Liraz Olmer

Prognostic significance of the admission electrocardiogram in acute myocardial infarction

OBJECTIONS We sought to access the ST segment and the terminal portion of the QRS complex in the initial electrocardiogram (ECG) as tools to predict outcome in patients with acute myocardial infarction given thrombolytic therapy. BACKGROUND Previous studies assessing early risk stratification of patients with acute myocardial infarction by ECG criteria have focused on the number of leads with ST segment elevation or the absolute magnitude of ST deviation. A new classification independent of the absolute values of ST deviation was pursued. METHODS Patients with ST elevation and positive T waves in at least two adjacent leads who received thrombolytic therapy were classified into two groups based on the absence (1,232 patients) or presence (1,371 patients) of distortion of the terminal portion of the QRS complex on the admission ECG. RESULTS There were no differences between groups in the prevalence of previous angina, hypertension, current smoking, anterior infarction, time from onset of symptoms to therapy of type of thrombolytic regimen. Patients with QRS distortion were less likely to have had a previous infarction (12.0% vs. 18.4%, p = 0.02) or diabetes mellitus (16.9% vs. 21.4%, p = 0.003). They had higher peak creatine kinase levels (1,617 +/- 1,670 vs. 1,080 +/- 1,343 IU, p = 0.00001). Hospital mortality for those with and without QRS distortion was 6.8% and 3.8%, respectively (p = 0.0008). Multivariable logistic regression analysis confirmed that hospital mortality was independently associated with distortion of terminal portion of the QRS complex (odds ratio 1.78, 95% confidence interval 1.19 to 2.68, p = 0.004). CONCLUSIONS Distortion of the terminal portion of the QRS complex on the admission ECG is independently associated with a higher hospital mortality rate in patients with acute myocardial infarction given thrombolytic therapy.

The relation between objective and subjective impairment in cognitive function among multiple sclerosis patients - the role of depression

Objective: To evaluate the relations between perceived cognitive function and objective cognitive deficit and to assess variables affecting perceived cognitive function among multiple sclerosis (MS) patients. Methods: A cross sectional study of patients with MS. All patients were interviewed and the Expanded Disability Status Scale (EDSS) score was determined. The dependent variables were four items assessing perceived concentration and thinking, attention, memory, and whether others have noticed memory or concentration problems. The explanatory variables were age, sex, duration of disease, number of relapses in the last 2 years, EDSS score, depressive symptoms score (CES-D) and the domains of the Neurobehavioral Cognitive Status Examination (NCSE) assessing cognitive performance. Bivariate and then multivariate analysis were performed. Results: One hundred and sixty-one MS patients were included. Mean age was 44.2 years (s.d. 11.3 years), mean EDSS score was 4.86 (s.d. 1.93). Seventy-two per cent of the patients had objective cognitive impairment and 51% reported decreased perceived cognitive function. In all models assessing perceived cognitive function we could explain only a small part of the variance (R2 ranged between 18-26%). In all these models depressive symptoms explained the highest portion of the variance (partial R2 ranging between 13-26%). The only domain of the NCSE that entered some of the models was calculation (partial R2 ranging between 3-7%). Conclusions: These findings emphasize the gap between objective and subjective assessment of cognitive function and the high correlation between perceived cognitive deficit and depressive symptoms.

Screening and Diagnosis of Gestational Diabetes Mellitus:: Critical appraisal of the new International Association of Diabetes in Pregnancy Study Group recommendations on a national level

OBJECTIVE To study the implications of implementing the International Association of Diabetes in Pregnancy Study Group (IADPSG) recommendations for screening and diagnosis of gestational diabetes mellitus (GDM) in Israel and explore alternative methods for identifying women at risk for adverse pregnancy outcomes. RESEARCH DESIGN AND METHODS We analyzed data of the Israeli Hyperglycemia and Adverse Pregnancy Outcomes study participants (N = 3,345). Adverse outcome rates were calculated and compared for women who were positive according to 1) IADPSG criteria, 2) IADPSG criteria with risk stratification, or 3) screening with BMI or fasting plasma glucose (FPG). RESULTS Adopting IADPSG recommendations would increase GDM diagnosis by ∼50%. One-third of IADPSG-positive women were at low risk for adverse outcomes and could be managed less intensively. FPG ≥89 mg/dL or BMI ≥33.5 kg/m2 at 28–32 weeks of gestation detected proportions of adverse outcomes similar to IADPSG criteria. CONCLUSIONS Implementing IADPSG recommendations will substantially increase GDM diagnosis. Risk stratification in IADPSG-positive women may reduce over-treatment. Screening with FPG or BMI may be a practical alternative.

