Moshe Garty

Comparison of ketorolac and diclofenac in the treatment of renal colic.

AbstractObjective: To compare the efficacy and adverse effects of ketorolac and diclofenac in the treatment of renal colic. Methods: In a double-blind, randomized clinical trial, 57 patients admitted to the emergency room for renal colic, received either 30 mg of ketorolac or 75 mg of diclofenac i.m. (intramuscularly). Evaluations were performed at 1, 2 h and 6 h after treatment. Pain was assessed by a four-point verbal rating scale (VRS) and a visual analogue scale (VAS). Only patients with at least moderate pain according to the VRS were included. Seventy-five milligrams of pethidine i.m. was given as rescue medicine, if insufficient analgesia was achieved. The adverse effects recorded were sedation, nausea and vomiting. Results: There was no significant difference between ketorolac and diclofenac, with respect to pain level over time, the number of patients requiring rescue medicine, or the level of adverse effects. Conclusion: Ketorolac and diclofenac are equally effective in the treatment of renal colic.

Predictors of long-term (4-year) mortality in elderly and young patients with acute heart failure.

The present study was designed to identify and compare predictors of short‐ and long‐term mortality in elderly and young patients hospitalized with acute heart failure (HF).

Lymphoma presenting with adrenal insufficiency: Adrenal enlargement on computed tomographic scanning as a clue to diagnosis

A 73-year-old woman who presented with primary adrenal insufficiency and enlarged adrenal glands on computed tomographic scanning was ultimately found to have a large-cell lymphoma that had initially involved the adrenals and the stomach. A search of the English language medical literature revealed only seven other cases of lymphoma presenting with hypoadrenalism, none of which involved the stomach. As in this case, in most of those cases adrenal enlargement was documented on computed tomographic scanning. Despite its rare occurrence, lymphoma should be searched for in patients presenting with Addisons disease and enlarged adrenal glands.

Prevalence and significance of unrecognized renal insufficiency in patients with heart failure

AIMS Renal insufficiency (RI) is a strong predictor of adverse outcome in patients with heart failure (HF). We aimed to determine the prevalence of RI being unrecognized and its significance in patients hospitalized with HF. METHODS AND RESULTS We analysed data from a prospective survey of 4102 hospitalized patients with HF. RI [defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2] was present in 2145 (57%) patients but, based on medical records, was unrecognized in 872 [41%, 95% confidence interval (CI) 39-43%] of them. Patients with unrecognized RI were more likely to be women, elderly, and with better functional class, compared with patients with recognized RI. In-hospital and 1 year mortality was significantly higher among patients with recognized and unrecognized RI compared with patients without RI: 6.5 and 7.1 vs. 2.1%, and 38.8 and 30.9 vs. 18.8% (P < 0.001), respectively. After adjustment, recognized and unrecognized RI comparably predicted increased in-hospital mortality: odds ratio (OR) and 95% CI of 2.34 (1.43-3.87), P < 0.001, and 2.30 (1.45-3.72), P < 0.001. After 1 year, recognized RI remained an independent predictor for mortality: OR 1.79 (1.45-2.20), P < 0.001, whereas there was a trend for increased mortality predicted by unrecognized RI: OR 1.22 (0.97-1.53), P = 0.08. CONCLUSION A high proportion of RI remains unrecognized among hospitalized patients with HF. As co-morbid RI has important prognostic and therapeutic implications, patients with HF may benefit from routine assessment of GFR.

