Acute Kidney Injury in Patients Undergoing Hip Fracture Surgery.

BACKGROUND: Hip fracture is common in elderly patients and is associated with high morbidity and mortality. Acute kidney injury (AKI) following hip fracture may have additional impact on clinical outcomes. OBJECTIVES: To investigate the incidence of AKI, the risk factors for its occurrence and impact on mortality, timing of surgery, and length of hospitalization (LOS) in patients undergoing hip fracture surgery. METHODS: We retrospectively examined the records of patients who underwent hip fracture surgery between 2013 and 2017. All patients had a baseline serum creatinine value and at least one later value. AKI was defined according to KDIGO guidelines. RESULTS: The study included 511 patients. Mean age was 72.6 years, 325 males (63.4%); 151 (29.5%) had baseline eGFR < 60 ml/min/1.73m2. Of these, 87 (17%) developed AKI. Older age, diabetes mellitus, hypertension, and chronic heart condition were significantly more common in patients who developed AKI. Patients with AKI had increased 30-day mortality (hazard ratio [HR] 3.96, 95% confidence interval [95%CI] 1.62-9.7, P = 0.003) and mortality at one year (HR 2.72, 95%CI 1.5-4.9, P = 0.002). AKI was associated with surgery delay > 48 hours (HR 2.241, 95%CI 1.206-4.165, P = 0.011). Mean LOS was 10.9 days and 8 days for patients with AKI and without, respectively, P < 0.0001. CONCLUSIONS: AKI is a common complication in patients with hip fracture and is associated with increased short- and long-term mortality, delayed surgery, and longer hospitalization. Interventions identifying and monitoring patients at risk may contribute to improve the outcomes.

Myocarditis following COVID-19 mRNA vaccination.

BACKGROUND: Clinical trials of the BNT162b2 vaccine, revealed efficacy and safety. We report six cases of myocarditis, which occurred shortly after BNT162b2 vaccination. METHODS: Patients were identified upon presentation to the emergency department with symptoms of chest pain/discomfort. In all study patients, we excluded past and current COVID-19. Routine clinical and laboratory investigations for common etiologies of myocarditis were performed. Laboratory tests also included troponin and C-reactive protein levels. The diagnosis of myocarditis was established after cardiac MRI. FINDINGS: Five patients presented after the second and one after the first dose of the vaccine. All patients were males with a median age of 23 years. Myocarditis was diagnosed in all patients, there was no evidence of COVID-19 infection. Laboratory assays excluded concomitant infection; autoimmune disorder was considered unlikely. All patients responded to the BNT162b2 vaccine. The clinical course was mild in all six patients. INTERPRETATION: Our report of myocarditis after BNT162b2 vaccination may be possibly considered as an adverse reaction following immunization. We believe our information should be interpreted with caution and further surveillance is warranted.

Waning Humoral Response 3 to 6 Months after Vaccination with the SARS-COV-2 BNT162b2 mRNA Vaccine in Dialysis Patients.

BACKGROUND AND OBJECTIVES: The short-term reported antibody response to SARS-COV-2 vaccination in dialysis patients is high, with a seroconversion response rate up to 97%. Data on the long-term durability of this response are scarce. Our objective was to characterize the long-term anti-spike antibody level in dialysis patients. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: In an observational study, we measured SARS-COV-2 anti-spike antibody levels in dialysis patients who completed 2 doses of the BNT162b2 mRNA SAR S-COV-2 vaccine at 1, 3 and 6 months after the second vaccine dose. We compared the response to dialysis patients who were infected with COVD-19 and to a control group of healthcare-employees. RESULTS: One hundred and forty-two dialysis patients who had been vaccinated (ages 64 ± 11.9 years, 61% male), 33 dialysis patients who had COVID-19 infection (ages 54 ± 14.3 years, 55% male) and 104 individuals in the control group (ages 50 ± 12.2 years, 44% male) were included. The response rate in the vaccinated dialysis patients was 94%, 78% and 73% at 1, 3 and 6 months after the second vaccine dose. In the COVID-19 infected dialysis group and in the control group, the response rate remained at 100% over 6 months. The percentage of change in antibody levels between one and 6 months was -66% in the vaccinated dialysis group, -28% in the control group (p < 0.001) and +48% in dialysis patients who had been infected with COVID-19 (p < 0.001). A non-responder status at 6 months was associated with a lower albumin level. No serious adverse events following vaccination were reported. In conclusion: the initially high response rate to the BNT162b2 vaccine in dialysis patients decreases rapidly. Our results indicate that an early booster (3rd) dose, at three months after the second dose, may be advised for this population to preserve the humoral immunity.

