Irena Alon

Warfarin for Stroke Prevention Still Underused in Atrial Fibrillation: Patterns of Omission

BACKGROUND AND PURPOSE The value of warfarin in preventing stroke in patients with chronic atrial fibrillation is well established. However, the prevalence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfarin treatment. METHODS Between 1990 and 1998, 1027 patients were discharged with chronic or persistent atrial fibrillation. This population was composed of (1) patients with cardiac prosthetic valves (n=48), (2) those with increased bleeding risks (n=152), (3) physically or mentally handicapped patients (n=317), and (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfarin use. RESULTS The respective rates of warfarin use on discharge in the 4 groups were 93.7%, 30.9%, 17.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatment rates increased with each consecutive triennial period (29.7%, 53.6%, and 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, and being hospitalized in a given medical department emerged as independent variables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI 0.17 to 0.55); P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and availability of echocardiographic information, regardless of the findings, each increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0001, OR 3.52 [95% CI 2.16 to 5.72], respectively). CONCLUSIONS Old age, language difficulties, insufficient doctor alertness to warfarin benefit, and patient disability produced reluctance to treat. Warfarin use still lags behind requirements.

Dietary Intake of Various Nutrients in Older Patients with Congestive Heart Failure

Background and Aims: Anorexia, nausea and premature satiety with eating, prevalent in congestive heart failure (CHF), have been held responsible for reduced dietary intake and deficiency of magnesium, potassium and probably other nutrients. Since solid data is not available, this study was undertaken with the following aims (1) to assess dietary intake in CHF, (2) to compare dietary intake in older CHF patients with a similar patient population free of CHF (control group), and (3) to evaluate these data in patients with moderate versus severe CHF. Methods and Results: Dietary intake of 57 consecutively hospitalized furosemide-treated CHF patients over the age of 60 was compared with that of 40 similar patients free of CHF. In addition, a statistical analysis was performed comparing the data of the 37 patients with moderate versus the 20 patients with severe CHF. Dietary content of various nutrients was assessed with the food frequency recall technique. Dietary intake was comparable in the two respective pairs of groups. However, the intake of magnesium, calcium, zinc, copper, manganese, energy, thiamin, riboflavin, and folate in all subgroups fell short of recommended levels for intake, while vitamins A, C and niacin contents exceeded those recommended. Intakes of potassium andproteins were within the recommended values. Conclusions: CHF per se, even severe CHF, is not responsible for a reduced dietary intake of various nutrients. A population-related dietary culture, old age or other chronic conditions, rather than CHF, might be mainly involved. The increased intake of vitamins A, C and niacin in our patients may be attributed to the high content of fruits and vegetables in the Mediterranean diet. Insufficient intake of the above-mentioned group of electrolytes and essential nutrients may contribute to the frequently observed negative balance of some of them. This is especially relevant in furosemide-treated CHF patients. Therefore, supplementation should be considered.

Acute inflammatory myopathy with severe subcutaneous edema, a new variant? Report of two cases and review of the literature

Abstract. Acute inflammatory myopathy with severe subcutaneous edema is extremely rare and has been reported in only a handful of cases. We describe two similar patients presenting with this disorder and generalized rash. Unlike the five previously reported cases, the clinical and histologic features of our two patients are more suggestive of dermatomyositis than polymyositis. Nevertheless, scrutinizing all seven reported patients, a number of specific characteristics could be defined. All patients were adult males. Dysphagia was present in four. In six patients, acute inflammatory myopathy was idiopathic while malignancy was present in one. Two patients died despite intensive therapy, three improved on corticosteroid treatment, and two recovered spontaneously. In all patients, limb involvement with marked subcutaneous edema was present, clinically mimicking deep vein thrombosis in both our patients. The presence of severe subcutaneous edema may be a hallmark of a distinctive variant of acute inflammatory myopathy. More cases are needed to discern subtypes of this general entity and to establish guidelines for treatment and prognosis.

