O. Amir, H. Paz, R. Ammar, N. Yaniv J.E. Schliamser and B.S. Lewis
Background: Serum natriuretic peptide levels are useful diagnostic and prognostic markers in patients with acute decompensated heart failure, but have been little used to stratify urgency of treatment in the outpatient situation.
Objectives: To examine the use of natriuretic peptide to guide priority of patient referral to a heart failure center.
Methods: We analyzed data from 70 consecutive patients with chronic heart failure (NYHA class 2-4) referred for first evaluation in a specialized outpatient heart failure center. Serum NT-proBNP[1] was measured at the initial patient visit. We examined correlates and predictive value of mid- and upper tertile NT-proBNP for mortality in comparison with other known prognostic indicators using univariate and multivariate logistic regression analysis.
Results: Mortality at 6 months was 26.0% in patients with upper tertile (> 1958 pg/ml) NT-proBNP, 8.7% in the middle tertile group and 0% in the lowest tertile (P = 0.017). Patients with upper tertile serum NT-proBNP levels (group 3) had lower left ventricular ejection fraction, were more often in atrial fibrillation (P = 0.04) and more often had renal failure (P = 0.03). Age-adjusted logistic regression analysis identified upper tertile serum NT-proBNP level as the strongest independent predictor of 6 month mortality with a sixfold risk of early death (adjusted odds ratio 6.08, 95% confidence interval 1.58–47.13, P = 0.04). NT-proBNP was a more powerful predictor of prognosis than ejection fraction and other traditional outcome markers.
Conclusions: In heart failure patients referred to an outpatient specialized heart failure center, an upper tertile NT-proBNP level identified patients at high risk for mortality. A single high > 550 pg/ml NT-proBNP measurement appears to be useful for selecting patients for care in a heart failure center, and a level > 2000 pg/ml for assigning patients to high priority management.
[1] NT-proBNP = - N-terminal pro-brain natriuretic peptide
D. Tanne, R. Tsabari, O. Chechk, A. Toledano, D. Orion, Y. Schwammenthal, T. Philips, E. Schammenthal and Y. Adler
Background: Regular physical activity is known to have a beneficial impact on multiple cardiovascular risk factors, but there is no routine provision of exercise training programs to patients after ischemic stroke.
Objectives: To assess the tolerability, safety and effect of an outpatient supervised exercise training program in patients after a non-disabling ischemic stroke.
Methods: Patients discharged home following a minor ischemic stroke (modified Rankin scale; mRS ≤ 2) were referred to a 3 month outpatient supervised exercise training program, performed twice weekly as prescribed by a physiologist and supervised by physical therapy. Exercise capacity was evaluated by the 6 minute walk test, and by the modified Bruce exercise test.
Results: Of the 52 patients who met the selection criteria, 43 underwent supervised exercise training within 2 months of stroke onset and 9 did not (control group). The baseline characteristics were comparable between the two groups. Following the exercise training program, an improvement in exercise capacity was observed manifested by improvement in the 6 minute walk test (444 ± 90 to 557 ± 99 meters in the exercise group vs. 438 ± 101 to 418 ± 126 in the control group; P = 0.002 for the score changes) and in the exercise duration achieved in the modified Bruce test and the metabolic equivalents achieved [9.6 ± 3.7 to 12.4 ± 3.2 minutes and 6.2 ± 2.8 to 8.5 ± 3.4 respectively in the exercise group (n=41) vs. 9.2 ± 3.5 to 8.0 ± 3.4 min and 5.8 ± 1.8 to 5.8 ± 2.8 in the control group (n=7); P = 0.0009 and 0.01 for score changes, respectively].
Conclusions: An outpatient supervised exercise training program after a minor ischemic stroke is feasible, well tolerated and is associated with improvement in exercise capacity. We strongly recommend that an aerobic exercise program be offered to suitable patients after an ischemic stroke.
F. Salameh, N. Cassuto and A. Oliven
Background: Falls are a common problem among hospitalized patients, having a significant impact on quality of life and resource utilization.
Objectives: To develop and validate a fall-risk assessment tool for patients hospitalized in the department of medicine that will combine simplicity with adequate accuracy for routine use.
Methods: This observational cohort study was conducted on the medical wards of an urban tertiary teaching hospital, and included all patients who fell in the medical wards during a 1 year period (n=140) compared to other hospitalized patients.
Results: Significant correlates of falls were previous falls, impairing medical conditions, impaired mobility, and altered mental state. In multivariate logistic regression analyses, only previous falls (odds ratio 3.8 with 95% confidence interval 2.65–5.45, P < 0.0001) and acute impairing medical conditions (OR 1.56, CI 1.06–2.29, P < 0.05) correlated independently with a higher risk for falls. Impaired mobility retained an OR of 1.46 (CI 0.95–2.24, P = 0.084). Accordingly, defining patients with either a history of previous falls or both acute impairing medical state and impaired mobility as fall-prone patients provided a sensitivity and specificity of 67% and 63%, respectively. In a subsequent prospective validation trial on 88 patients who fell during hospitalization and 436 controls, the sensitivity and specificity of this fall-risk grouping were 64% and 68% respectively.
Conclusions: Our new simple and easy-to-use fall-risk assessment tool identified most of the fall-prone patients. These findings suggest that using this tool may enable us to prevent two-thirds of falls on the medical ward by providing effective fall-prevention facilities to only one-third of the patients.
B. Kessel, K. Peleg, Y. Hershekovitz, T. Khashan, A. Givon, I. Ashkenazi and R. Alfici
Background: Non-operative management following abdominal stab wounds is possible in selected patients who are both hemodynamically stable and do not have signs of peritonitis. However, the rate of failure of non-operative management is higher in Israel than in western countries.
Objectives: To assess the patterns of injury following abdominal stabbing.
Methods: Data from the Israeli Trauma Registry were used to identify all patients with abdominal stab injury admitted to eight different trauma centers between 1997 and 2004.
Results: The number of patients admitted per year more than doubled between 1997 and 2004, from 257 to 599. The percentage of patients with severe injury (Index Severity Score ≥ 16) increased from 9.4% to 19.0%. The incidence of multiple stab injuries almost doubled, from 37% to 62%.
Conclusions: Review of the data in the Israeli Trauma Registry indicates an increase in both absolute rate and relative incidence of serious stab injuries. This indicates that patterns of injury following stab wounds are not necessarily similar, not even within the same geographical area over time.
I. Amirav and A. Zacharasiewicz
Management of asthma is currently based on symptoms (in children, usually a second-hand report from parents) and lung function measurements. Inhaled steroids, targeted at controlling airway inflammation, are the mainstay of asthma management. Due to possible side effects they should be used at the lowest possible doses while asthma is adequately controlled. Fractional exhaled nitric oxide is a simple non-invasive method to assess inflammation in asthma and its role in asthma management is increasing in popularity. The present review summarizes recent research on the use of FeNO in monitoring airway inflammation and optimizing asthma management. The addition of FeNO measurements to the conventional assessment of asthma control appears promising. The practicability of including this measuring method into everyday clinical practice is currently being evaluated.
G. Harel, E. Georgeta and Y. Copperman