Pavel Rabinovich

Alleviating Constipation in the Elderly Improves Lower Urinary Tract Symptoms

Background: Constipation and lower urinary tract symptoms (LUTS) very frequently occur in the elderly, and several reports have suggested that dysfunction in either one of these systems may affect the other. Most studies correlating rectal and bladder dysfunction, however, have been carried out in children or young women. Objective: To examine the effect of alleviating constipation on LUTS in the elderly. Methods: Fifty-two patients aged 65–89 (mean 72 ± 13) years with chronic constipation and LUTS participated in this prospective cohort study. Before treatment of constipation was initiated and on their monthly visits, patients completed a questionnaire regarding their constipation pattern, urinary symptoms, sexual function and mood, and underwent urinalysis. Urinary tract anatomy and residual urine were evaluated by abdominal ultrasound at the commencement and completion of the study. Patients were followed up for 4 months. Results: Treatment of constipation increased the number of weekly defecations from 1.5 ± 0.9 to 4.7 ± 1.2 (p < 0.001). Patients spent less time on the toilet (25 ± 2.1 versus 63 ± 1.9 min, p < 0.0001). Fewer patients reported urgency (16 versus 34, p < 0.001), frequency (25 versus 47, p < 0.001) and burning sensation during urination (6 versus 17, p < 0.05). There was improvement in the scoring of urgency, frequency and burning sensation (from a baseline of 52 to 126, 131 and 95, respectively, p < 0.001). Urinary stream disturbances improved in 32 of the 52 patients (p < 0.001). Residual urine volume decreased from 85 ± 39.5 to 30 ± 22.56 ml (p < 0.001). There was also a significant decrease in the number of patients with bacteriurial events (5 versus 17, p < 0.001), and an improvement in sexual activity and mood (p < 0.05). Conclusions: Our data demonstrated that medical relief of constipation significantly improves LUTS in the elderly which, in turn, improves the patient’s mood, sexual activity and quality of life.

Transthoracic monitoring of the impedance of the right lung in patients with cardiogenic pulmonary edema.

Objective To evaluate the suitability of the new electrical impedance monitor RS-205 for monitoring of cardiogenic pulmonary edema (CPE). Design Prospective, controlled study. Setting A department of internal medicine in a 1,200-bed university-affiliated, teaching hospital. Patients Sixty patients, aged 52–80 yrs, 30 without CPE (controls) and 30 with or at high risk for CPE. Interventions Internal thoracic impedance (ITI) was monitored by the RS-205. The RS-205 is approximately three times more sensitive than the Kubicek monitor, and it eliminates the effect of the drift of skin-to-electrode impedance. This is achieved by eliminating skin electrode impedance by a special algorithm, thus allowing measurement of ITI rather than total transthoracic impedance. Measuring ITI, the main component of which is lung impedance, is a noninvasive and safe method. CPE was diagnosed in accordance with well-accepted clinical and roentgenological criteria. Measurements and Main Results The controls’ initial ITI was 68.3 ± 12.38 ohms. During 6 hrs of monitoring, the ITI attained a minimum average value of −1.3 ± 2.08% and a maximum average value of 4.6 ± 3.56% relative to baseline. In all patients entering CPE, ITI decreased by 14.4 ± 5.42% on the average (p < .001) 1 hr before the appearance of clinical symptoms. In patients with evolving CPE, ITI decreased significantly compared with controls (22.25 ± 9.82%, p < .001). In patients at the peak of pulmonary edema, ITI was 2.1 times lower than in the control group (33.1 ± 10.90 ohms, p < .001). In the last hour before the resolution of CPE, ITI increased in all patients by 17.7 ± 19.74% compared with the peak of disease (p < .05). After the resolution of pulmonary edema, ITI increased in all patients by 44.14 ± 26.90% compared with the peak of disease (p < .001). Importantly, the trend in ITI in all patients changed in accordance with the dynamics of CPE. A mixed general linear model shows that ITI values correlated well with the degree of crepitation, a direct characteristics of CPE. Conclusions The RS-205 is suitable for monitoring patients at high risk of CPE development. It enables detection of CPE and the monitoring of patients at all stages of CPE.

