Medical cannabis treatment for chronic pain: Outcomes and prediction of response.

BACKGROUND: Although studied in a few randomized controlled trials, the efficacy of medical cannabis (MC) for chronic pain remains controversial. Using an alternative approach, this multicentre, questionnaire-based prospective cohort was aimed to assess the long-term effects of MC on chronic pain of various aetiologies and to identify predictors for MC treatment success. METHODS: Patients with chronic pain, licensed to use MC in Israel, reported weekly average pain intensity (primary outcome) and related symptoms before and at 1, 3, 6, 9 and 12 months following MC treatment initiation. A general linear model was used to assess outcomes and identify predictors for treatment success (≥30% reduction in pain intensity). RESULTS: A total of 1,045 patients completed the baseline questionnaires and initiated MC treatment, and 551 completed the 12-month follow-up. At 1 year, average pain intensity declined from baseline by 20% [-1.97 points (95%CI = -2.13 to -1.81; p < 0.001)]. All other parameters improved by 10%-30% (p < 0.001). A significant decrease of 42% [reduction of 27 mg; (95%CI = -34.89 to 18.56, p < 0.001)] from baseline in morphine equivalent daily dosage of opioids was also observed. Reported adverse effects were common but mostly non-serious. Presence of normal to long sleep duration, lower body mass index and lower depression score predicted relatively higher treatment success, whereas presence of neuropathic pain predicted the opposite. CONCLUSIONS: This prospective study provides further evidence for the effects of MC on chronic pain and related symptoms, demonstrating an overall mild-to-modest long-term improvement of the tested measures and identifying possible predictors for treatment success.

The impact of concomitant fibromyalgia on visual analogue scales of pain, fatigue and function in patients with various rheumatic disorders.

OBJECTIVES: To evaluate the impact of concomitant fibromyalgia on the rating of pain, fatigue, and dysfunction, in patients with various rheumatic disorders. METHODS: A cross-sectional study was carried out in a hospital-based rheumatology unit. Standard clinical and laboratory data were obtained and all patients completed questionnaires on pain, fatigue, and daily function. The rate of concomitant fibromyalgia was estimated using the 1990 American College of Rheumatology (ACR) classification criteria for fibromyalgia and the analysis concentrated on visual analogue scales (VAS). RESULTS: Six hundred and eighteen visits of 383 patients with inflammatory as well as non-inflammatory rheumatic disorders were analyzed. Concomitant fibromyalgia was noted in 74 patients (23% of the cohort). Patients with rheumatic diseases and concomitant fibromyalgia had significantly higher mean VAS scores for pain, fatigue, and function (79±17, 81±18, 80±18, respectively) as compared to patients who had no features of fibromyalgia (47±28, 50±29, 44±30 respectively; all p values <0.001). The scores reported by patients with rheumatic diseases and concomitant fibromyalgia were similar to the scores obtained from patients with primary FM. CONCLUSIONS: Concomitant FM is common both among patients with inflammatory and patients with non inflammatory rheumatic disorders. Concomitant FM has a remarkable impact on the severity of symptoms and, moreover, patients with concomitant FM exhibit extreme and significantly distinct levels of pain and fatigue which is as severe as that reported by patients with primary FM. It seems that fibromyalgic features dominate and become the main cause of morbidity in rheumatological patients with concomitant FM.

Visual Analogue Scales of Pain, Fatigue and Function in Patients with Various Rheumatic Disorders Receiving Standard Care.

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.

On-spot rheumatology consultations in a multilevel geriatric hospital.

BACKGROUND: Musculoskeletal and joint disorders are extremely common in the elderly. They directly affect mobility, gait stability, quality of life, and independence. 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 consultation records 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. A rheumatologic joint problem was the main reason for hospitalization in 53% of these patients. Monoarthritis was the most frequent complaint (50%), followed by pauciarticular arthritis (two to five joints) in 30% of patients. Arthrocentesis, diagnostic and therapeutic, was performed in 225 patients, most of them in 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, nonspecific 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.

Evaluation of an intra-institutional diabetes disease management program for the glycemic control of elderly long-term care diabetic patients.