[THE ROLE OF COMPREHENSIVE CONSERVATIVE MANAGEMENT IN ELDERLY PATIENTS WITH END STAGE RENAL DISEASE].

INTRODUCTION: The number of dialysis patients is consistently growing and the dialysis population is aging. Of all age groups of dialysis patients, the higher prevalence rate is in the elderly group (aged 75 years and older). The elderly patients have a high rate of comorbidities. Chronic dialysis treatment is expected to prolong survival. Older age and comorbidities are among the most powerful prognostic factors for survival on chronic dialysis. Observational studies found that after adjustment for age and comorbidities, dialysis treatment does not confer survival advantage when compared to conservative management in elderly patients with multiple comorbidities. Comprehensive conservative management is targeted for those patients who are not expected to benefit from chronic dialysis. The focus is on patients' preferences, specifically regarding issues of quality of life, and not necessarily on prolonging survival. For this process, shared decision-making is the recommended strategy. The rate of patients who opt for conservative management varies between countries. There is no data from Israel in this regard, but it is assumed that the conservative option is underutilized. There are different reasons for the current situation, factors that: depend on the caregivers' side, are patient dependent, relate to the health care system and available services and some cultural aspects. Addressing these gaps may require further collection of data, construction of needed services for conservative management and education of the caregivers and the patients.

[Cost-effectiveness of angiotensin receptor blockers in patients with type 2 diabetes mellitus and nephropathy in Israel].

BACKGROUND: Besides its toll on human life, the steep rise in the rate of diabetes as the cause of end stage renal disease (ESRD), with the consequent increase in the need for renal replacement therapy has created a substantial economic burden on health care systems. Clinical trials have found angiotensin receptor blockers (ARBs) to be more beneficial than traditional antihypertensive therapy in patients with type 2 diabetic nephropathy (DN). However, in Israel, ARBs are not considered first-line therapy. OBJECTIVES: To determine the cost-effectiveness of ARB treatment for diabetic nephropathy in the Israeli health care system. METHODS: A Markov model was constructed wherein utility values were assigned to each consecutive health state of diabetic nephropathy. The transition probabilities from one state to another were derived from reported clinical trials. Quality-adjusted life years (QALYs) were calculated and sensitivity analysis was performed. For the economic evaluation, the researchers used data from the Israeli health system. RESULTS: Treatment with ARBs over a 3-year period yielded a higher QALY than conventional anti-hypertensive treatment (2.63 vs. 2.59) and a lower cost (NIS 36,678 vs. NIS 39,932). For a time horizon of 10 years, the cost difference increased to NIS 50,000, with a 20% reduction in the number of patients with ESRD. Sensitivity analysis revealed that these results were valid over a wide range of parameters. CONCLUSIONS: The use of ARBs to delay ESRD appears to be cost-effective. We recommend that ARBs be considered in Israel as first-line treatment for patients with type 2 diabetic nephropathy.

Comparison of specific expiratory, inspiratory, and combined muscle training programs in COPD.

BACKGROUND: Respiratory muscle weakness may contribute to dyspnea and exercise limitation in patients with significant COPD. In an attempt to reduce the severity of breathlessness and to improve exercise tolerance, inspiratory muscle training has been applied in many COPD patients. On the other hand, there is a paucity of data related to expiratory muscle performance and training in COPD. METHODS: Thirty-two patients with significant COPD (ie, mean FEV(1), 37% of predicted) were recruited for the study. The patients were randomized into four groups: eight patients were assigned to receive specific expiratory muscle training (SEMT); eight patients received specific inspiratory muscle training (SIMT); eight patients received SEMT and SIMT (ie, the SEMT + SIMT group); and eight patients who were assigned to a control group received training with very low load. All patients trained daily, six times a week, with each session consisting of one half hour of training, for 3 months. Spirometry, respiratory muscle strength and endurance, 6-min walk test distance, the perception of dyspnea, and the Mahler baseline dyspnea index (BDI) were measured before and following training. RESULTS: Training caused a statistically significant specific increase in the expiratory muscle strength and endurance (in the SEMT and SEMT + SIMT groups) and in the inspiratory muscle strength and endurance (in the SIMT and SEMT + SIMT groups). There was significant increase in the distance walked in 6 min in the SEMT, SIMT, and SEMT + SIMT groups. However, the increase in the SIMT and SEMT + SIMT groups was significantly greater than that in the SEMT group. There was a statistically significant increase in the BDI, and a decrease in the mean Borg score during breathing against resistance in the SIMT and SEMT + SIMT groups, with no changes in the SEMT and control groups. CONCLUSIONS: The inspiratory and expiratory muscles can be specifically trained with improvement of both muscle strength and endurance. The improvement in the inspiratory muscle performance is associated with an increase in the 6-min walk test distance and the sensation of dyspnea. There is no additional benefit gained by combining SIMT with SEMT, compared to using SIMT alone.