Seasonal Changes in Blood Pressure and Frequency of Related Complications in Elderly Israeli Patients with Essential Hypertension

Background: Earlier studies on hypertension demonstrated seasonal variations in different age groups. However, slightly greater fluctuations were found in the hypertensive elderly. Objective: We conducted a prospective 5-year study from January 1997 to December 2001 to evaluate the seasonal variation in blood pressure and the variables of age, gender, body mass index and related complications in elderly Israeli patients with essential hypertension. Methods: Blood pressure was measured in four seasons in 182 patients (98 men and 84 women; age range 65–91 years) treated for hypertension in our outpatient clinic. Results: Both systolic and diastolic mean blood pressures were higher during winter compared to summer (165 ± 11.6 and 90 ± 13.7 and 134 ± 47.3 and 74 ± 8.5 mm Hg, respectively; p < 0.001). There were no significant seasonal differences between spring and autumn or any correlation between the seasonal winter-summer difference in blood pressure and other studied parameters. Patients aged 65–75 years were unexpectedly more sensitive to winter-summer changes than older patients. There was a correlation between a large winter-summer difference in systolic blood pressure and a body mass index between 20 and 30, but there was none in lower or higher ranges. Supplementary antihypertension treatment was required during winter in 38% of these selected patients. Complications such as myocardial infarctions and strokes occurred twice as frequently in winter than in any other season (p < 0.0001). Conclusions: Both systolic and diastolic blood pressures were highest during winter. Hypertension complications were more frequent in winter. Our results refute those of earlier studies that failed to find significant seasonal variations in blood pressure among the elderly.

The association of bile acid excretion and atherosclerotic coronary artery disease.

Background: Excess cholesterol is usually eliminated from the body by conversion to bile acids excreted in feces as bile salts. The excretion of large amounts of bile protects against atherosclerosis, while diminished excretion may lead to coronary artery disease (CAD). Objective: To investigate a relationship between CAD and bile acid excretion. Methods: Bile acid excretion was compared between 36 patients with proven CAD and 37 CAD-free individuals (controls). The groups were comparable for demographics and selected risk factors. All subjects received a 4-day standard diet that included ∼500 mg of cholesterol. Fecal bile acids from 24-hour stool collections were measured by gas liquid chromatography. Results: CAD patients excreted lower amounts of total bile acids (358 ± 156 mg) than controls (617 ± 293 mg; p < 0.01) and less deoxycholic acid (188.29 ± 98.12 mg versus 325.96 ± 198.57 mg; p < 0.0001) and less lithocholic acid (115.43 ± 71.89 mg versus 197.27 ± 126.87 mg; p < 0.01). Advanced age, male gender, left ventricular ejection fraction and total bile acid levels were significant independent factors that predicted CAD (p < 0.05). Mortality, CAD and cerebrovascular accident development rates were significantly lower for the controls at the 13-year follow up. Conclusion: CAD patients have significantly decreased bile acid excretion levels than non-CAD patients. An impaired ability to excrete cholesterol may be an additional risk factor for CAD development.

The Role of Bile Acid Excretion in Atherosclerotic Coronary Artery Disease

The impact of cholesterol and different classes of lipoproteins on the development of coronary artery disease (CAD) has been investigated in extensively during the past 50 years. The cholesterol metabolism is dependent on numerous factors, including dietary fat, fractional absorption of dietary cholesterol, tissue stores of cholesterol, endogenous cholesterol synthesis, and fecal bile excretion. Several studies showed significantly lower amounts of bile acid secretion in adult patients with CAD compared to non-CAD patients. Could it be that the inability to efficiently excrete bile acids may lead to CAD development?

Streamlining Differential Diagnosis of Coronary Heart Disease in a Primary Care Clinic: Atypical and Typical Symptoms and Their Combinations

Background: We sought to identify the most predictive symptoms of coronary heart disease (CHD) in the setting of a very busy community primary care clinic. By examining the variability, distribution and frequency of symptoms sin- gly and in combination we hoped to streamline the process of correctly identifying a patient presenting with CHD. Meth- ods: All 449 patients suspected of having CHD by one primary physician (1995-2004) were evaluated by thallium scan, treadmill ergometry, and/or coronary angiography, as well as ECG and creatine phosphokinase /troponin levels. Group 1 included 216 subjects (117 males, 98 females, mean age 69.7±11.2 years) diagnosed as having acute coronary syndrome, stable angina pectoris or acute myocardial infarction. Group 2 included 233 (126 males, 108 females, mean age 65.2±12.1 years) subjects whose comprehensive evaluations ruled out CHD. Results: The leading symptom in Groups 1 and 2 was chest pain (80%) vs (80.3%) (NS). Dyspnea was present in 10% and 5%; (p<0.037) patients, and jaw pain in 11% and 1% (p<0.0001) patients. The symptom combinations found more frequently in Group 1 were chest pain+jaw pain (7% vs 1. 04%; p<0.0001) and dyspnea+sweating (2.8% vs 0%, p<0.01). Conclusion: Isolated symptoms (jaw pain, dyspnea) and combined symptoms (chest pain+jaw pain, dyspnea+sweating) were more specific for CHD than classical chest pain.