Comparison of ketorolac and diclofenac in the treatment of renal colic.

OBJECTIVE: To compare the efficacy and adverse effects of ketorolac and diclofenac in the treatment of renal colic. METHODS: In a double-blind, randomized clinical trial, 57 patients admitted to the emergency room for renal colic, received either 30 mg of ketorolac or 75 mg of diclofenac i.m. (intramuscularly). Evaluations were performed at 1, 2 h and 6 h after treatment. Pain was assessed by a four-point verbal rating scale (VRS) and a visual analogue scale (VAS). Only patients with at least moderate pain according to the VRS were included. Seventy-five milligrams of pethidine i.m. was given as rescue medicine, if insufficient analgesia was achieved. The adverse effects recorded were sedation, nausea and vomiting. RESULTS: There was no significant difference between ketorolac and diclofenac, with respect to pain level over time, the number of patients requiring rescue medicine, or the level of adverse effects. CONCLUSION: Ketorolac and diclofenac are equally effective in the treatment of renal colic.

[Malignant epidural cord compression].

Malignant epidural spinal cord compression (MSCC) may appear in 5-10% of adults and 3-5% of children with active malignant disease. Early diagnosis and treatment are imperative to prevent irreversible neurological damage below the level of cord compression. Unfortunately such procedures are often subjected to patient and/or doctor delay, when the emergency nature of MSCC is not understood. 3 women and 2 men, aged 17-74, are described, who illustrate both the variability of the presentation of MSCC and of its clinical course, and also problems related to imaging studies necessary to reach appropriate therapeutic decisions. These cases should increase physicians' awareness of the necessity for its early diagnosis and treatment. In addition, it is suggested that a multidisciplinary team approach be followed when MSCC is suspected (in accord with flow chart in Hebrew text).

Paroxysmal atrial fibrillation and stroke (cerebrovascular accidents) in males and females above and below age 65 on days of different geomagnetic activity levels.

UNLABELLED: The goal of this study was to determine whether differences exist in the frequency of paroxysmal atrial fibrillation and stroke (cerebrovascular accident) on days of different geomagnetic activity levels. Geomagnetic activity was divided into four levels: quiet (I degree), unsettled (II degree), active (III degree), and stormy (IV degree). Measurements were made according to the six highest hourly geomagnetic parameters, in nanotesla units, over 24 hours. The study period covered 1185 consecutive days, from January 1990 to March 1993. All patients treated in the Admissions Department of a major multiprofile university hospital for stroke (cerebrovascular accident) (977 patients) or paroxysmal atrial fibrillation (653 patients) were included. Groups were also divided by sex and age (< or = 65 years vs. > 65 years) for comparison. RESULTS: (1) There was a significant negative correlation between daily paroxysmal atrial fibrillation and geomagnetic activity level (r = 0.976, p = 0.02); (2) The absolute number of daily admission for paroxysmal atrial fibrillation was higher on geomagnetic activity I degree days than on IV degree days (p < 0.004); (3) Stroke showed the same negative correlation with geomagnetic activity as paroxysmal atrial fibrillation, but only in males 65 years of age or less (r = 0.976, p = 0.027) suggesting a predominantly arrhythmic origin of stroke (cerebrovascular accident) in this group; (4) The male/female ratio for stroke was also adversely correlated with geomagnetic activity (r = 0.99, p = 0.0008), with the highest absolute number occurring on geomagnetic activity I degree days (X2 = 4.538, p = 0.03). These data are in accordance with previous studies showing increased heart electrical instability during periods of lowest geomagnetic activity.

Israeli ED experience during the Gulf War.

The experience in an emergency department (ED) during the Gulf War in treating casualties referred to the ED soon after each missile attack is reported. Data were gathered within an 8-hour period of each nationwide alert on all patients who presented to the ED with injuries or complaints directly related to the missile attacks of the Tel Aviv area. One hundred three patients presented with symptoms directly related to the missile attacks. Of 103, 70 suffered from acute psychological reaction, 19 from false autoinjection of atropine, and nine from physical injuries from the explosion. Of the remainder, four had mild symptoms of smoke inhalation, and one had intercurrent myocardial infarction. The missile attacks resulted in a relatively small number of serious injuries. Most of the patients who presented to the ED soon after the missile attacks suffered from either anxiety reaction or false atropin injection.