The perception of dyspnea after bronchoconstriction and bronchodilation in patients with asthma.

BACKGROUND: It is well documented that the perception of dyspnea (POD), subjectively reported by patients, is an important index used to guide treatment. The severity of dyspnea following methacholine-induced bronchoconstriction and added mechanical loads is increasing in popular. No formal attention has been addressed to the reduction in dyspnea following bronchodilators. STUDY OBJECTIVE: To investigate if the magnitude of dyspnea perceived by a subject is independent on the direction (e.g., bronchoconstriction or bronchodilation) of the change in airway resistance. METHODS: The POD was measured in 26 mild moderate asthmatic patients following bronchodilation, using beta2-agonists, and following bronchoconstriction, induced by methacholine challenge, to almost the same magnitude. RESULTS: The increase in forced expiratory volume in 1 s (FEV1), 30 min after the inhalation of beta2-agonist (mean +/- SEM 22.3 +/- 0.8%), was associated with a statistically significant decrease (P < 0.005) in the POD. The mean decrease in FEV1 following methacoline challenge, was 23 +/- 0.7% and was followed by a statistically significant increase (P < 0.005) in the POD. The magnitude of the decrease in the POD following albuterol was almost identical to the magnitude of the increase in the POD following methacholine. CONCLUSIONS: In stable mild-moderate asthmatic patients, the changes in the magnitude of dyspnea, perceived by a subject, is independent on the direction of the change in the FEV1.

Specific expiratory muscle training in COPD.

BACKGROUND: There are several reports showing that expiratory muscle strength and endurance can be impaired in patients with COPD. This muscle weakness may have clinically relevant implications. Expiratory muscle training tended to improve cough and to reduce the sensation of respiratory effort during exercise in patients other than those with COPD. METHODS: Twenty-six patients with COPD (FEV(1) 38% predicted) were recruited for the study. The patients were randomized into two groups: group 1, 13 patients were assigned to receive specific expiratory muscle training (SEMT) daily, six times a week, each session consisting of 1/2 h of training, for 3 months; and group 2, 13 patients were assigned to be a control group and received training with very low load. Spirometry, respiratory muscle strength and endurance, 6-min walk test, Mahler baseline dyspnea index (before), and the transitional dyspnea index (after) were measured before and after training. RESULTS: The training-induced changes were significantly greater in the SEMT group than in the control group for the following variables: expiratory muscle strength (from 86 +/- 4.1 to 104 +/- 4.9 cm H(2)O, p < 0.005; mean difference from the control group, 24%; 95% confidence interval, 18 to 32%), expiratory muscle endurance (from 57 +/- 2.9% to 76 +/- 4.0%, p < 0.001; mean difference from the control group, 29%; 95% confidence interval, 21 to 39%), and in the distance walked in 6 min (from 262 +/- 38 to 312 +/- 47 m, p < 0.05; mean difference from the control group, 14%; 95% confidence interval, 9 to 20%). There was also a small but not significant increase (from 5.1 +/- 0.9 to 5.6 +/- 0.7, p = 0.14) in the dyspnea index. CONCLUSIONS: The expiratory muscles can be specifically trained with improvement of both strength and endurance in patients with COPD. This improvement is associated with increase in exercise performance and no significant change in the sensation of dyspnea in daily activities.

[The effect of time on the perception of dyspnea following inhaled long-acting bronchodilator].

STUDY OBJECTIVES: To assess the effect of time on the change in the perception of dyspnea (POD) following inhalation of long-acting bronchodilator. PATIENTS AND METHODS: Spirometry and the POD were measured in 32 asthmatic patients, with moderate asthma, before and following inhalation of placebo, and salmeterol. The POD was measured while breathing against progressive loads, using a visual analogue scale (VAS). RESULTS: The highest FEV1 levels and the lowest POD were measured one hour after salmeterol inhalation. Although the mean FEV1 remained close to its peak value for at least six hours following the inhalation of salmeterol, there was a gradual statistically significant increase in the POD. CONCLUSIONS: Following inhalation of long-acting bronchodilator (LABD) there is relationship between the increase in the FEV1 and the decrease in POD. With time there is a gradual increase in the perception of dyspnea regardless of the FEV1.

[The relation between the perception of dyspnea and beta 2-agonists consumption in patients with mild-moderate asthma].