Relation of Bundle Branch Block to Long-Term (Four-Year) Mortality in Hospitalized Patients With Systolic Heart Failure

There is controversy regarding type of bundle branch block (BBB) that is associated with increased mortality risk in patients with heart failure (HF). The present study was designed to explore the association between BBB pattern and long-term mortality in hospitalized patients with systolic HF. Risk of 4-year all-cause mortality was assessed in 1,888 hospitalized patients with systolic HF (left ventricular ejection function <50%) without a pacemaker in a prospective national survey. Cox proportional hazards regression modeling was used to compare mortality risk in patients with right BBB (RBBB; 10%), left BBB (LBBB; 14%), and no BBB (76%) on admission electrocardiogram. At 4 years of follow up, mortality rates were highest in patients with RBBB (69%), intermediate in those with LBBB (63%), and lowest in those without BBB (50%, p <0.001). Multivariate analysis demonstrated a significant 36% increased mortality risk in patients with RBBB versus no BBB (p = 0.002) but no significant difference in mortality risk for patients with LBBB versus no BBB (hazard ratio 1.04, p = 0.66). RBBB versus LBBB was associated with a 29% (p = 0.035) increased risk for 4-year mortality in the total population and with a 58% (p = 0.015) increased risk in patients with ejection fraction <30%. In conclusion, RBBB but not LBBB on admission electrocardiogram is associated with a significant increased long-term mortality risk in hospitalized patients with systolic HF. Deleterious effects of RBBB compared to LBBB appear to be more pronounced in patients with more advanced left ventricular dysfunction.

Use of intravenous morphine for acute decompensated heart failure in patients with and without acute coronary syndromes

Background: Current guidelines regarding the use of intravenous morphine (IM) in the management of patients with acute decompensated heart failure (ADHF) are discordant; whereas the American guidelines reserve IM for terminal patients, the European guidelines recommend its use in the early stage of treatment. Our aim was to determine the impact of IM on outcomes of ADHF patients. Methods: Stepwise logistic regression and propensity score analysis of ADHF patients with and without use of IM was performed in a national heart failure survey. Results: Of the 4102 enrolled patients, we identified 2336 ADHF patients, of whom 218 (9.3%) received IM. IM patients were more likely to have acute coronary syndromes, acute rather than exacerbation of chronic heart failure, and diabetes mellitus and dyslipidemia. They had higher heart rate, were less likely to receive diuretics and more likely to receive aspirin and statins. Unadjusted in-hospital mortality rates were 11.5% versus 5.0% for patients who did or did not receive IM, and the adjusted odds ratio (OR) for in-hospital death was: 2.0 (1.1–3.5, P = 0.02). Using propensity analysis, we identified 218 matched pairs of patients who did or did not receive IM. In multivariable analysis accounting for the propensity score (c-statistic 0.82), IM was not associated with increased in-hospital death (OR: 1.2 (0.6–2.4), P = 0.55). Conclusion: IM was used sparingly in our ADHF cohort, and was independently associated with increased in-hospital death in multivariable analysis, but not in propensity score analysis. Thus, IM may be used in ADHF, but with caution. Further randomized trials are warranted.

Atrial fibrillation and long-term prognosis in patients hospitalized for heart failure: results from heart failure survey in Israel (HFSIS).

AIMS Atrial fibrillation (AF) and heart failure (HF) commonly coexist, and each adversely affects the other. The aim of the study was to prospectively evaluate the impact of AF and its subtypes on management, and early and long-term outcome of hospitalized HF patients. METHODS AND RESULTS Data were prospectively collected on HF patients hospitalized in all public hospitals in Israel as part of a national survey (HFSIS). Atrial fibrillation patients were subdivided into intermittent and chronic AF subgroups. During March-April 2003, we enrolled 4102 HF patients, of whom 1360 (33.2%) had AF [600 (44.1%) intermittent, 562 (41.3%) chronic]. Patients with AF were older (76.9 +/- 10.5 vs. 71.7 +/- 12.6 years, P = 0.0001), males, with preserved LV systolic function. Crude mortality rates for AF patients were progressively and consistently higher during hospitalization and during the 4-year follow-up period, especially in the chronic AF group (P = 0.0001). After covariate adjustment, AF was associated with increased 1-year mortality [HR 1.19, 95% CI (1.03-1.36)]. CONCLUSION AF was present in a third of hospitalized HF patients, and identified a population with increased mortality risk, largely due to co-morbidities.

