Adherence to Guidelines in Heart Failure, Is It Valid for Elderly Patients?

BACKGROUND: Current guidelines for the treatment of heart failure with reduced ejection fraction (HFrEF) are based on studies that have excluded or underrepresented older patients. OBJECTIVES: To assess the value of guideline directed medical therapy (GDMT) in HFrEF patients 80 years of age and older. METHODS: A single-center retrospective study included patients hospitalized with a first and primary diagnosis of acute decompensated heart failure (ADHF) and ejection fraction (EF) of ≤ 40%. Patients 80 years of age and older were stratified into two groups: GDMT, defined as treatment at hospital discharge with at least two drugs of the following groups: beta-blockers, angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or mineralocorticoid antagonists; and a personalized medicine group, which included patients who were treated with up to one of these drug groups. The primary outcomes were 90-day all-cause mortality, 90-day rehospitalization, and 3-years mortality. RESULTS: The study included 1152 patients with HFrEF. 254 (22%) patients who were at least 80 years old. Of the group, 123 were GDMT at discharge. When GDMT group was compared to the personalized medicine group, there were no statistically significant differences in terms 90-day mortality (17% vs. 13%, P = 0.169), 90-day readmission (51 % vs. 45.6%, P = 0.27), or 3-year mortality (64.5% vs. 63.3%, P = 0.915). CONCLUSIONS: Adherence to guidelines in the older adult population may not have the same effect as in younger patients who were studied in the randomized clinical trials. Larger prospective studies are needed to further address this issue.

Teaching During the COVID-19 Pandemic: The Experience of the Faculty of Medicine at the Technion-Israel Institute of Technology.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic forced drastic changes in all layers of life. Social distancing and lockdown drove the educational system to uncharted territories at an accelerated pace, leaving educators little time to adjust. OBJECTIVES: To describe changes in teaching during the first phase of the COVID-19 pandemic. METHODS: We described the steps implemented at the Technion-Israel Institute of Technology Faculty of Medicine during the initial 4 months of the COVID-19 pandemic to preserve teaching and the academic ecosystem. RESULTS: Several established methodologies, such as the flipped classroom and active learning, demonstrated effectiveness. In addition, we used creative methods to teach clinical medicine during the ban on bedside teaching and modified community engagement activities to meet COVID-19 induced community needs. CONCLUSIONS: The challenges and the lessons learned from teaching during the COVID-19 pandemic prompted us to adjust our teaching methods and curriculum using multiple online teaching methods and promoting self-learning. It also provided invaluable insights on our pedagogy and the teaching of medicine in the future with emphasis on students and faculty being part of the changes and adjustments in curriculum and teaching methods. However, personal interactions are essential to medical school education, as are laboratories, group simulations, and bedside teaching.

Prognostic value of cardiac troponin levels in patients presenting with supraventricular tachycardias.

BACKGROUND: An association between paroxysmal supraventricular tachycardias (PSVT) and elevated cardiac troponin I (cTnI) has been reported in small studies, even in the absence of significant coronary artery or structural heart disease. We sought to explore the prognostic significance of elevated cTnI among patients presenting with PSVT. METHODS: This is a retrospective single-center observational study conducted between January 2014 and Decemebr 2016. 165 patients (60% men, mean age 55 ± 17 year-old) with an acute episode of regular supraventricular tachyarrhythmia were admitted to the emergency department at Rambam Medical Center. 131 patients had at least one serum cTnI value measured. Of those, 57 had a positive result, defined as serum cTnI of more than 0.028 ng/dL. RESULTS: Multivariate analysis showed that heart rate > 150 beats per minute (bpm) on admission (OR = 3.9; 95% CI 1.1.6-9.5; p < 0.003) and history of coronary artery disease (CAD) (OR = 3.4; 95% CI 1.2-10.1; p = 0.026) were the only independent predictors of cTnI elevation. After mean follow-up period of 23 ± 7 months, the combined primary outcome of death, coronary intervention (PCI) or myocardial infarction (MI) occurred in 7 patients (12.3%) out of 57 patients with positive cTnI and in zero patients with negative cTn (p = 0.002). Cox proportional hazard model showed that elevated cTnI on admission was an independent predictor of adverse outcomes only in patients with known coronary artery disease (CAD) (HR = 3.3, p = 0.05). CONCLUSION: Elevated cTnI among patients presenting with PSVT appears to have prognostic significance only in patients with history of CAD. In this patient group elevated cTnI is associated with increased risk of adverse cardiac outcomes. We therefore believe serum cTnI should be measured selectively, such as in patients with symptoms of ischemic chest pain and a high pretest likelihood of having CAD.

