Can desalinated seawater contribute to iodine-deficiency disorders? An observation and hypothesis.

OBJECTIVE: Over 300 million people rely on desalinated seawater and the numbers are growing. Desalination removes iodine from water and could increase the risk of iodine-deficiency disorders (IDD). The present study assessed the relationship between iodine intake and thyroid function in an area reliant on desalination. DESIGN: A case-control study was performed between March 2012 and March 2014. Thyroid function was rigorously assessed by clinical examination, ultrasound and blood tests, including serum thyroglobulin (Tg) and autoimmune antibodies. Iodine intake and the contribution made by unfiltered tap water were estimated by FFQ. The contribution of drinking-water to iodine intake was modelled using three iodine concentrations: likely, worst-case and best-case scenario. SETTING: The setting for the study was a hospital located on the southern Israeli Mediterranean coast. SUBJECTS: Adult volunteers (n 102), 21-80 years old, prospectively recruited. RESULTS: After screening, seventy-four participants met the inclusion criteria. Thirty-seven were euthyroid controls. Among those with thyroid dysfunction, twenty-nine were classified with non-autoimmune thyroid disease (NATD) after excluding eight cases with autoimmunity. Seventy per cent of all participants had iodine intake below the Estimated Average Requirement (EAR) of 95 µg/d. Participants with NATD were significantly more likely to have probable IDD with intake below the EAR (OR=5·2; 95 % CI 1·8, 15·2) and abnormal serum Tg>40 ng/ml (OR=5·8; 95 % CI 1·6, 20·8). CONCLUSIONS: Evidence of prevalent probable IDD in a population reliant on desalinated seawater supports the urgent need to probe the impact of desalinated water on thyroid health in Israel and elsewhere.

[SERUM THYROGLOBULIN LEVELS AND ESTIMATED IODINE INTAKE IN ADULTS EXPOSED TO IODINE­DILUTED DESALINATED DRINKING WATER].

AIMS: The aim of this study was to describe thyroglobulin levels and iodine intake estimations in a convenience sample of Israeli adults without TD in the Ashkelon District, where SWRO desalination has become the major source of drinking water. BACKGROUND: Iodine deficiency (ID) is a significant risk factor for thyroid disease (TD). Recently, there were increases in both selfreported use of TD medication among Israeli adults and the national use of sea water reverse osmosis (SWRO) desalinated water. METHODS: Iodine concentrations in tap water (supplied by Mekorot Israel National Water Co.) were estimated before and after SWRO desalination was implemented in the Ashkelon District. Volunteers were recruited at the Barzilai Medical Center Ashkelon between January 2012 and October 2013. Data regarding residency, BMI and use of iodine-containing or steroidal drugs were obtained for all volunteers. Blood was drawn from matching participants for determination of serum thyrotropin, thyroid peroxidase antibodies, thyroglobulin (Tg) antibodies and Tg. A semi-quantitative iodine food frequency questionnaire (sIFFQ) was administered. RESULTS: Iodine concentration estimation in tap water declined from 52 µg/L to 27 µg/L after SWRO desalination was implemented in the Ashkelon District. A total of 50 participants without reported or known TD were included in the study after screening 92 volunteers. The median serum Tg was 21 ng/mL, and 76% (35 participants) had elevated values (Tg ≥ 10 ng/mL), indicating a high prevalence of apparent ID. Iodine intake estimation (median 99 µg/d by sIFFQ) was lower than the Recommended Dietary Allowance (150 µg/d). Unfiltered tap water was estimated to provide 16% of the mean daily iodine intake. CONCLUSIONS: The finding of apparent ID in this sample, underscores the need to obtain further data regarding many other regions across Israel. This is particularly urgent in the context of Israel's increased dependence on SWRO desalination.

[TREATMENT OF MECHANICALLY VENTILATED PATIENTS IN AN INTERNAL MEDICINE DEPARTMENT - OVERVIEW 2013].

BACKGROUND: Over recent years the number of mechanically ventilated patients in internal medicine departments has grown. These patients are elderly, mostly disabled and suffer from many chronic illnesses. Most of them require prolonged mechanical ventilation. OBJECTIVES: The study aimed to evaluate the population of mechanically ventilated patients in an internal department, the treatment and outcomes, particularly the morbidity in hospitalization and to identify the prognostic causes of death. METHODS: A retrospective study was conducted to check the medical records of ventilated patients between the years 2012- 2013 in internal medicine departments including demographic information, chronic illnesses, cause of hospitalization and ventilation, complications and results of treatment. RESULTS: The study includes 97 patients over the age of 60, 50% of them disabled, average Apache score was 29.9; 65% of the patients required ventilation for over 3 days and 35% for over 10 days; 71% of the patients died. The most common causes of death were pneumonia, sepsis, cerebrovascular accident, cardiac event, worsening of heart failure, worsening of chronic obstructive pulmonary disease or a combination of these. The patients who died displayed an Apache score significantly higher at admittance to the hospital. Significant risk factors for mortality included chronic diabetes, sepsis, pneumonia and renal failure. CONCLUSIONS: The results raise the question of whether to increase the number of beds for internal intensive care. A discussion is required among medical personnel and laymen to define a group of patients who should not deteriorate to mechanical ventilation or any other invasive procedures.