Factors affecting mortality following myeloablative cord blood transplantation in adults: a pooled analysis of three international registries

A retrospective analysis was conducted to examine factors affecting early mortality after myeloablative, single-unit cord blood transplantation (CBT) for hematological malignancies in adolescents and adults. Data were collected from the three main CBT registries pooling 514 records of unrelated, single, unmanipulated, first myeloablative allogeneic CBTs conducted in North America or Europe from 1995 to 2005, with an HLA match ⩾4/6 loci, in patients aged 12–55. Overall 100-day, 180-day and 1-year survival (Kaplan–Meier method) were 56, 46 and 37%, respectively, with no significant heterogeneity across registries. Multivariate analysis showed cell dose <2.5 × 107/kg (odds ratio (OR) 2.76, P<0.0001), older age (P=0.002), advanced disease (P=0.02), positive CMV sero-status (OR 1.37 P=0.11), female gender (OR 1.43, P=0.07) and limited CBT center experience (<10 records contributed, OR 2.08, P=0.0003) to be associated with higher 100-day mortality. A multivariate model predictive of 1-year mortality included similar prognostic factors except female gender. Transplant year did not appear as a significant independent predictor. This is the first analysis to pool records from three major CBT registries in the United States and Europe. In spite of some differences in practice patterns, survival was remarkably homogeneous. The resulting model may contribute to better understanding factors affecting CBT outcomes.

A comparison of three measures: the time trade-off technique, global health-related quality of life and the SF-36 in dialysis patients

We investigated the correlation between descriptive and valuational measures of health-related quality of life (HRQL) and assessed determinants affecting these measures. Our suspicion was that there is little similarity in the content of descriptive and valuational measures of HRQL. We thus conducted a cross-sectional observational study of 56 hemodialysis patients. All underwent structured interviews. Dependent variables were patients utilities [time trade-off (TTO)], global rating of HRQL and generic HRQL (SF-36). Independent variables were socioeconomic details, disease severity, comorbidity, symptoms, depression, social support, and laboratory data. The correlation between TTO and global HRQL was -0.33 (P = .0178) and between TTO and the SF-36 physical and mental summary scores -0.16 (P = .2383) and -0.20 (P = .1443), respectively. The regression models for the SF-36 physical and mental summary scores explained 75% and 64% of the variance, and for global HRQL 29% of the variance. The independent variables had no effect on the TTO. This confirmed our suspicion that a qualitative difference exists between TTO and descriptive quality of life tools. The TTO content could not be explained by the variables that entail the content of HRQL instruments.

Prognostic significance of precordial ST segment depression on admission electrocardiogram in patients with inferior wall myocardial infarction

OBJECTIVES This study assessed retrospectively the correlation between the pattern of precordial ST segment depression on the admission electrocardiogram (ECG) and hospital mortality in patients with an inferior myocardial infarction treated with intravenous thrombolytic therapy. BACKGROUND Previous studies have shown that in acute inferior myocardial infarction, ST segment depression in the precordial leads is associated with increased hospital mortality. However, the significance of the different patterns of precordial ST segment depression has been evaluated in only two previous studies. METHODS The study included 1,321 patients (1,020 men) who enrolled in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) trial in Israel and received intravenous thrombolytic therapy. Patients with an ST segment elevation > or = 0.1 mV in at least two of the inferior leads were included. Patients were classified into four groups on the basis of their admission ECG: group I = patients with no precordial ST segment depression (n = 346); group II = those for whom the sum of ST segment depression in leads V1 to V3 was greater than that in leads V4 to V6 (n = 700); group III = those for whom the sum of ST depression in leads V1 to V3 was equal to that in leads V4 to V6 (n = 162); group IV = those with maximal ST depression in leads V4 to V6 (n = 113). RESULTS The overall hospital mortality rate was 3.6% (48 patients): for groups I, II, III and IV it was 2.9%, 2.8%, 4.3% and 9.7%, respectively. Multivariable logistic regression analysis confirmed that hospital mortality was independently associated with the pattern of precordial ST segment depression. The odd ratios in group IV relative to group I was 2.78 (95% confidence interval 1.26 to 6.13, p = 0.007). CONCLUSIONS The risk of mortality is higher in patients with an inferior myocardial infarction and maximal ST segment depression in precordial leads V4 to V6 versus precordial leads V1 to V3 on the admission ECG.

Time-Dependent Risk of Cancer After a Diabetes Diagnosis in a Cohort of 2.3 Million Adults

Using a time-dependent approach, we investigated all-site and site-specific cancer incidence in a large population stratified by diabetes status. The study analyzed a closed cohort comprised of Israelis aged 21-89 years, enrolled in a health fund, and followed from 2002 to 2012. Adjusting for age, ethnicity, and socioeconomic status, we calculated hazard ratios for cancer incidence using Cox regression separately for participants with prevalent and incident diabetes; the latter was further divided by time since diabetes diagnosis. Of the 2,186,196 individuals included in the analysis, 159,104 were classified as having prevalent diabetes, 408,243 as having incident diabetes, and 1,618,849 as free of diabetes. In both men and women, diabetes posed an increased risk of cancers of the liver, pancreas, gallbladder, endometrium, stomach, kidney, brain (benign), brain (malignant), colon/rectum, lung (all, adenocarcinoma, and squamous cell carcinoma), ovary, and bladder, as well as leukemia, multiple myeloma, non-Hodgkin lymphoma, and breast cancer in postmenopausal women. No excess risk was observed for breast cancer in premenopausal women or for thyroid cancer. Diabetes was associated with a reduced risk of prostate cancer. Hazard ratios for all-site and site-specific cancers were particularly elevated during the first year following diabetes diagnosis. The findings of this large study with a time-dependent approach are consistent with those of previous studies that have observed associations between diabetes and cancer incidence.

