Elevated Baseline Cortisol Levels Are Predictive of Bad Outcomes in Critically Ill Children.

OBJECTIVE: The definition of an adequate adrenal response in critically ill children continues to be controversial. We aimed to evaluate the cortisol levels at baseline and after adrenocorticotropin (ACTH) stimulation and determine their association to clinical outcome of critically ill children. METHODS: All children who underwent an ACTH test in the pediatric intensive care unit (PICU) in a tertiary medical center between 2006 and 2013 were included in the study. Data on age, sex, diagnosis, vasoactive-inotropic score, length of pediatric intensive care unit stay, and mortality were obtained. Laboratory variables included hematologic and chemistry data, arterial lactate, and total plasma cortisol levels at baseline and after ACTH stimulation. RESULTS: Ninety-nine patients (61 males; median [range] age, 2 [0-204] months) were enrolled. The mortality rate of children with a baseline cortisol level of 600 nmol/L or greater was 36% (12/33 patients) versus 18% (12/66 patients) for children with a baseline cortisol level of less than 600 nmol/L (odds ratio, 2.6 [95% confidence interval, 1-6.6]; P = 0.05). There was a positive correlation between baseline cortisol and lactate levels (r = 0.40, P < 0.0001), vasoactive-inotropic scores (r = 0.24, P = 0.02), and mortality (P = 0.05). There was no correlation between peak cortisol measured at the ACTH test or the delta increment of cortisol from baseline and mortality. CONCLUSIONS: A high baseline cortisol level in critically ill children was associated with more severe illness, higher lactate level, and a higher mortality rate. Routine baseline cortisol assessment is recommended to identify patients at high mortality risk.

Smoking Behavior Change During Compulsory Military Service in Israel, 1987-2011.

INTRODUCTION: Smoking in military settings is of major concern. We aimed to assess the association between personal, family, and military factors and smoking behavior change during compulsory military service in Israel. METHODS: Participants were soldiers recruited between 1987 and 2008 who were interviewed at recruitment and reinterviewed at discharge (1987-2011) (total: 29 189; males:15 136; females:14 053). The primary outcome variables were smoking initiation during service among nonsmokers at recruitment, and cessation during service among smokers at recruitment. We examined potential predictors of change, and trends by calendar year. RESULTS: Smoking prevalence increased by 39.4% during military service (recruitment: 26.2%, discharge: 36.5%). 18.4% of nonsmoking recruits initiated smoking, and 12.4% of smoking recruits quit smoking between recruitment and discharge. There was no observed trend in initiation between 1987 and 2011. The strongest predictor of smoking initiation among nonsmokers at recruitment was smoking history (former vs. never-smoker, odds ratio (OR) [95% confidence interval [CI]]: males: 5.63 [4.63,6.85], females: 6.76 [5.27, 8.68]. Other variables had smaller effects on initiation. Females were less likely to initiate smoking than males (OR [CI]): 0.75 [0.69,0.81]. Both males and females with high military fitness levels were more likely to initiate smoking. Among women, those with lower education, with fathers with lower education, of lower socioeconomic status, and ever-users of contraceptives were more likely to initiate smoking. Cessation among males modestly increased over the years (OR [CI]): 1.03 [1.01,1.05]. CONCLUSIONS: Smoking increased substantially during mandatory military service in Israel. Former smokers were at greatly increased risk of initiation and should be targeted for relapse prevention. Military service represents a golden opportunity for tobacco control. IMPLICATIONS: Military tobacco control policy is an important contributor to longevity among service personnel, and population-wide mortality in countries with compulsory service. The increased smoking prevalence among military personnel, and increases in smoking during military service should act as a wake-up call to governments and health systems in countries lacking strong military tobacco control policies. The substantial progress in military tobacco control in the United States, which includes strong antitobacco policies for prevention of smoking initiation, aid to smokers to quit smoking, and protection of nonsmokers from tobacco smoke, should be emulated by others. Former smokers and others at high risk should be targeted for relapse prevention. The closed environment of military service provides a golden opportunity for tobacco control.