Circulating aggregated platelets, number of platelets per aggregate, and platelet size during acute myocardial infarction.

Circulating aggregated platelets (total, reversibly and irreversibly aggregated), the number of platelets per aggregate and "big" platelets were measured by a modification of the Wu and Hoak method in 42 patients on the first, second and fifth day of acute myocardial infarction (AMI). Among them, 30 had an uncomplicated course and 12 patients had complications that occurred between the 5th and 10th day of hospitalization (7 patients had reinfarction and 5 died). In all patients the measured parameters were elevated compared with those of control subjects. There was a significant increase, especially after the first observation day, in the values of total aggregated platelets (37 +/- 11% vs 26 +/- 12%, p < 0.001), reversibly aggregated platelets (27 +/- 9% vs 17 +/- 8%, p < 0.001) and the average platelets per aggregate (8.6 +/- 0.3 vs. 2.3 +/- 0.4) in patients with versus without complications. In considering the role of platelets in the development of AMI, these findings may add information to the role of platelets in determining the course of AMI.

Big platelets in hyperlipidemic patients.

Both "big" platelets and hyperlipidemia are associated with increased coronary risk. This study was undertaken to search for a possible effect of various hypolipidemic drugs on big platelets. The percentage of big platelets, assessed microscopically, was measured in 66 patients who had hyperlipidemia of various types. Twenty-seven patients with hypertriglyceridemia were randomly selected to receive either fish oil or placebo in a crossover study. Another group of 39 patients with hypercholesterolemia, among them 13 with heterozygous familial hypercholesterolemia (FH), received lovastatin. The pretreatment level of big platelets was elevated, and similar in all groups: 23.3 +/- 12% versus 22 +/- 9%, in the fish oil versus placebo group, 19.1 +/- 6.3% versus 24 +/- 11% in the FH versus non-FH primary hypercholesterolemia group (reference value, 6.8 +/- 3.5%). After treatment, despite the improvement in lipoprotein profile, the percentage of big platelets did not change. The relationship between lipid reduction and big platelets is thus questionable, and necessitates further study.

Admissions of patients with epileptic seizures (E) and dizziness (D) related to geomagnetic and solar activity levels: differences in female and male patients.

Admissions of 762 patients for epileptic seizures and 1553 for dizziness were studied for the connection with the level of monthly and yearly solar activity in the 11-year solar cycle and with four levels of daily geomagnetic activity levels (400 epileptic patients and 802 patients suffering with dizziness). The most significant differences of the studied groups were in the male/female ratio in different conditions of solar and geomagnetic activity. Changes in the group of epileptic patients were accompanied by similar, but adverse changes in the group suffering from dizziness. Different conditions of responses of females and males to environmental changes can explain the demonstrated results.

Detection of aggregated leukocytes in the circulating pool during stress-demargination is not necessarily a result of decreased leukocyte adhesiveness.

Leukocyte endothelial interactions are essential for a normal immune response. It is known that this response is influenced by stress and that the latter induces demargination. We examined the question of whether stress demargination results from a decreased state of leukocyte adhesiveness. Included were various volunteers and patients under different degrees of stress. 66 young athletes before beginning their daily exercises, 67 middle-aged healthy volunteers, 25 patients before ergometry for evaluation of chest pain, 75 patients who were referred to the emergency room with chest pain without ischemia/infarction, 78 patients with ischemia/infarction, 65 patients with minor trauma, 25 with a fracture and 12 with polytrauma. The leukocyte adhesiveness/aggregation (LAA) values were measured with a direct slide test. The respective LAA values were 7.4 +/- 4.7, 6.3 +/- 4.4, 5.8 +/- 3.6, 5.2 +/- 3.5, 10.8 +/- 8.5, 9.1 +/- 5.8, 12.2 +/- 6.6 and 19 +/- 12.6% of aggregated leukocytes. We conclude that an increase in aggregated white blood cells can be detected in the circulating pool during major stress. It is therefore suggested that stress demargination is not necessarily a result of diminished leukocyte adhesiveness.