AIM: Increasing numbers of nursing home elderly patients suffer from diabetes requiring individually optimized glycemic control. This is a complicated challenge because of their high comorbidity level, and heterogeneous and changing eating status varying from independent to dysphagia and enteral feeding. In order to cope with these complex needs, we developed and implemented a diabetes disease management program. The purpose of the present study was to evaluate this program. METHODS: We used the point prevalence approach by checking for fasting blood glucose, glycated hemoglobin and other routine biochemical tests. Eating status was evaluated by the Functional Outcome Swallowing Scale. Details about the diabetes disease management program are given in the text. RESULTS: A total of 86 (36%) of the 234 patients on the study day were diabetics. Of these, 80 were eligible for the study. Their mean fasting blood glucose was 143.1 ± 60.6 mg/dL. The mean glycated hemoglobin level was 7.23 ± 1.39%. CONCLUSION: No case of hypoglycemia was detected on the examination day, or during the preceding 3 weeks. No significant difference was found among the different Functional Outcome Swallowing Scale categories. These results are within satisfactory range for this category of patients suggesting that our diabetes disease management program contributes to a better glycemic control.

The impact of refeeding on blood fatty acids and amino acid profiles in elderly patients: a metabolomic analysis.

BACKGROUND: Refeeding of elderly frail patients after food deprivation is commonly associated with a high mortality rate. OBJECTIVE: To evaluate the effect of refeeding on metabolite fluctuation of blood carnitine fatty acids (15 compounds) and free amino acids (14 compounds). METHODS: Metabolite fluctuation was followed up in an exploratory, cohort, and noninterventional study in elderly and frail patients (84.5 ± 5 years) after a long period of food deprivation. Patients in the study group were refed by enteral nutrition (EN) and were followed up during 7 days for blood metabolites (n = 27). Patients in the control group (n = 26) had been fed by EN for more than 3 months. Refeeding was initiated with 10 kcal/kg/d and gradual increases of 200 kcal/d for 3 days afterwards. Blood metabolites were assayed in a sample of 25 µL. RESULTS: On food deprivation, the concentrations of all even monocarboxylic carnitine fatty acids were much higher in the study group than in the EN control group (P < .01). Upon refeeding, a remarkable decrease in all carnitine fatty acids was observed. In addition, significant daily fluctuations were observed for most metabolites in the study group of the refed patients as compared with the EN control group (P < .01). The highest fluctuations were observed following refeeding in the 7 patients who later died. CONCLUSION: A significant metabolic instability is observed on refeeding even with a slow refeeding schedule of 10 kcal/kg/d. Measurement of metabolomics parameters may be used for the evaluation of malnutrition, refeeding status, and optimization of the enteral formula.

The effect of anti-tuberculosis treatment on levels of anti-phospholipid and anti-neutrophil cytoplasmatic antibodies in patients with active tuberculosis.

The aim of this study is to determine the prevalence and effect of anti-tuberculosis treatment on anti-phospholipid antibodies and anti-neutrophil cytoplasmatic antibodies (ANCA) in patients with active mycobacterial infections. Thirty-three consecutive patients (age 56 years, 26 males) with recently diagnosed active tuberculosis (TB) were enrolled. Data included clinical disease features, symptom duration, multidrug resistance and presence of HIV. Serum samples taken before and after TB treatment were frozen at -20 °C and tested for anti-cardiolipin IgG (aCL), anti-ß2 glycoprotein IgG (anti-ß2GPI), anti-prothrombin, anti-proteinase 3 (PR3), myeloperoxidase (MPO), bactericidal/permeability (BPI) and lactoferrin. Thirty percent of patients had higher than cut-off value for anti-ß2GPI, and 9 % had increased aCL. The levels of antibodies against ß2GPI and aCL normalized post-treatment. A substantial proportion of patients had high baseline anti-PR3, MPO, BPI and lactoferrin levels. Most anti-lactoferrin and anti-MPO levels decreased post-treatment, while anti-PR3 increased in most of the baseline-positive patients. Some patients had de novo anti-PR3 and MPO formation after 6-month treatment. Patients with active TB have significantly increased anti-ß2GPI and ANCA titers. While anti-ß2GPI titers normalize post-treatment, ANCA behave in a complex way. Anti-TB treatment may induce normalization of anti-lactoferrin and anti-MPO, and de novo anti-PR3 and MPO formation.

QT interval disturbances in elderly residents of long-term care facilities.