Elevated serum homocysteine is a predictor of accelerated decline in renal function and chronic kidney disease: A historical prospective study

OBJECTIVE To estimate the effect of elevated serum homocysteine level on renal function decline and on the incidence of chronic kidney disease (CKD) in the general population. METHODS A historical prospective study on 3602 subjects attending a screening center in Israel between the years 2000 and 2012. Only subjects with normal estimated glomerular filtration rate (eGFR) and without proteinuria were included. Subjects were divided to two groups according to mean total serum homocysteine level (≤ 15, >15μmol/l). Linear mixed effect model was used to estimate the annual eGRF decline in respect to homocysteine group. Cox proportional hazards models were used to estimate hazard ratios for CKD in the normal compared to the elevated homocysteine group. RESULTS Annual eGFR decline was 25% higher in subjects with elevated versus normal mean homocysteine level (0.90 ± 0.16 ml/min/1.37 m(2) vs. 0.72 ± 0.14 ml/min/1.37 m(2), p<0.001). In a median follow up of 7.75 years, 38 subjects developed CKD (1.05%). Elevated mean homocysteine level was highly associated with developing CKD (HR 4.85, 95% CI 2.48-9.49, p<0.001). In a multivariate analysis which adjusted for age, baseline kidney function, HDL cholesterol, BMI, vitamin B12 and folic acid levels, these relationships remained substantially unchanged. CONCLUSIONS Elevated mean serum homocysteine level is associated with an accelerated decline in renal function in both men and women, and is an independent risk factor for the development of CKD in the general population. Further prospective randomized clinical trials are needed to clarify whether the reduction in serum homocysteine concentrations will result in an improved renal prognosis.

Reduction of serum theophylline levels by terbutaline in children with asthma

We studied the effect of oral terbutaline on serum theophylline levels in 12 children with asthma. Sustained‐release theophylline (10 mg/kg twice a day) was given with placebo or terbutaline (0.075 mg/ kg three times a day) in a chronic, randomized, double‐blind, crossover design. The trough serum theophylline concentration fell from 13.8 ± 4.0 to 10.8 ± 3.6 μg/ml and the peak expiratory flow rate increased from 285 ± 30 to 310 ± 29 L/min after terbutaline. Further investigation is needed to clarify the mechanism of action by which terbutaline decreases serum theophylline levels.

Underuse of Standard Care and Outcome of Patients with Acute Myocardial Infarction and Chronic Renal Insufficiency

Objectives: To investigate characteristics, management and outcome of patients with acute myocardial infarction (AMI) and chronic renal insufficiency (CRI). Background: Patients with AMI and CRI are considered to be at high risk of complications and death. Physicians may be reluctant to prescribe life-saving medications to patients with concomitant CRI. Methods: We compared clinical characteristics, management and outcome of 1,683 consecutive AMI patients in three categories of renal function: (1) normal renal function (<1.5 mg/dl) (n = 1,559), (2) mild to moderate CRI (1.5– 3.5 mg/dl) (n = 77), and (3) severe CRI (>3.5 mg/dl) (n = 47). Results: CRI patients were older and were more likely to have other co-morbidities such as hypertension, diabetes mellitus, prior AMI, stroke, angina and heart failure. Compared with patients with normal renal function, standard therapy for AMI including thrombolysis, aspirin, angiotensin-converting-enzyme inhibitors, β-blockers and lipid lowering agents was underutilized in CRI patients and these patients were more likely to have in-hospital complications such as heart failure, atrial or ventricular fibrillation, cardiogenic shock, sepsis, worsening of renal function and death within 30 days [odds ratio (OR) = 3.3; 95% confidence interval (CI) = 2.0–4.8]. After adjustment for age and co-morbidities, the association between mild to moderate CRI and 30-days mortality declined, whereas severe CRI remained an independent determinant of mortality (OR = 4.8; 95% CI = 2.0–11.4). Adjustment for aspirin, angiotensin-converting-enzyme inhibitors and β-blocker therapy weakened the association between CRI and death within 30 days after AMI. Conclusions: CRI patients are more likely to experience serious complications and death early after AMI. Underutilization of standard care, particularly β-blocker therapy, contributes to increased mortality risk in these patients.