Factors Affecting Change in Quality of Life After Prostatectomy for Benign Prostatic Hypertrophy: The Impact of Surgical Techniques

PURPOSE The impact of prostatectomy on quality of life was assessed in patients with benign prostatic hypertrophy (BPH) who were classified according to the expected benefit from surgical intervention. The relative impact of the 2 surgical techniques (open versus closed) on short-term quality of life was compared. MATERIALS AND METHODS An observational study was done on 545 consecutive patients with BPH undergoing prostatectomy at 3 medical centers in Israel between 1991 and 1992. Repeated structured interviews preoperatively, and at 4 and 12 months postoperatively were performed, including 6 quality of life questionnaires evaluating BPH specific (symptom severity and symptom effect) and generic (activity, independence, mental health and health perception) parameters. In addition, the interviews consisted of socio-demographic data elements. Clinical details regarding severity of prostatic disease and co-morbidity were obtained from the medical charts. RESULTS We found a correlation between postoperative change in symptom effect and in generic quality of life measures (r-0.11 to 0.20, p < 0.04). The postoperative decrease in the mean symptom effect score was 56% and 52% for severe and moderate preoperative levels, respectively. There was no decrease in the mean symptom effect score for the mild preoperative level (18% of these patients had postoperative deterioration). A secondary operation, and the combination of diabetes mellitus and poor activity level were risk factors for lack of improvement in patients with moderate preoperative symptom effects. We found that the impact of open prostatectomy on quality of life was similar to that of the closed technique after adjustment for patient attributes, except for those with an indwelling urinary catheter in whom an open operation was advantageous. CONCLUSIONS In patients with BPH and mild symptom effects, and in subgroups of patients with moderate symptom effects surgery should not be recommended. Based on short-term measures of quality of life there is no justification for a preference between open and closed operations.

Admission Clinical and Electrocardiographic Characteristics Predicting In-Hospital Development of High-Degree Atrioventricular Block in Inferior Wall Acute Myocardial Infarction

This study assessed the ability of simple clinical and electrocardiographic variables routinely obtained on admission to identify patients who are at high risk of developing high-degree atrioventricular (AV) block during hospitalization in 1,336 patients with inferior wall acute myocardial infarction (AMI). Patients were classified into 2 initial electrocardiographic patterns based on the J-point to R-wave amplitude ratio: pattern 1: those with J point/R wave <0.5 and pattern 2: patients with J point/R wave > or =0.5 in > or =2 leads of the inferior leads II, III, and aVF. High-degree AV block was found in 6.7% of patients (41 of 615) with pattern 1 versus 11.8% of the patients (85 of 721) with pattern 2 on admission electrocardiogram (p = 0.0008). Multivariate logistic regression analysis revealed that the only variables found to be independently associated with high-degree AV block were female gender (odds ratio [OR] 1.48; 95% confidence interval [CI] 0.98 to 2.23; p = 0.06); Killip class on admission > or =2 (OR 2.24; CI 1.43 to 3.51; p = 0.0004); initial electrocardiographic pattern 2 versus pattern 1 (OR 1.82; CI 1.22 to 2.21; p = 0.003); and absence of abnormal Q waves on admission (OR yes vs no 0.68; CI 0.44 to 1.05; p = 0.08). A simple electrocardiographic sign (J point/R wave > or =0.5 in > or =2 leads) is a reliable predictor of the development of advanced AV block among patients receiving thrombolytic therapy for inferior wall AMI.

A national study of postoperative mortality associated with coronary artery bypass grafting in Israel

BACKGROUND Investigation of observed differences in outcomes among medical centers is of major interest to the medical community and the public and has a substantial impact on efforts to improve the quality of medical care. METHODS This study analyzed data from consecutive patients who underwent isolated coronary artery bypass grafting at 14 medical centers. Data included demographic and clinical information, comorbidity, cardiac catheterization results, and 30-day postoperative vitality status. Logistic regression analysis was used to identify variables associated with mortality. An outlier hospital was defined as one having an observed mortality outside the 95% confidence interval boundaries around the expected mortality rate calculated, given the patient risk factors. RESULTS The overall crude 30-day mortality rate for isolated coronary artery bypass grafting among the 4,835 patients in this study was 3.1%. The rate varied among centers, ranging from 0.85% to 7.05%. Predictors of 30-day mortality included advanced age, female sex, diabetes mellitus, poor left ventricular function, high creatinine level, high priority of operation, and three-vessel disease (with or without left main coronary artery disease). After adjustment for risk factors, two hospitals were defined as outliers. CONCLUSIONS The observed disparity in early mortality among patients undergoing coronary artery bypass grafting is not due solely to differences in case mix.