It is well documented that, in patients with asthma, there is a considerable variation in the severity of breathlessness for any particular degree of airflow obstruction. The factors underlying this variability are still to be explored. The consumption of beta 2-agonists and the perception of dyspnea were assessed in eighty asthmatic patients, with mild-moderate asthma, attending the asthma clinic. The perception of dyspnea was compared to sixty normal subjects. All patients received treatment with inhaled corticosteroid and beta 2-agonists as needed. Nine patients were excluded from the study, hence the data reported relates to 71 patients. In 55% of the patients the mean score of the perception of dyspnea during breathing against resistance was normal, it was low in 20 (28%) and high in the remaining 12 (17%). There was no correlation between the FEV1 and the perception of dyspnea. The mean +/- SEM beta 2-agonists consumption was 2.9 +/- 0.4 puffs/day (range 0-7.2). There was a statistically significant difference in beta 2-agonists consumption between the mid asthmatic and the moderate asthmatic groups (p < 0.01). In both groups the mean beta 2-agonists consumption was significantly higher in the high preception of dyspnea group than in the normal (p < 0.05) and the low (p < 0.01) perception of dyspnea groups. We conclude that about half of mild-moderate asthmatic patients have normal perception of dyspnea while the other half have either high or low perception of dyspnea. More obstructed patients have higher beta 2-agonists consumption. However, in every degree of severity there is a close relation between the perception of dyspnea and the beta 2-agonists consumption.

The relationship among inspiratory muscle strength, the perception of dyspnea and inhaled beta2-agonist use in patients with asthma.

BACKGROUND: It is well documented that the perception of dyspnea (POD), subjectively reported by patients, is related to the activity and strength of the inspiratory muscles, and influences the use of 'as needed' beta2-agonists. STUDY OBJECTIVE: To investigate the relationship among the increase in inspiratory muscle strength after specific inspiratory muscle training, beta2-agonist consumption and the POD in patients with persistent, mild to moderate asthma. METHODS: Inspiratory muscle strength, daily beta2-agonist consumption and the POD were measured in 30 patients with mild to moderate asthma. Patients were then randomly assigned to two groups: one group received specific inspiratory muscle training until an increase of more than 20 cm H2O was reached, and one group was a control group and received sham training. Inspiratory muscle strength, the POD and daily beta2-agonist consumption were assessed during and after the training period. RESULTS: There was no good correlation between the baseline maximal inspiratory pressure and the POD, or between the baseline maximal inspiratory pressure and the mean daily beta2-agonist consumption. However, there was a significant correlation between the POD and the mean daily beta2-agonist consumption. The increase in inspiratory muscle strength after the inspiratory muscle training was closely correlated with the decrease in the POD (P<0.001) and the decrease in beta2-agonist consumption (P<0.001). CONCLUSIONS: The present study shows that, in patients with mild to moderate, persistent asthma, there is a correlation between the POD and the mean daily beta2-agonist consumption. When the inspiratory muscles are strengthened, there is a significant decrease in the POD and in beta2-agonist consumption.

C-reactive protein as a marker for active coronary artery disease in patients with chest pain in the emergency room.

BACKGROUND: Markers of inflammation, such as C-reactive protein (CRP), were found to be related to risk for cardiovascular disease (CVD) events in patients with angina pectoris. In addition, recent studies have shown that, in the case of atherosclerosis, increased CRP concentration reflects the inflammatory condition of the vascular wall. HYPOTHESIS: The study was undertaken to determine whether CRP levels in individuals with chest pain attending the emergency room (ER) may be used as a marker of active CVD. METHODS: Serum CRP level was measured in 226 of 326 consecutive patients (128 men, 98 women; mean age 61.3 +/- 5.9 years; range 19-87 years) referred to the ER with chest pain. The decision whether to admit orrelease the subjects was determined without taking the CRP level into account. Follow-up was then performed for 1 year. RESULTS: Eighty-four patients were admitted to the hospital. Of these, 9 with acute coronary syndrome (ACS) had very high levels of CRP (25-40 mg/l), 35 had had an acute coronary event within the preceding 3 months, with levels of CRP 14-20 mg/l. Only eight patients with nonsignificant CVD had elevated CRP levels. Twenty-eight subjects who were released from the ER had elevated CRP levels (7-14 mg/l); 8 of these, in addition to 4 subjects with normal CRP levels, had a late coronary event. CONCLUSION: This study indicates that in patients referred to the ER with chest pain and no other indication for hospitalization, a normal level of CRP suggests safe release. Most hospitalized patients with normal CRP will not have acute coronary syndrome. Patients who will develop early coronary events have very high CRP levels. High serum CRP level, after excluding other inflammatory sources, was proven to be a sensitive diagnostic and prognostic marker for significant coronary disease.