BACKGROUND: The QT interval reflects the total duration of ventricular myocardial repolarization. Disturbed QT--either prolonged or shortened--is associated with arrhythmia and is life-threatening. OBJECTIVES: To investigate an elderly population for disturbed QT interval. METHODS: We conducted a cross-sectional study on residents of long-term care wards in a geriatric hospital. Excluded were those with pacemaker, atrial fibrillation or bundle branch block. The standard 12 lead and lead 2 electrocardiograms in the patients' files were used for the evaluation of QT interval. RESULTS: We screened the ECGs of 178 residents. QTc prolongation based on the mean 12 ECG leads was detected in 48 (28%), while 45 (25%) had prolonged QTc based on lead L2. Factors associated with QT prolongation were male gender, chronic renal failure and diabetes mellitus. Short QT was found in 7 residents (4%) and was not related to any parameter. CONCLUSIONS: About one-third of the elderly long-term care residents in our study had QT disturbances. Such a considerable number warrants close QT interval follow-up in predisposed patients.

Bacteremia in a multilevel geriatric hospital.

BACKGROUND: Bloodstream infection (BSI) is a major cause of morbidity and mortality in hospitals. Bacteremia in the elderly remains a diagnostic as well as a therapeutic challenge to the clinician. METHODS: We investigate the clinical features, microbiological characteristics, and outcome of bacteremic episodes in a mixed LTC elderly population in a multilevel geriatric hospital. Data of patients with the diagnosis of BSI (during 2 years) was collected retrospectively from the records of the bacteriology laboratory of a 400-bed multilevel geriatric hospital. RESULTS: During the 2 years of the study period, 3453 blood cultures have been performed; 368 positive blood cultures (10%) were detected in 309 patients. The total mortality rate at 2 weeks was 42%. One quarter of the deaths occurred in the first 3 days of the septic event (rapidly fatal period). Escherichia coli was the most common isolate (detected in 31% of cases). The second most common isolates were Staphylococcus aureus (19%; 63% of them MRSA) with a mortality of 39% and Proteus mirabilis (18%) with a 51% mortality rate. Urinary tract infection was the leading cause (70%), followed by decubitus ulcers (25%) and respiratory tract infections (12%). CONCLUSIONS: the number of elderly skilled patients with severe and complex conditions in LTC facilities is increasing and more infections complicated by bacteremia are expected, requiring high clinical suspicion, close surveillance, and adequate reporting.

Community physicians' knowledge on basic health care for elderly persons in Israel: comparing findings from 2006 to 1996.

Community physicians should be knowledgeable of basic geriatrics to cope with the challenges posed by the growing number of older patients and their complex needs. A survey of knowledge in basic health care for elderly persons, carried out by our team in 1996, revealed that it was insufficient. The authors repeated this survey in 2006, by using the same methodology, namely, a mailed questionnaire sent to 500 randomly sampled community physicians. No significant changes were found after this 10-year period. Likewise, no difference was evidenced between physicians that participated in geriatric training of any kind and those who did not. This lack of change requires health system leaders to coordinate their efforts and develop efficient teaching programs to prevent similar findings 10 years from now.

Phenytoin blood concentrations in hospitalized geriatric patients: oral versus nasogastric feeding tube administration.

Many medications administered to frail geriatric patients are not in a liquid form, but are crushed and dissolved in water before their administration through a nasogastric tube (NGT). Some medications are enteric coated and others are extended release. Only sparse information is available on their pharmacokinetics when administered through NGT. The aim of our study was to evaluate the pharmacokinetics of phenytoin administered through an NGT and to compare these with the pharmacokinetics of a group of patients receiving the drug orally. Twenty patients were studied in a stable clinical condition, from the long-term care ward of the Geriatric Medical Center Shmuel Harofeh. They were consistently treated with phenytoin for the prevention of seizure disorders. Patients in group 1 (n = 12) had oropharyngeal dysphagia and received feeding and medications by NGT. Group 2 (n = 8), included age-matched orally fed patients from the same department, who received phenytoin orally. Blood samples for phenytoin concentration were taken at baseline, time 0, and at 1, 3, 4, 6, and 8 hours postdrug administration; phenytoin was measured using the AxSYM assay. The mean daily dose was not statistically different between the 2 groups: 291 +/- 28 (200-300) mg/d and 300 +/- 53 (200-400) mg/d, in the NGT, and the orally fed group, respectively, in one dose. Pharmacokinetic parameters of phenytoin were not significantly different between the 2 groups; trough concentrations, 1.9 +/- 1.7 (0.5-4.9) versus 2.2 +/- 1.8 (1.0-6.5) microg/mL; Cmax, 6.6 +/- 3.4 (2.5-9.1) versus 7.3 +/- 6.7 (2.7-8.4) microg/mL; tmax, 5.1 +/- 3.1 (3.1-8.2) versus 4.6 +/- 2.7 (2.3-8.4) hours; area under the curve, 52.2 +/- 40.1 (41.1-61.2) versus 62.3 +/- 84.7 (30.2-77.2) microg/h/mL, in the NGT fed versus the oral fed, respectively. Phenytoin pharmacokinetic parameters are not significantly different between patients receiving the drug through NGT as compared with those who received it orally, but the implication of the low concentrations measured should be evaluated carefully.