Health and health care in Israel: an introduction.

Starting well before Independence in 1948, and over the ensuing six decades, Israel has built a robust, relatively efficient public system of health care, resulting in good health statistics throughout the life course. Because of the initiative of people living under the British Mandate for Palestine (1922-48), the development of many of today's health services predated the state's establishment by several decades. An extensive array of high-quality services and technologies is available to all residents, largely free at point of service, via the promulgation of the 1994 National Health Insurance Law. In addition to a strong medical academic culture, well equipped (albeit crowded) hospitals, and a robust primary-care infrastructure, the country has also developed some model national projects such as a programme for community quality indicators, an annual update of the national basket of services, and a strong system of research and education. Challenges include increasing privatisation of what was once largely a public system, and the underfunding in various sectors resulting in, among other challenges, relatively few acute hospital beds. Despite substantial organisational and financial investment, disparities persist based on ethnic origin or religion, other socioeconomic factors, and, regardless of the country's small size, a geographic maldistribution of resources. The Ministry of Health continues to be involved in the ownership and administration of many general hospitals and the direct payment for some health services (eg, geriatric institutional care), activities that distract it from its main task of planning for and supervising the whole health structure. Although the health-care system itself is very well integrated in relation to the country's two main ethnic groups (Israeli Arabs and Israeli Jews), we think that health in its widest sense might help provide a bridge to peace and reconciliation between the country and its neighbours.

The association between serum magnesium levels and community-acquired pneumonia 30-day mortality.

BACKGROUND: Community acquired pneumonia (CAP) is a common illness affecting hundreds of millions worldwide. Few studies have investigated the relationship between serum magnesium levels and outcomes of these patients. We aimed to study the association between serum magnesium levels and 30-day mortality among patients with CAP. METHODS: Retrospective overview of patients hospitalized with CAP between January 1, 2010 and December 31, 2016. Participants were analyzed retrospectively in order to identify the risk factors for a primary endpoint of 30-day mortality. Normal levels of magnesium levels in our laboratory varies between 1.35 and 2.4 mg/dl. RESULTS: 3851 patients were included in our cohort. Age > 75 years, blood urea nitrogen (BUN) > 20 mg/dl, hypoalbuminemia, and abnormal levels of magnesium were all associated with increased risk of 30-day mortality. Normal magnesium levels were associated with the lowest mortality rate (14.7%). Notably, within the normal levels, high normal magnesium levels (2-2.4 mg/dl) were correlated with higher mortality rates (30.3%) as compared to levels that ranged between 1.35-2 mg/dl (12.9%). Hypomagnesemia and hypermagnesemia were both associated with excess of 30-day mortality, 18.4 and 50%, respectively. CONCLUSION: Hypomagnesemia and hypermagnesemia on admission were associated with an increased rate of 30-day mortality among adult patients hospitalized with CAP. Interestingly, magnesium levels within the upper normal limits were associated with higher mortality.

Unexpected bleeding after Exenatide treatment: a causative relationship or a coincidence?

OBJECTIVES: Diabetes mellitus is an endemic disease of the current era. It is important to treat it properly. All antidiabetic medications have side effects and various safety profiles. CASE REPORT: Fifty-two years old patient with type II diabetes mellitus, who had spontaneous cutaneous and intra muscular bleeding after starting treatment with Exenatide. The patient's history did not include any kind of spontaneous bleeding. Investigations did not reveal abnormal platelets count and function or coagulation profile. The use of the Exenatide was discontinued and during one year of follow-up, the patient did not experience an additional occurrence of spontaneous bleeding. CONCLUSIONS: To the best of our knowledge, this is the first report of spontaneous bleeding probably caused by Exenatide. The exact pathophysiology, by which the drug can cause spontaneous bleeding, is still not clear and has to be revealed.