Seating-Induced Postural Hypotension Is Common in Older Patients with Decompensated Heart Failure and May Be Prevented by Lower Limb Compression Bandaging

Background: Postural hypotension induced by transition from supine to sitting position and measures for its prevention in heart failure has not been investigated. Objective: Our purpose was to evaluate the prevalence of postural hypotension and associated clinical manifestations as well as the contribution of various risk factors for postural hypotension on transition from lying to sitting in older patients with decompensated heart failure, and to study the eventual preventive effect of leg bandaging. Methods: Seating-induced postural hypotension (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic blood pressure fall) was assessed on the first study day in 108 patients aged ≥60 years, hospitalized for acutely decompensated heart failure. On the next day, in patients manifesting postural hypotension, compression bandages were applied along both legs before seating. Blood pressure, heart rate, O2 saturation, and the occurrence of dizziness or palpitations were recorded prior to and 1, 3 and 5 min following seating. Results: Postural hypotension occurred in 49.1% of patients. Dizziness and/or palpitations manifested in 25%. Diastolic (36.1%) versus systolic (23.1%) postural hypotension prevailed (p = 0.05). On univariate analysis, postural hypotension was associated with female sex (p = 0.03), more severe heart failure (p = 0.05), longer bedrest (p = 0.04), higher supine systolic (p = 0.01) or diastolic (p = 0.002) blood pressure, nonischemic heart failure (p = 0.002), and not using nitrates (p = 0.01). On multivariate analysis, longer bedrest (OR = 1.58, 95% CI = 1.13–2.2, p < 0.001), higher supine diastolic blood pressure (OR = 1.33, 95% CI = 1.1–1.61, p = 0.001), and nonischemic heart failure (OR = 3.48, 95% CI = 1.4–8.63, p = 0.009) were the most predictive of postural hypotension. Compression bandages prevented postural hypotension in 21 of 49 patients and decreased the degree of postural blood pressure fall (p < 0.001). Conclusion: Seating-induced postural hypotension is common among older inpatients with decompensated heart failure, especially with longer bedrest, higher supine diastolic blood pressure and non-ischemic etiology. Leg compression bandaging may be useful for the prevention of postural hypotension in these patients.

First morning standing up may be risky in acutely ill older inpatients

Information about orthostatic hypotension (OH) among elderly patients hospitalized for acute conditions in short‐term facilities is scarce. Many older inpatients carry various predisposing factors for OH. However, its existence goes frequently unrecognized. In this context, first morning standing up following admission for an acute disease may be dangerous. The aim of this study was to investigate OH and associated manifestations in this situation. OH (⩾20 mmHg systolic and/or ⩾10 mmHg diastolic blood pressure fall), heart rate, arrhythmias and appearance of dizziness or palpitations were recorded in 121 sequential inpatients aged >65 years, prior to and 1, 3 and 5 min following first morning standing. OH occurred in 64.5% of patients, while dizziness and/or palpitations appeared in 76%. Severe adverse effects were registered in 11.5% of OH patients. Significantly associated with OH were: bed rest lasting 9–24 h (vs ⩽8 h, p<0.001), appearance of dizziness or palpitations (p<0.001 and p = 0.005, respectively), heart failure (p = 0.02) and renal dysfunction (p = 0.04). OH and/or associated symptoms are frequent in acutely ill older inpatients on first morning standing up following nocturnal bed rest. The ominous potential consequences call for alertness to this phenomenon and application of appropriate preventive measures.

Lower Limb Compression Bandaging Is Effective in Preventing Signs and Symptoms of Seating-Induced Postural Hypotension

Background and Aims: Data concerning postural hypotension (PH) induced by transition from supine to sitting position are scarce and measures for its prevention have not been investigated. Our objective was to assess the preventive role of lower limb compression bandaging on PH and associated manifestations in older inpatients when seated from lying position. Methods: In a randomized crossover study, 61 patients aged >65 years were enrolled. Following bed rest lasting >36 h, each patient was seated and studied for 2 consecutive days, unbandaged or bandaged. PH was defined as a fall of ≧20 mm Hg and/or ≧10 mm Hg in systolic/diastolic blood pressure, respectively. Compression bandages were applied along both legs before seating; the pressure was approximately 30 mm Hg. Blood pressure, heart rate, O2 saturation, dizziness and palpitations were recorded prior to and 1, 3, and 5 min following seating. Results: Prevalence of PH was identical in the unbandaged versus bandaged state (55.7%). However, dizziness, palpitations, accelerated heart rate and decreased O2 saturation over 5 min were more prevalent in the unbandaged versus bandaged state (p < 0.01, <0.001, <0.05, <0.001, respectively). In the unbandaged state, presence versus absence of PH was associated with significantly greater incidence of palpitations, tachycardia and decline of O2 saturation over time (p < 0.04, <0.03, <0.03, respectively). In the bandaged state, O2 saturation over 5 min tended to rise irrespective of PH, but mean values were higher in patients without PH (p < 0.02). Conclusions: Lower limb compression bandaging does not reduce the incidence of PH. However, associated manifestations are largely prevented.