[Fatal attack in patients with bronchial asthma].

What is most notable about asthma deaths is that they continue to occur despite increased understanding of the pathophysiology of asthma, more effective treatment and improvements in asthma education. Studies of fatal and near fatal asthma revealed two distinct groups of patients. The first is a "slow onset-late arrival" group (type I) in whom the final common pathway is a period of poor asthma control, increased use of bronchodilators, late arrival for care of the final attack and underutilization of glucocorticosteroids. This group of patients is characterized by the presence of eosinophilia in the airways. The second group (type II), includes only the minority of death cases. These patients have a sudden, unexpected and rapidly progressive attack. This group of patients is characterized by the presence of neutrophilia in the airways. Two cases of death due to asthma attach, one presenting type I patients and the second type II patients, are described.

Respiratory muscle performance and the Perception of dyspnea in Parkinson's disease.

BACKGROUND: Pulmonary and respiratory muscle function impairment are common in patients with Parkinson's disease (PD). However, dyspnea is not a frequent complaint among these patients, although it is well documented that the intensity of dyspnea is related to the activity and the strength of the respiratory muscles. PATIENTS AND METHODS: We studied pulmonary function, respiratory muscle strength and endurance and the perception of dyspnea (POD) in 20 patients with PD (stage II and III Hoehn and Yahr scale) before and after their first daily L-dopa dose. Respiratory muscle strength was assessed by measuring the maximal inspiratory and expiratory mouth pressures (PImax and PEmax), at residual volume (RV) and total lung capacity (TLC) respectively. The POD was measured while the subject breathed against progressive load and dyspnea was rated using a visual analog scale. RESULTS: Respiratory muscle strength and endurance were decreased and the POD was increased during the off medication period compared to normal subjects. There was a nonsignificant trend to an increase in Plmax, PEmax and endurance after L-dopa intake. The POD of PD patients decreased (p<0.05) following medication, although, it remained increased (p<0.01) as compared to the normal subjects. Even if patients had spirometry data showing a mild restrictive pattern, before medication, both forced vital capacity (FVC) and forced expiratory volume (FEV)1 remained almost identical after L-dopa intake. CONCLUSIONS: Patients with PD have higher POD, compared to normal subjects and this increased perception is attenuated when the patients are on dopaminergic medication. The change in the POD is not related to changes in respiratory muscle performance or pulmonary functions. A central effect or a correction of uncoordinated respiratory movements by L-dopa may contribute to the decrease in POD following L-dopa treatment.

The risk of hospitalization and near-fatal and fatal asthma in relation to the perception of dyspnea.

BACKGROUND: A life-threatening asthma attack is still of major concern. One of the main goals in treating patients with asthma is identification of the patients at risk of having these attacks. It has been shown that patients who have a near-fatal asthma attack have a blunted perception of dyspnea (POD). The purpose of this study is to measure the POD in patients with asthma, and to relate POD to life-threatening attacks within a 24-month follow-up period. METHODS: The POD was scored using the Borg scale during breathing against a progressive load at 1-min intervals, in order to achieve mouth pressure up to 30 cm H(2)O, in 113 consecutive asthmatic patients with stable asthma attending an outpatient clinic. All patients were invited to regular follow-up every 3 months for up to 24 months, and all hospitalizations and near-fatal and fatal asthma attacks were recorded. The prebronchodilator morning peak expiratory flow rate (PEFR), daily regular treatment, and beta(2)-agonist consumption were recorded in a diary card for the first 4 weeks. RESULTS: Seventeen patients (15%) had high POD compared to the normal subjects, 67 patients (59%) had POD within the normal range, and 29 patients (26%) had lower-than-normal POD. In the patients with low POD, there was a tendency for higher age, higher female/male ratio, and a longer duration of disease. The rate of severe asthma was higher in the low-POD group than in the normal-POD group, but did not differ from the rate in the high-POD group. The mean daily beta(2)-agonist consumption in the patients with low POD was significantly lower (p < 0.01) than in the patients with high POD, although the mean PEFR was lower in the low-POD group. During the 2 years of follow-up, the patients in the low-POD group had statistically significantly more emergency department (ED) visits, hospitalizations, near-fatal asthma attacks, and deaths compared to the normal-POD and high-POD groups. CONCLUSIONS: Approximately 26% of the referral subjects with asthma had low POD when compared to healthy matched subjects. Patients with low POD had statistically significantly more ED visits, hospitalizations, near-fatal asthma attacks, and deaths during the follow-up period. Reduced POD may predispose patients to a life-threatening attack.