The anti-cyclic citrullinated peptide response in tuberculosis patients is not citrulline-dependent and sensitive to treatment.

INTRODUCTION: Patients with tuberculosis (TB) frequently produce anti-citrullinated protein antibodies (ACPA). The objective of this study is to characterize the citrulline-dependence of the ACPA reactivity in sera of patients with mycobacterium infections. METHODS: Serum samples of 134 patients with untreated mycobacterium infections (122 TB, 12 nontuberculous mycobacterium) were tested for antibodies against both the citrullinated (Cit) and the non-citrullinated (Arg) form of 2 cyclic synthetic peptides. In 33 patients, a follow-up sample was tested six months after starting anti-mycobacterial drugs. RESULTS: A substantial proportion of patients with mycobacterial infections demonstrated antibodies against 0401Cit, 0401Arg, 0722Cit and 0722Arg. Fourteen patients demonstrated anti-0401Cit, 83 anti-0401Arg, 22 anti-0722Cit and 61 anti-0722Arg, while none of these antibodies were detected in the 20 healthy controls. All the patients but one, who were anti-0401Cit and anti-0722Cit positive, demonstrated reactivity against the respective Arg peptide. In the subset of 33 patients with a follow-up test six months after starting treatment, the mean levels of antibodies to 0401Cit, 0401Arg, 0722Cit and 0722Arg significantly decreased after treatment. All the patients who were anti-0401Cit and anti-0722Cit positive turned negative after treatment. The presence of anti-0401Cit/Arg and anti-0722Cit/Arg was found to be significantly correlated with the presence of HIV. CONCLUSIONS: ACPA may be found in patients with TB. In most of the cases, the reactivity is citrulline independent. A positive cyclic citrullinated peptide (CCP) test in these patients should therefore be interpreted with care, and preferably followed by a control ELISA with a non-citrullinated antigen.

Serum trace elements in elderly frail patients with oropharyngeal dysphagia.

Microelements have an important role in many vital enzymatic functions. Their optimal intake and serum concentration are not properly defined. For nursing home residents, this issue is further complicated by the high prevalence of oropharyngeal dysphagia. The purpose of this study was to measure microelement concentrations in 3 groups of elderly subjects that differ in their feeding methods and functional state. Forty-six frail elderly patients, in stable clinical condition, 15 on naso-gastric tube (NGT) feeding, 15 orally fed (OF), from skilled nursing departments were recruited to this study. As controls, we studied a group of 16 elderly independent ambulatory patients. A battery of 16 microelements was examined using the Inductively Coupled Plasma Atomic Emission Spectrometry (ICP-AES) and Inductively Coupled Plasma Mass Spectrometry (ICP-MS). The OF frail elderly patients had significantly lower levels of chromium as compared to the NGT fed and the control group. Both frail elderly groups had lower levels of zinc and copper as compared to the controls. In contrast, in the nursing groups, we found higher levels of aluminum, boron, barium, bromine and nickel. Elderly, in particular frail and disabled subjects, are vulnerable to insufficiency or overload of microelements. There is a need to evaluate the actual requirements for each microelement for this population.

[The screen for caregiver burden of demented patients].

Most elderly individuals with dementia live in the community with the assistance of their caregivers, usually their family members. Their strength is essential for continuing home care and avoiding or postponing institutionalization. The screen for caregiver burden (SCB) is a 25 item scale, in use for the evaluation of caregivers of demented persons in the USA. A recent study in the USA showed that answers to 7 of those 25 questions, rapid screen for caregiver burden (RSCB), are sufficiently indicative and may replace and simplify the application of this questionnaire. In this study, the authors translated the SCB into Hebrew and tested it on 94 caregivers of demented elderly patients. The study results suggest that the shortened cluster of 7 items could also be used in Israel and is adequately indicative for the evaluation of the caregiver's burden.

QT interval disturbances in hospitalized elderly patients.

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 QTwas 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.

Mortality after nasogastric tube feeding initiation in long-term care elderly with oropharyngeal dysphagia--the contribution of refeeding syndrome.

