed for diagnosis of deep vein thrombosis (DVT). However, the interassay correlation is poor. Therefore, we tested four D-dimer methods for their ability to rule out DVT, including the Miniquant test, a new D-dimer assay method. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated vs. duplex sonography. Twenty-nine of 108 (27%) patients with suspected DVT were diagnosed as having DVT by sonography. The Vidas enzyme-linked immunoabsorbent assay (ELISA) test, the Miniquant turbidimetric test and the latex agglutination test for D-dimer all provided discriminate values for achieving 100% sensitivity and 100% NPV. D-dimer results demonstrated higher specificity and PPV in the outpatient vs. the inpatient group. This probably reflects the higher proportion of inpatients with comorbid conditions, such as malignancy and postsurgery status, in whom D-dimer results show very poor specificity and PPV. The new Miniquant turbidimetric assay performed as well as the more established ELISA method. We conclude that the D-dimer tests were shown to possess the necessary sensitivity and NPV to be useful in screening patients with suspected DVT. A negative D-dimer test in selected patients could be helpful in reducing the number of sonograms performed for diagnosis of DVT.

Adult↗
PubMed2001

Adult patients with occult bacteremia discharged from the emergency department: epidemiological and clinical characteristics.

To determine the epidemiological and clinical characteristics of patients who were discharged from the emergency department (ED) and subsequently proved to have bacteremia, we prospectively assessed all patients examined in the ED during an 18-month period from whose blood cultures a significant organism was isolated. Discharged patients were contacted and reevaluated. Two case-control studies were conducted, in which each study patient was matched with a total of 4 control patients. During the study period, 46,336 patients were examined in the ED; 78% were adults and 22% were children. Blood cultures were performed for 25% of the adult patients and for 44% of the children. Although the occurrence of occult bacteremia in patients who were discharged from the ED is 3.7 times more common in children than in adults, the absolute numbers of discharged adults and children with occult bacteremia are similar. Careful clinical assessment will not prevent discharge of some of these patients; however, these patients in general do well and can be safely recalled for reevaluation and complementation of therapy.

Adolescent↗
PubMed2001

Erythropoietin deficiency causes anemia in nephrotic children with normal kidney function.

Anemia in persistent nephrotic syndrome (NS) has been described in a few case reports but has not been studied systematically. We present a group of 19 children with NS who developed anemia before the deterioration of kidney function. The aim of our study is to determine whether erythropoietin (EPO) and/or iron deficiency are causative factors and to evaluate the effect of EPO replacement therapy. Serum EPO levels, iron status, and vitamin B(12) concentrations were measured in nephrotic patients with anemia (NS-A) and compared with those of nephrotic children with normal hemoglobin (Hb) levels (NS-NHb; n = 13). Two control groups consisted of age-matched patients without kidney disease or hypoxemia with either iron deficiency anemia (IDA; n = 19) or normal Hb concentrations (NHb; n = 16). Most NS-A patients experienced persistent steroid-resistant NS, whereas most NS-NHb children had steroid-responsive NS. Although serum iron, ferritin, and B(12) levels were significantly lower in NS-A children, appropriate replacement therapy that resulted in normalization of ferritin and/or cobalamin levels did not lead to correction of the anemia. NS-A patients had greater EPO levels than those without anemia (21.6 +/- 3.3 versus 5.5 +/- 0.8 IU/L; P: < 0.001), but their response to anemia was inappropriately low compared with IDA children (EPO, 94.6 +/- 15.1 IU/L) despite similar Hb concentrations. EPO therapy for 4 to 9 months in 6 NS-A children with Hb levels less than 9 g/dL led to resolution of the anemia. In conclusion, anemia is a common feature of persistent NS that develops before the deterioration of kidney function. Depletion of iron stores may contribute to the development of anemia, but iron replacement therapy is ineffective. Nephrotic patients have EPO deficiency with a blunted response to anemia. The EPO deficiency is amenable to EPO therapy, which is recommended for this group of patients.

Adolescent↗
PubMed2001

Longitudinal surveillance of antibiotic use in the hospital.

