Israel Medical Association Journal

Background: Pain, fatigue and functional disability are common key outcomes in most rheumatologic disorders. While many studies have assessed the outcomes of specific disease states, few have compared the outcomes of various rheumatic diseases.

Objectives: To assess how the intensity and rating of pain, fatigue and functional disability vary among groups of patients with various rheumatic disorders receiving standard care. 

Methods: In a cross-sectional study conducted in a hospital-based rheumatology unit, standard clinical and laboratory data were obtained and all patients filled out questionnaires on pain, fatigue and daily function. The analysis concentrated on visual analogue scales (VAS) using specific statistical methods.

Results: A total of 618 visits of 383 patients with inflammatory as well as non-inflammatory rheumatic disorders were analyzed. Fibromyalgia patients had significantly higher VAS scores compared to all other groups. On the other hand, patients with polymyalgia rheumatica demonstrated significantly lower VAS scores compared to all other groups of patients. Patients with psoriatic arthritis also demonstrated relatively low VAS scores. VAS scores were lower in patients with inflammatory disorders as compared to patients with non-inflammatory disorders.

Conclusions: Our results suggest a spectrum of outcome intensity in various rheumatic disorders receiving standard care, ranging from fibromyalgia patients who report distinctive severity to patients with inflammatory disorders who are doing relatively well as compared to patients with non-inflammatory disorders. The findings emphasize the need to explore the underlying mechanisms of pain and fatigue in patients with non-inflammatory rheumatic disorders. 

 

Objectives: To assess the nature of joint problems encountered in a geriatric inpatient population and evaluate the contribution of a rheumatologist.

Methods: We reviewed the rheumatology consultations that were conducted in a geriatric medical center over a 10 year period.

Results: A total of 474 consultations were held; most of these patients (86%) were hospitalized in the acute geriatric departments, 10% in the rehabilitation ward and 4% in the long-term care wards. Some patients were seen more than once. The rheumatologic joint problem was the main reason for hospitalization in 53% of these patients. Monoarthritis was the most frequent complaint (50%), followed by pauci-articular arthritis (two to five joints) in 30% of patients. Arthrocentesis, diagnostic and therapeutic, was performed in 225 patients, most of them on knee joints (81%). The most frequent diagnosis was osteoarthritis with acute exacerbation (28%), followed by gout (18%), pseudo-gout (9%) and rheumatoid arthritis (9%). In 86 cases (18%) the diagnosis was a non-specific rheumatologic problem: arthralgia, non-specific generalized pain, or fibromyalgia.

Conclusions: Prompt and appropriate evaluation, as well as arthrocentesis and treatment initiation, including local injections, were made possible by the presence of an in-house rheumatologist. 

Background: The QT interval reflects the total duration of ventricular myocardial repolarization. Its prolongation is associated with increased risk of polymorphic ventricular tachycardia, or torsade de pointes, which can be fatal.

Objectives: To assess the prevalence of both prolonged and short QT interval in patients admitted to an acute geriatric ward.

Methods: This retrospective study included the records over 6 months of all patients hospitalized in an acute geriatric ward. Excluded were patients with pacemaker, bundle branch block and slow or rapid atrial fibrillation. The standard 12 lead electrocardiogram of each patient was used for the QT interval evaluation.

Results: We screened the files of 422 patients. QTc prolongation based on the mean of 12 ECG leads was detected in 115 patients (27%). Based on lead L2 only, QTc was prolonged in 136 (32%). Associated factors with QT prolongation were congestive heart failure and use of hypnotics. Short QT was found in 30 patients (7.1%) in lead L2 and in 19 (4.5%) by the mean 12 leads. Short QT was related to a higher heart rate, chronic atrial fibrillation and schizophrenia.

Conclusions: Our study detected QT segment disturbances in a considerable number of elderly patients admitted acutely to hospital. Further studies should confirm these results and clinicians should consider a close QT interval follow-up in predisposed patients.
 

Background: Pulmonary tuberculosis continues to be a major cause of mortality, particularly in developing countries. Despite modern anti-TB[1] treatment, the elderly and immigrants from TB-endemic countries are at risk. Multidrug resistance has yet to be resolved..

Objectives: To determine the mortality rate and predictors of mortality among patients hospitalized with TB in Israel.

Methods: We evaluated the medical records of 461 patients with active pulmonary TB who were hospitalized in the department of respiratory care during the 5 year period 2000–2004. Data included demographic, clinical, laboratory and radiological findings, drug resistance as well as adverse reactions to anti-TB treatment.

Results:| Three main ethno-geographic groups were observed: 253 patients from the former USSR, 130 from Ethiopia, and 54 of Israeli origin (as well as 24 residents of other countries). Of the 461 patients 65 patients (13%) died in hospital. The factors that were best predictors of mortality were older age, ischemic heart disease, cachexia, prior corticosteroid treatment, hypoalbuminemia and pleural effusion (P < 0.005 for all). The ethno-geographic factor and the presence of multidrug-resistant bacteria had no significant effect on mortality in our study group.

Conclusions: The mortality rate in our study was relatively low, and there was no significant difference between the three ethno-geographic groups.