BACKGROUND: The refeeding syndrome (RS) is an underappreciated but clinically important entity characterized by acute electrolyte abnormalities, mainly hypophosphatemia, fluid retention and dysfunction of various organs and systems, which can result in significant morbidity and occasionally death. OBJECTIVE: To examine the incidence of death cases and death causes following nasogastric tube (NGT) feeding initiation in frail elderly with particular reference to RS. METHODS: Forty patients with feeding problems for at least 72 h before restarting of alimentation by NGT were included. Excluded were those in any critical clinical situation. Clinical parameters and nutritional assessment were recorded before and after refeeding. Blood samples were taken before, daily for the first 3 days and 1 week after refeeding initiation. RESULTS: During the 1st week of refeeding, 9 patients (22.5%) died and within 1 month 10 more, summing to 47.5%. Most deaths were due to infectious causes [15 out of 19, (79%)]; some were due to no obvious reason [4 out of 19, (21%)]. Significant electrolyte changes were observed in the 2-3 days following refeeding. Significant were the decreases in phosphorus and elevations in potassium and lymphocytes (day 7). We found no correlations between the severity of decreases in levels of phosphorus and mortality. CONCLUSIONS: Mortality after NGT feeding initiation was high, mainly due to infectious complications. However, in a considerable number of patients hypophosphatemia was noted, suggesting that RS could be a contributory factor of mortality. Since this is a treatable condition, more attention should be paid to detecting and coping with this problem.

Metabolic alkalosis in skilled nursing patients.

Renal failure is common among the long-term care (LTC) elderly. Little is known about the acid/base status of these patients. The aim of this study is to evaluate the relationship between the acid base status and renal function in a representative group of skilled nursing patients and relate it to their feeding status. LTC elderly patients, in stable clinical condition, 50 on naso-gastric tube (NGT) feeding, 40 orally fed (OF), were recruited to this study. As controls, we studied a group of 30 elderly independent, ambulatory patients admitted to the acute geriatric departments of the hospital for different causes which were not related to their acid-base status. Venous blood was taken for the routine tests and blood gases. In the LTC study groups a 24-h urine collection was examined for biochemical parameters and calculations of all clearances. Glomerular filtration rate (GFR) was estimated by the Cockroft and Goult and MDRD formulas. Renal function was similar in the two main study groups. Daily secretion of sodium and chloride were 50% lower in the NGT fed patients (p<0.001). The LTC elderly patients had significantly higher venous pH values, with no differences in pCO(2) or HCO(3). An alkalotic state (pH>7.45) was found in 13.6% of them (18% in the NGT and 6.5% in the OF) while none of the independent elderly had such values (p<0.05). Similarly, HCO(3)>34 was found in 12% of the LTC elderly versus none in the independents (p=0.06). Values of pO(2) and O(2) saturation were significantly higher in the nursing elderly and mainly those fed by NGT. Hemoglobin levels had a significantly negative correlation with the pH (r=-0.3, p<0.002). In conclusion, unexpected metabolic alkalosis was found in a group of skilled nursing patients, more prominent in those fed by NGT. This finding warrants the inclusion of routine pH determination in patients whenever pharmacokinetic considerations are essential.

Edema of the paretic hand in elderly post-stroke nursing patients.

Post-stroke edema of the paretic hand constitutes an additional, functional, and esthetic nuisance for the patient. Although often encountered in daily practice, it is not even mentioned in the stroke chapters of the various textbooks. The phenomenon is far from being elucidated and various aspects are still obscure. In this study we tried to estimate the extent of post-stroke hand edema (PSHE) in a sample of elderly patients. The study group consisted of 188 elderly post-stroke nursing patients with hemi or only hand paresis. Seventy, age matched, non-paretic patients were examined as controls. The basis of comparison was the difference in circumference between the two arms at three sites: mid-finger, hand, and wrist as measured in the control group. Values above two standard deviations (S.D.) of the mean difference in circumference of the controls, at two or three sites, were considered as edema. Edema of the paretic hand was detected in 37% of post-stroke patients. Most (about three-quarters), could be classified as simple PSHE, while the rest may have had reflex sympathetic dystrophy (RSD).

Mortality of patients hospitalized for active tuberculosis in Israel.

BACKGROUND: Pulmonary tuberculosis continues to cause of mortality, particularly in developing countries. Despite modern anti-TB 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 respiratory care department 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 (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.

Renal effects of low dose aspirin in elderly patients.

BACKGROUND: Aspirin is commonly used by elderly patients. In previous studies we found transient changes in renal function induced by low doses of aspirin. 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 was 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 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 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, 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.