We evaluated antimicrobial use in our hospital by department, including indications for use, source of infections, use of the microbiology laboratory, and appropriateness of prescribing, in a prospective, comparative, non-interventional study of all patients receiving antimicrobial agents. We excluded departments where antimicrobial use was negligible. The other 19 departments were followed for 3 (n=4) or 4 (n=15) months, including 2 consecutive months in the spring-summer and either 1 or 2 in the autumn-winter. Antimicrobial therapy was followed from initiation, through possible adaptations, and possible change from intravenous to oral therapy, until discontinuation of treatment. Overall, 6376 antibiotics were given to 2306 patients. Of the surveyed hospitalized patients, 62%+/-22% received antibiotics, with a range of 4-100% per department. Antibiotics were prescribed for infections acquired in the community (3037 instances, 47%), in the hospital (2182, 34%), in a nursing home (575, 9%), and for prophylaxis continued post-operatively (582, 9%). The most common indications for antimicrobial use were: respiratory tract infection (1729, 27%), urinary tract infection (955, 15%), sepsis (701, 11%), intra-abdominal infections (663, 10%), prophylaxis 582 (9%), soft-tissue infection (572, 9%), and surgical site infection (319, 5%). Univariate indicators for appropriateness of treatment were: age, department, site of infection, source of infection, antimicrobial drug and serum creatinine (all p<0.001). Forty-nine antimicrobials were prescribed in 279 combinations, 58% as single agent and 42% as drug combinations. Half of all antimicrobial use consisted of four agents: cefuroxime (19.1%), metronidazole (11.3%), gentamicin (10.6%) and ampicillin (10.2%), which together accounted for 20% of expenditure on antibiotics. Although use of as many as 53% of antimicrobials (26/49) surveyed was restricted, use in this category accounted for only 29% of all antimicrobial courses. Of 6376 antibiotic courses, 4101 (64%) were given intravenously and 2275 (36%) orally. Appropriateness of use of restricted drugs was lower (70%) than of unrestricted ones (84%, p<0.001). Of 24571 defined daily doses (DDD) given orally, 4587 (19%) were restricted, compared to 7264 (34%) of 21602 DDDs given intravenously (p<0.001). Antibiotic treatment in our hospital appears to be substantial and increasing, justifying efforts to improve appropriateness of therapy and improve clinical and financial results.

Administration, Oral↗
PubMed2001

Incidence of immunoglobulin G antibodies to Chlamydia pneumoniae in acute myocardial infarction patients.

BACKGROUND: Recent studies have suggested a possible association between Chlamydia pneumoniae infection and coronary heart disease. OBJECTIVES: To determine titers of antibodies to C. pneumoniae in patients with acute myocardial infarction compared with titers in several control groups. METHODS: This prospective case-control study investigated 209 individuals. We assessed the serum IgG antibody titers to C. pneumoniae in 57 consecutive patients admitted with AMI to our intensive coronary care unit during a 4 month period. A serum sample was drawn upon admission and after 6 weeks. Results were compared with those of four control groups: a) patients admitted with community-acquired pneumonia (n = 18), b) patients with community-acquired urinary tract infection (n = 42), c) patients with angiographically normal coronary artery disease (n = 44), and d) patients with stable coronary artery disease (n = 48). Serum immunoglobulin G antibody titers to C. pneumoniae were determined using standard micro-immunofluorescence technology. RESULTS: Of 57 patients with AMI, 32 (56%) had a high IgG titer to C. pneumoniae (> or = 1:256) on the initial test, which remained unchanged (62%) after 6 weeks. The percentage of patients with high titers was significantly lower in the control groups: 5 of 18 patients (28%) in the pneumonia group (P < 0.01), 11 of 42 (26%) in the urinary tract infection group (P < 0.01), 11 of 44 (25%) with normal coronary arteries (P < 0.01), and 17 of 48 (35%) with stable chronic ischemic heart disease (P < 0.05). CONCLUSION: The detection of high titers of IgG antibodies to C. pneumonia in many patients with AMI, compared to control groups, suggests that chronic Chlamydia pneumoniae infection plays a role in the pathogenesis of atherosclerosis and acute ischemic events.

Antibodies↗
PubMed2000

Functions of the DNA damage response pathway target Ho endonuclease of yeast for degradation via the ubiquitin-26S proteasome system.