Measured adolescent body mass index and adult breast cancer in a cohort of 951,480 women.

Body mass index (BMI) in adolescence, studied predominantly as a self-reported risk factor for breast cancer (BC), may have been subjected to recall bias. We examined the association between measured BMI in adolescence and the incidence of BC by menopausal status. 951,480 Jewish Israeli females aged 16-19 who underwent anthropometric measurements in 1967-2011 were followed up to 31.12.2012 for BC incidence. Cox proportional hazards models assessed the association between adolescent BMI (as age-specific CDC percentiles) and time to BC diagnosis, adjusting for sociodemographic covariates. The analysis was also subdivided by age at diagnosis. 9619 BC cases diagnosed during 18,078,941 person-years of follow-up were included in multivariable analyses: 4901 premenopausal, 3809 perimenopausal, and 909 postmenopausal. Compared with 'healthy' BMI (5th-<85th percentiles) and adjusted for country of origin, education, and height, adolescent BMI was largely negatively associated with BC: hazard ratio (HR) = 1.057 (95 % confidence interval (CI) 0.955-1.169, p = 0.286) in underweight (<5th percentile); HR = 0.918 (95 % CI 0.849-0.993, p = 0.032) in overweight (85th-<95th percentiles); and HR = 0.682 (95 % CI 0.552-0.843, p = 0.00004) in obese (≥95th percentile) women. In premenopausal, but not peri- and postmenopausal BC, associations were statistically significant; underweight was associated with increased risk of premenopausal BC (HR = 1.15, 95 % CI 1.01-1.31, p = 0.037), and overweight and obesity with significantly lower risk. Adolescent thinness was associated with increased risk for early BC. Overweight and obesity were protectively associated with premenopausal but not postmenopausal BC. The lack of an association of adolescent overweight/obesity with increased peri- and postmenopausal BC suggests a causal role for adult weight gain.

Time trends of viral meningitis among young adults in Israel: 1978-2012.

Viral meningitis (VM) is a medical condition of public health concern, as it is a common sporadic and epidemic illness. However, there is limited data on the epidemiology of VM. The purpose of this study was to analyze long-term and seasonal trends of VM in a young adult military population. VM is a obligatory notifiable disease in the Israel Defense Forces. For the present study, the archives of the Army Health Branch were reviewed for all cases of VM from January 1, 1978 to December 31, 2012, and the annual, monthly, and seasonal rates were calculated. The annual incidence over the 35-year period showed a high peak every 3-5 years followed by a quiescent period of 2-3 years, reaching as high as 58.4 per 100,000 in 1980 and as low as 3.0 per 100,000 in 2005. This cyclic pattern has diminished over the last decade, reflected by a decline in mean incidence (10.46 per 100,000 in 2003-2012 compared to 19.79 per 100,000 in 1978-2002). Average monthly rates ranged from 1.0 cases per 100,000 soldiers in January/February to 2.2 per 100,000 in July/August. The difference in average rates between winter (1.2 cases per 100,000) and summer (1.9 cases per 100,000) was statistically significant (p < 0.001). Analysis of the long-term epidemiology of VM shows an epidemic pattern, with predominance in the warmer months. Identifying viral causes of meningitis may spare patients unnecessary treatment while prompting the introduction of public health interventions and control measures, especially in crowded settings.

Blood lactate levels differ significantly between surviving and nonsurviving patients within the same risk-adjusted Classification for Congenital Heart Surgery (RACHS-1) group after pediatric cardiac surgery.