Objectives: To investigate the mechanisms of these effects.

Methods: The study group included 106 long-term care stable geriatric inpatients. Diet and drugs were kept stable. The study lasted 5 weeks; during the first 2 weeks 100 mg aspirin was administered once a day. Clinical and laboratory follow-up were performed at baseline and weekly for the next 3 weeks. The glomerular filtration rate was estimated by creatinine clearance measured in 24 hour urine and serum creatinine, and by the Cockcroft-Gault formula (C-G) equation. Uric acid clearance (Cu acid) was determined from serum concentrations and 24 hour excretion of uric acid. Patients with serum creatinine > 1.5 mg/dl were not included.

Results: After 2 weeks on low dose aspirin, measured creatinine and uric acid clearances decreased significantly compared with the initial values in 70% and 62% of the patients, respectively, with mean decreases of 19% and 17%, respectively (P < 0.001). Blood urea nitrogen increased by 17% while serum creatinine and uric acid concentrations increased by 4% (P < 0.05 for all). The C-G[1] values decreased by 3% (P < 0.05). After withdrawal of aspirin all parameters improved. However, 67% of the patients remained with some impairment in their measured Ccr[2], compared to baseline. Patients who reacted adversely to low dose aspirin had significantly better pre-study renal function (Ccr), lower hemoglobin and lower levels of serum albumin.

Conclusions: Short-term low dose aspirin affected renal tubular creatinine and uric acid transport in the elderly, which may result in a prolonged or permanent deterioration of the renal function. It is suggested that renal functions be monitored even with the use of low dose aspirin in elderly patients.

Backgound: Colchicine is widely used for treating gout and familial Mediterranean fever. However, studies in animal models have reported ill effects of colchicine on the central nervous system, including cognitive function.

Objectives: To evaluate the cognitive status of elderly FMF[1] patients on long-term colchicine treatment.

Methods: The study group consisted of 55 FMF patients aged 74 ± 5, attending an FMF outpatient clinic and receiving colchicine treatment for 25.1 ± 8.9 years. The Mini-Mental State Examination was used for cognitive evaluation. Patients' scores were compared with accepted age- and education-adjusted cutoff scores, population-based norms, and scores of a matched control group of 56 subjects.

Results: Individually, all colchicine-treated FMF patients scored well above the age- and education-corrected cutoff scores. Overall, there was a large difference, 5.0 ± 1.6, from the expected cutoff points, in favor of the study group scores (P < 0.001). The individual scores of the control group were also above the cutoff points, however with a lower but still statistically significant difference (3.71 ± 1.15 points, P < 0.001). Compared to population-based norms adjusted by age and education, the study group had significantly higher mean MMSE[2] scores (27.2 ± 2.2 vs. 25.5 ± 2.4, P < 0.001). The control group’s scores were also somewhat higher than expected, but not significantly so.

Conclusions: Our results do not support the view that prolonged colchicine treatment may be associated with cognitive impairment. On the contrary, it is possible that long-term colchicine treatment may even confer protection against cognitive decline in patients with FMF.

Objectives: To investigate the time relation between the insertion of a new NGT and formation of the biofilm.

Methods: We examined sequential samples on NGTs that were forcibly pulled out by the patients themselves during any of the 7 days after insertion. Scanning electron micrography and confocal laser scanning microscopy were used for biofilm detection.

Results: Biofilm was identified on 60% of the 35 samples of day 1 and on all the samples of the following days, by both microscopic methods.

Conclusions: Biofilms form within a single day on most NGTs inserted for the feeding of elderly patients with dysphagia. Further research should be devoted to prevention of biofilm formation on NGTs.

Objective: To reexamine the impact of prolonged nasogastric tube feeding on the oral microbiota and to explore the salivary flow and composition in elderly patients in long-term care.

Methods: We compared a group of elderly patients fed by nasogastric tube with a control group of elderly patients in long-term care who are fed orally. Bacteriologic studies were performed by culturing samples from the oropharynx. Saliva studies included quantitative and biochemical analysis of basal and stimulated salivary flow.

Results: Bacteriologic studies performed in 90 patients revealed a significantly higher prevalence of gram-negative bacteria in nasogastric tube-fed patients (73% vs. 13%, P < 0.001). It is emphasized that Pseudomonas aeruginosa and Klebsiella pneumoniae were commonly and exclusively isolated from the oral flora of the nasogastric tube-fed patients (P < 0.001, P < 0.05). In the saliva studies performed on 23 nasogastric tube-fed and 21 control patients, basal and stimulated salivary flow was not significantly different in the two groups, however the ratio of stimulated to basal flow was reduced in the nasogastric tube-fed group (P < 0.05). Significant differences were also found in the concentrations of sodium, amylase, phosphor and magnesium. Noteworthy was the concentration of uric acid, the main non-enzymatic antioxidant of saliva, which was significantly lower in nasogastric-tube fed patients (P < 0.002).

Conclusions: These findings suggest that prolonged nasogastric tube feeding is associated with pathologic colonization of the oropharynx and with alterations in the saliva that are related to the risk of aspiration pneumonia. Further research is called for, as well as a thorough revision of the existing oral cleansing procedures in these patients.