Elevated Serum Thyroglobulin and Low Iodine Intake Are Associated with Nontoxic Nodular Goiter among Adults Living near the Eastern Mediterranean Coast.

Background. Information about iodine intake is crucial for preventing thyroid diseases. Inadequate iodine intake can lead to thyroid diseases, including nontoxic nodular goiter (NNG). Objective. To estimate iodine intake and explore its correlation with thyroid diseases among Israeli adults living near the Mediterranean coast, where iodine-depleted desalinated water has become a major source of drinking water. Methods. Cross-sectional study of patients attending Barzilai Medical Center Ashkelon. Participants, who were classified as either NNG (n = 17), hypothyroidism (n = 14), or control (n = 31), provided serum thyroglobulin (Tg) and completed a semiquantitative iodine food frequency questionnaire. Results. Elevated serum Tg values (Tg > 60 ng/mL) were significantly more prevalent in the NNG group than in the other groups (29% versus 7% and 0% for hypothyroidism and controls, resp., P < 0.05). Mean estimated iodine intake was significantly lower in the NNG group (65 ± 30 µg/d) than in controls (115 ± 60 µg/d) (P < 0.05) with intermediate intake in the hypothyroid group (73 ± 38 µg/d). Conclusions. Elevated serum Tg values and low dietary iodine intake are associated with NNG among adult patients in Ashkelon District, Israel. Larger studies are needed in order to expand on these important initial findings.

[Etiology of severe pulmonary hypertension--possible role of metabolic syndrome].

BACKGROUND: In clinical practice the association between obesity and pulmonary hypertension (PH) is not rare. AIM: The aim of this study was to examine the prevalence of obesity and metabolic syndrome in patients with severe PH, especially cases without significant cardiac, pulmonary or vascular causes. METHODS: We retrospectively anaLyzed the records of 91 patients with severe PH in order to establish its causes. RESULTS: A total of 64% of the patients were women. The women were older than the men, 76.5 years vs 74.0. The BMI of the women was higher than the men, 37.0 vs 30.07. The most common causes of severe PH seen in an internal medicine ward are: severe heart failure (45.1%), chronic lung disease (16.5%) or a combination of both (12.1%). Overall, 11% of our study patients were morbidly obese without significant cardiac, pulmonary or vascular causes of PH. This group was characterized by high incidence of diabetes meLLitus, arterial hypertension, hyperlipidemia, atrial fibrillation and left ventricular (LV) diastolic dysfunction. CONCLUSION: Our results point to a possible association between metabolic syndrome and PH.

The influence of smoking cessation on hemodynamics and arterial compliance.

Cigarette smoking is associated with consistent changes in small arteries and arterioles. Recently, arterial compliance was determined in smokers; however, the effect of smoking cessation on arterial compliance has not yet been investigated. The objective of the study was to assess how smoking cessation, achieved with use of behavioral and pharmacologic therapy, influences vascular compliance and arterial stiffness in smokers. In an open-label study, 60 habitual smokers were treated for 2 months with buproprion 300 mg per day and personal and group conversations in order to facilitate smoking cessation. Hemodynamic variables, including vascular compliance and augmentation index (AI), were measured twice, at the beginning of the study and after 6 months. Of the 60 smokers, 35 stopped smoking and 25 failed at the end of the 2-month treatment period. Of the 35 who were initially successful, 12 went back to smoking, and thus only 23 remained nonsmokers at the end of 6 months. Smoking cessation was accompanied by significantly lower arterial pressure and heart rate but by weight gain. Among the 23 subjects who stopped smoking for 6 months capacitive compliance (C(1)) did not change but oscillatory compliance (C(2)) rose significantly (from 5.1 +/-2.3 to 6.3 +/-3.0 p<0.01), and AI decreased significantly (from 63.1 +/-22 to 50.6 +/-17 p<0.05), whereas in smokers who still smoked after this period, both C(1) and C(2) and augmentation index did not change significantly from their basal values. The authors conclude that smoking cessation improves arterial stiffness as assessed by the augmentation index, owing mainly to increasing the small artery compliance, which is known to be an early index of endothelial damage.

Effect of weight loss on blood pressure, arterial compliance, and insulin resistance in normotensive obese subjects.