Medical students' attitudes towards participating in a palliative medicine course: A new specialty in Israel.

BACKGROUND: Palliative medicine is a growing field in Israel, and its training program is still in process. The current study aimed to evaluate students' attitudes regarding a course in palliative care established in a division of oncology. METHOD: Some 45 medical students in their 5th to 6th years participated in a one-week course on palliative care. At the end of each training week, students were asked to complete a questionnaire, evaluating their attitudes regarding different aspects of the program content, such as its importance and relevance to their training as physicians, as well as the contribution of specific parts of the program to their knowledge regarding palliative care. RESULTS: The overall satisfaction of the 45 students was high. The most contributory parts of the course were the multidisciplinary team and the complementary and alternative medicine. Participating in the staff meetings and accompanying physicians in their daily work were scored as the least contributory parts.Significance of resultsThis preliminary study demonstrated students' overall high satisfaction with the newly established palliative care course and their need for more practical skills. Future studies should investigate and evaluate educational programs in palliative care in order to establish suitable training for medical students.

[THE CELLULAR MECHANISMS OF LUNG EDEMA CLEARANCE: DOES THE ALVEOLAR EPITHELIUM PLAY A ROLE?]

INTRODUCTION: Pulmonary edema develops as a result of either alteration in the hydrostatic and oncotic pressure gradients across the pulmonary circulation and the lung interstitium or due to increased lung permeability. Alveolar fluid clearance is important in keeping the airspaces free of edema. This process is carried out via the alveolar epithelial active transport of Na+ across the alveolo-capillary barrier mostly by apical Na+ channels and basolateral Na,K-ATPases. Several pharmacologic agents such as catecholamines, vasopressin and gene therapy interventions have currently been found to stimulate the active Na+ transport and lung edema clearance. While others such as amiloride, ouabain, high tidal volume ventilation, hyperoxia and sepsis decrease the rate of alveolar fluid clearance. In conclusion, this review discusses the mechanisms and signal pathways by which the alveolar epithelium impacts lung edema clearance.

[REDUCTION OF ANTIBIOTIC CONSUMPTION IN RAMBAM HEALTH CARE CAMPUS - THE ROLE OF AN ANTIBIOTIC STEWARDSHIP PROGRAM].

INTRODUCTION: Antibiotic stewardship programs (ASP) are designed to optimize antibiotic use in hospitals. Antibiotic consumption is one of the measures assessing the effects of ASPs. AIMS: To evaluate the effect of an ASP on antibiotic consumption in our hospital and compare it to hospitals in Israel and worldwide. METHODS: Between October 2012 and March 2013 an ASP was implemented in Rambam Hospital. The program included educational activities, publication of local guidelines for empirical antibiotic treatment, structured infectious diseases consultations, pre-authorization antibiotic restrictions and stop orders. We compared antibacterial antibiotic consumption in defined daily doses (DDD)/100 hospital days (HD) between the periods before (1/2010-3/2013) and after (4/2013-9/2014) implementing the ASP. The study was conducted in the medical departments, hematology, the intensive care unit (ICU) and all pediatric wards. RESULTS: Total antibiotic consumption before implementing the ASP was 96±11.2 DDD/100 HD in medical departments, 186.4±42.8 in the ICU and 185.5±59 in hematology; all values were higher than the worldwide-reported averages for these departments. Following the ASP, total antibiotic consumption decreased by 12% (p=0.008) in the medical departments and by 26% (p=0.002) in hematology, mostly due to reductions in non-restricted antibiotics. No significant changes were observed overall in the ICU and in pediatric wards. There was a significant reduction in consumption of vancomycin and carbapenems in all settings, the latter was reduced to nearly half. Amikacin use quadrupled in the medical departments. CONCLUSIONS: Implementation of an ASP lead to a reduction in non-restricted and restricted antibiotic consumption, especially carbapenems.