Ho endonuclease of Saccharomyces cerevisiae is a homing endonuclease that makes a site-specific double-strand break in the MAT gene in late G(1). Here we show that Ho is rapidly degraded via the ubiquitin-26S proteasome system through two ubiquitin-conjugating enzymes UBC2(Rad6) and UBC3(Cdc34). UBC2(Rad6) is complexed with the ring finger DNA-binding protein Rad18, and we find that Ho is stabilized in rad18 mutants. We show that the Ho degradation pathway involving UBC3(Cdc34) goes through the Skp1/Cdc53/F-box (SCF) ubiquitin ligase complex and identify a F-box protein, Yml088w, that is required for Ho degradation. Components of a defined pathway of the DNA damage response, MEC1, RAD9, and CHK1, are also necessary for Ho degradation, whereas functions of the RAD24 epistasis group and the downstream effector RAD53 have no role in degradation of Ho. Our results indicate a link between the endonuclease function of Ho and its destruction.

Anaphase-Promoting Complex-Cyclosome↗
PubMed2000

Prospective surveillance of vancomycin-resistant enterococci in a neonatal intensive care unit.

A point-prevalence study of vancomycin-resistant enterococci colonization of the gastrointestinal tract in an Israeli hospital revealed that 14.7% of the 320 inpatients were colonized. Vancomycin-resistant enterococci colonization was detected in most departments except the neonatal intensive care unit. Hence, a prospective longitudinal study of the prevalence of vancomycin-resistant enterococci colonization in the neonatal intensive care unit was conducted. A rectal swab was obtained from every newborn on admission to the neonatal intensive care unit and once weekly thereafter until the patient was discharged. Enterococci were isolated and tested for susceptibility to vancomycin. A total of 84 neonates were enrolled and monitored on average for 3 weeks (SD +/- 3.9, range 1-20 weeks). Mean gestational age was 35.7 weeks (SD +/- 3.9, range 25-42 weeks), and mean birth weight was 2.4 kg (SD +/- 0.9, range 0.45-4.1 kg). Most patients had one or more of the known risk factors associated with colonization with vancomycin-resistant enterococci. Eighty percent of the patients received antibiotics during the study, and 14.3% received vancomycin. The median duration of vancomycin treatment was 12.5 days (SD +/- 16.8, range 5-55 days). Fifty-one of 84 (61%) patients acquired enterococci sensitive to vancomycin during the study period, but no newborn had vancomycin-resistant enterococci. Possible explanations for this finding may be physical isolation of the neonatal intensive care unit from the rest of the hospital, intrinsic differences in the bowel milieu of this age group and the lack of exposure to food and other environmental sources of vancomycin-resistant enterococci from the community.

Adolescent↗
PubMed2000

Assessment of knowledge of guidelines for the prevention of infective endocarditis amongst clinicians in a teaching hospital.

A significant minority of instances of endocarditis appear to be the result of invasive procedures performed in susceptible patients with underlying cardiac conditions. Absence, or inappropriate administration, of antimicrobial prophylaxis could expose the patient to the development of a potentially lethal infection. This study was formulated, therefore, to assess the knowledge of guidelines for the prevention of infective endocarditis among hospital-based physicians and surgeons. A multiple choice test was developed, including: (1) cardiac conditions at increased risk for development of infection; (2) procedures more likely to be associated with bacteraemia and endocarditis; and (3) type and route of antimicrobials prescribed when endocarditis prophylaxis is indicated. The quality of the test was determined in several ways. Success was defined as a pass rate of 11 of 18 questions (61%). The test was taken by 153 of 251 (60%) physicians employed by the hospital; 95 (62%) passed the test. No significant difference in success rates was found according to sex, professional status or medical school. Internists performed substantially better (with a pass rate of 41 of 53, 77%) than both paediatricians (13 of 26, 50%, P<0.05) and surgeons (41 of 74, 55%, P<0.01). The range of success varied from 100% to 36% according to specialty (P<0.001). The mean score was 69+/-21 in the study group and 94+/-10 in a control group of 20 infectious disease physicians (P<0.001). In conclusion, this study demonstrates the need for improved education of hospital-based clinicians regarding endocarditis prophylaxis recommendations.

Antibiotic Prophylaxis↗
PubMed2000

Practical guidelines for vancomycin usage, with prospective drug-utilization evaluation.

To strengthen guidelines for vancomycin use, practical guidelines were developed. A prospective survey was conducted of all patients receiving vancomycin during two 1-month periods, 1 year apart, during which significant improvements were noted. Practical guidelines may contribute to appropriateness of vancomycin use, serve as educational tools, and facilitate improved surveillance.

Drug Utilization Review↗