BACKGROUND: Obesity is characterized by insulin resistance and hyperinsulinemia that may elevate arterial pressure due to sympathetic overactivity and volume overload. The aim of the study is to measure hemodynamic parameters and metabolic variables in obese normotensive subjects. METHODS: Twenty-four normotensive, overweight subjects from our medical staff were enrolled. They had personal and group meetings with a physician, dietician, and psychologist to improve their compliance with regard to physical activity and personal low-calorie diet. In addition, each subject was given orlistat 120 mg three times daily for 12 weeks. Noninvasive hemodynamic parameters including arterial compliance were measured using radial artery pulse wave analysis, at the beginning and 1 month after taking the last dose of Orlistat, and insulin resistance was calculated using HOMA score. RESULTS: At the end of the 3-month period, the average weight was reduced from 89.5 +/- 12 kg to 81.5 +/- 9 kg. The systolic arterial pressure was reduced from 128 +/- 12 mm Hg to 121 +/- 10 mm Hg and diastolic arterial pressure was reduced from 75.4 +/- 9 mm Hg to 69.6 +/- 7 mm Hg. Arterial compliance measurements showed significant improvement in large artery compliance from 13 +/- 4 to 15.8 +/- 3.6 while no change occurred in small arteries. The insulin sensitivity assessed by HOMA score improved significantly from 6.5 +/- 4.5 to 4.8 +/- 3.1 with weight reduction. CONCLUSIONS: Our data show that weight loss is accompanied by lowering of blood pressure, even in normotensive obese patients. This weight loss brings about an improvement in insulin resistance and a rise in large artery compliance, whereas no change occurs in small artery compliance.

Hemodynamic effects of anemia correction by recombinant human erythropoietin in predialysis patients with renal failure.

Most patients with chronic renal failure have anemia, which can be corrected by recombinant human erythropoietin (rHuEpo) treatment. Increase in arterial pressure (AP) was reported in some studies and was related to higher systemic vascular resistance induced either by the rise of erythrocyte mass or the change in various endogenous vasopressors, including the direct action of rHuEpo itself. We investigated the effect of rHuEpo treatment on hemodynamic variables, including small and large arterial compliance in 20 patients with chronic renal failure who were not receiving dialysis (CCT 29 +/- 12 mL/min), with Hb levels of 40.4 +/- 0.58 g/dL. They were treated with 2,000 units intravenously followed by 80 to 120 s/c units/kg/body weight, with dosage titration according to Hb level. Noninvasive hemodynamic evaluation was performed before the first rHuEpo treatment, 30 min after the first IV rHuEpo administration and at least 3 months later when target hemoglobin (Hb) and hematocrit (Hct) were reached. No rise in AP occurred after rHuEpo administration either short term or long term. The significant hemodynamic changes were a fall in pulse pressure and a rise in large artery compliance, with no change in small artery compliance after 3 months of rHuEpo treatment when Hb and Hct levels were corrected. These findings show improvement in arterial stiffness when Hb is corrected with rHuEpo treatment.

Small artery compliance in cirrhotic patients during total paracentes.

BACKGROUND: Hemodynamic changes, including systemic vascular resistance, in cirrhotic patients during massive paracentesis have been reported, but large and small artery compliance has not yet been investigated. OBJECTIVE: To investigate hemodynamic variables, including small and large artery compliance, in cirrhotic patients during total paracentesis. METHODS: The study included 15 cirrhotic patients admitted for an episode of tense diuretic-resistant ascites. Hemodynamic variables including vascular compliance were measured using an HDI pulse wave cardiovascular profiling instrument CR-2000. The variables were measured in these patients before, immediately after, and 24 hours following large volume (mean 5.6 L) paracentesis. RESULTS: Cardiac output increased immediately after paracentesis due to increment in stroke volume, with no change in heart rate. However, 24 hours later the cardiac output decreased to below the basal level. The fluctuation was statistically significant (P < 0.05). There was no change in large artery compliance, but small artery compliance increased after paracentesis (P < 0.05) and partially retumed to the basal level after 24 hours. Systemic vascular resistance measurement showed the same pattern of change: vasodilatation occurred during paracentesis and was attenuated 24 hours later. CONCLUSIONS: Large volume paracentesis with albumin replacement caused an accentuation of the vasodilatation (small but not large artery) already present in these patients. This may be the first sign of enhanced vasodilatation due to large volume paracentesis before the clinical expression of impaired hemodynamics and deterioration of renal function.

Malignant pericardial effusion and cardiac tamponade as a late complication of endometrial carcinoma.

Malignant pericardial effusion, as a complication of gynecological cancer, is a rare occurrence. A review of the literature reveals only four cases of malignant pericardial effusion from endometrial carcinoma diagnosed during life. All of them were followed by cardiac tamponade a short time after being diagnosed and were associated with extensive myometrial invasion and multiple metastases. We describe a case of malignant pericardial effusion and cardiac tamponade due to recurrence of endometrial carcinoma characterized by the long period from diagnosis to clinical evidence of pericardial involvement. The causes of long-term disease-free interval are discussed.