Benign familial microcytic thrombocytosis with autosomal dominant transmission

Familial thrombocytosis is an extremely rare disorder, so far reported in only a handful of families. In the majority of cases the characteristics were of essential thrombocythemia. Most patients presented with a platelet count above 800000/mm3, were diagnosed as having a myeloproliferative disease, and some required chemotherapy. We describe a benign form of familial thrombocytosis with autosomal dominant inheritance in five healthy members of three generations of a family, all of whom had moderate thrombocytosis within the range 422 000–662 000/mm3, characterized by low mean platelet volume. A careful medical history and a 5‐year follow up of the subjects did not reveal any untoward clinical development. This variant of familial thrombocytosis is therefore of a benign nature. Possible mechanisms linking thrombocytosis with platelet microcytosis in this family are discussed.

Effect of Various Clinical Variables on Total Intracellular Magnesium in Hospitalized Normomagnesemic Diabetic Patients before Discharge

Deficiency of intracellular magnesium (icMg) may coexist with normal serum Mg levels. Little is known about clinical and pharmacological factors affecting icMg in normomagnesemic patients with diabetes mellitus (DM). Moreover, no information exists regarding the icMg state in diabetic patients after acute illness and before hospital discharge. We have evaluated the effect of antihyperglycemic medications and other relevant clinical variables on icMg in 119 such patients. Total icMg was measured in peripheral blood mononuclear cells. Twenty healthy volunteers served as controls. IcMg content (µg/mg cell protein) was lower in DM compared to controls (1.74 ± 0.44 vs 2.4 ± 0.39, p < 0.001). It was also significantly lower in patients treated with insulin (1.57 ± 0.31 vs 1.8 ± 0.46, p = 0.01), while metformin treatment was associated with higher icMg (1.86 ± 0.49 vs 1.63 ± 0.35, p = 0.003). After adjustment for age, gender, and concomitant use of other hypoglycemic drugs, only treatment with metformin was independently associated with increased icMg (p = 0.03). No statistically significant association or correlation was found between icMg content and age, causes of hospitalization, comorbid conditions, treatment with other drugs, concentrations of HbA1c, serum glucose, Mg, or creatinine. In conclusion, icMg is depleted in normomagnesemic DM patients. Insulin treatment is associated with worsening of icMg status, while metformin treatment may confer protective effect.

Seated postural hypotension is common among older inpatients.

Abstract.Bed-rest > 12 hours produced postural hypotension (PH) in 54% of seated older inpatients. PH was multifactorial, equally initiated throughout 5 minutes and symptoms arised frequently following small blood pressure drops. In this context PH should be anticipated and prevented.

Dermonecrotic Loxoscelism in the Mediterranean Region

AbstractPublications on loxosceles spider bites in the Mediterranean region are scarce. This spider is frequently found in Israel and its bite may cause severe medical problem. We report on 11 patients who sustained such bites and required hospitalization between 1988 and 1997 in a regional hospital serving a population of 300,000. Most of them were bitten in the summer, 10 on the medial aspect of the arm or thigh. All patients exhibited the typical loxosceles skin lesion; systemic manifestations were evident in six. Seven patients were misdiagnosed. All were treated with antibiotics and eight with the addition of corticosteroids. Ten patients fully recovered within 2-3 weeks.The estimated incidence of severe dermonecrotic loxoscelism requiring hospitalization is 0.37 cases/100,000 population/year. It seems that the clinical course in our cases was somewhat milder than in other reported cases from the United States. This can possibly be attributed to the bite of Loxosceles rufescens, which is the prevaili...