This study aimed to examine the association between lactate levels in the first hours after surgery for congenital heart defects and the results of Risk-Adjusted Classification for Congenital Heart Surgery (RACHS-1) scoring and to evaluate serial lactate levels over time to determine whether they can serve as a supplementary tool for postoperative assessment within the same RACHS-1 group of patients. A retrospective cohort study was performed using data retrieved from a clinical database of 255 children who had surgery for congenital heart defects between 1999 and 2001 at Sheba Medical Center. Lactate levels were measured postoperatively four times (mg/dL units). The last sample was taken at the end of the surgical procedure, and lactate levels were measured at admission to the pediatrics critical care unit, then 6 and 12 h after admission. The lactate level was measured via arterial blood gases. A total of 27 deaths occurred, yielding a mortality rate of 7.4% when Norwood operations were excluded and 10.16% when they were included. The mean initial postoperative lactate level was significantly lower for survivors (42.2 ± 32.0 mg/dL) than for nonsurvivors (85.4 ± 54.1 mg/dL) (p < 0.01). The serial mean lactate levels decreased progressively for all surviving patients (r (2) = 0.96) compared with nonsurvivors (r (2) = 0.02). The lactate levels correlated with the RACHS-1 subgroups at each time point (r (2) > 0.96 for all). The Pearson correlations between postoperative lactate levels (last lactate measurement taken in the operating room) and cardiopulmonary bypass (CPB) duration (r = 0.549), clamp duration (r = 0.586), and the inotropic score (r = 0.466) (p < 0.001 for all) were significantly positive. The correlations between the maximum lactate levels (during the first 12 postoperative hours) and CPB duration (r = 0.496), clamp duration (r = 0.509), and the inotropic score (r = 0.633) (p < 0.001 for all) were extremely positive. The early elevation of lactate levels in RACHS-1 subgroups 1 to 3 were highly correlated with poor prognosis and death (p < 0.03). In addition, the lactate levels differed significantly between survivors and nonsurvivors within the same RACHS-1 subgroup. The survivors in RACHS-1 subgroups 1 to 3 had lower mean lactate levels than the nonsurvivors in this group (P = 0.011), and this also held true for the survivors and nonsurvivors in RACHS-1 subgroups 4 to 6 (P = 0.026). Lactate levels differed significantly between survivors and nonsurvivors within the same RACHS-1 subgroup. This combination allows the targeting of appropriately intensive interventions and therapies toward the sickest patients.

[The military role in a flu pandemic].

Pandemic influenza is a major challenge to emergency preparedness agencies and health systems throughout the world. It requires preparation for a situation of widespread morbidity due to flu and its complications which will lead to a huge burden on the health system in the community and in hospitals, and work absenteeism, also among health care personnel. This may require major involvement of the army in both preparedness and measures to be taken to tackle such an event. This article reviews the different roles armies could take in such a crisis, and presents the Israeli test case. Defense systems are characterized by a number of attributes that may be major advantages during pandemic influenza: crisis management capacities, ability to deal with varied tasks in sub-optimal conditions, logistic resources (fuel, food and water), widespread deployment in the country and sometimes in the world, and the ability to activate people in risky situations, even against their will. The army roles during pandemic outbreaks could include: taking national and regional command of the event, assigning workforce for essential civilian missions, use of logistic and military resources, maintaining public order and implementing public health measures such as isolation and quarantine. In addition, the army must continue its primary role of maintaining the security and guarding the borders of the state, especially in times of global geopolitical changes due to pandemic. Since March 2009, the influenza A/H1N1 2009 virus spread throughout the world, leading the WHO to declare a state of pandemic influenza. According to Israeli preparedness plans, the management of the event was supposed to pass to the defense system. However, due to the moderate severity of the illness, it was decided to leave the management of the event to the health system. In view of the necessity of maintaining military combat capabilities, and the possibility of outbreaks in combat units, which actually occurred, the Israel Defense Forces (IDF) policy for the pandemic was stricter than the policy of the Ministry of Health. Defense systems in Israel and the world should prepare, the sooner the better, for the possibility of a worse pandemic, in which the army may take a major role, especially since regular life in the country, in such a case, would be disturbed.