Effects of fish-oil ingestion on cardiovascular risk factors in hyperlipidemic subjects in Israel: a randomized, double-blind crossover study.

Effects of a daily fish-oil supplement on serum lipids, apolipoproteins, and some platelet functions and hemorheologic variables were examined in 27 hyperlipidemic subjects in a randomized, controlled, double-blind, crossover fashion with an identically encapsulated vegetable oil serving as the control treatment. Despite the habitual high linoleic acid intake of the study population, significant incorporation of n-3 (omega-3) fatty acids into the serum, platelet, and erythrocyte lipids was observed after the fish-oil supplement. Ingestion of fish oil resulted in a 40% decrease in the triglyceride concentration, a 12% increase in HDL cholesterol, and a significant decrease in plasma viscosity, whereas the vegetable-oil placebo had no significant effect. We conclude that a moderate intake of fish oil (15 g/d) is a feasible treatment for hypertriglyceridemia even in patients with a background of high linoleic acid intake and that it may have a beneficial effect on several cardiovascular risk factors.

Plasma viscosity, fibrinogen and haematocrit in the course of unstable angina.

Plasma viscosity, fibrinogen and haematocrit were measured in 80 patients with unstable angina on the 1st, 2nd and 5th day of hospitalization. In the group of patients who developed acute myocardial infarction (AMI) during hospitalization (20 patients), plasma viscosity was elevated during the entire observation period (1.69 +/- 0.05 cp, normal range 1.38-1.48 cp), while in patients who did not develop AMI, plasma viscosity was only mildly elevated (1.59 +/- 0.05 cp, P less than 0.001 vs the group who developed AMI) and tended to normalize towards the 5th day of hospitalization. Fibrinogen and haematocrit showed similar variations between the two groups. In a group of 20 patients who received heparin, the studied parameters were similar to the group who did not develop AMI. The importance of haemorheological factors in the clinical course of unstable angina is thus emphasized.

Alterations in total lactate dehydrogenase and its isoenzyme-5 in hepatic disorders.

Values for total lactate dehydrogenase (LD, EC 1.1.1.27) and LD isoenzyme-5 were determined in serum of 106 patients with benign hepatic disorders, 54 of whom had acute liver disorders, either acute hepatitis (39 patients) or acute circulatory disturbances (15 patients). Fifty-two had chronic hepatic disorders, either cirrhosis (25 patients) or chronic right heart failure (27 patients). Overall, values for LD were above normal for 86 percent of the 106 patients with benign hepatic disorders. In 83 percent of 30 patients with non-fulminant viral hepatitis, LD values were below 350 U per L, while in all nine patients with either fulminant viral or toxic hepatitis, and in all 15 patients with acute circulatory disturbances, LD values were above 500 U per L. In all 52 patients with chronic hepatic disorders, LD values were below 350 U per L. In patients with acute liver disorders, both the total LD and LD-5 proportions were sensitive for liver injury (87 percent and 91 percent, respectively). On the other hand, LD-5 proportion was much less sensitive than total LD in patients with chronic liver disorders (40 percent versus 85 percent). In conclusion, a difference was found in LD values and LD-5 ratios between patients with non-fulminant viral hepatitis and patients with other causes for acute liver injury. The LD-5 proportions are more sensitive for hepatic injury in patients with acute liver disorders than in those with chronic liver disorders.

Native valve infective endocarditis in the 1970s versus the 1980s: underlying cardiac lesions and infecting organisms.

A retrospective review of the records of 135 patients with proven or suspected endocarditis, seen between January 1970 and December 1987, is presented. Among the findings: (1) Mitral valve prolapse (MVP) as an underlying lesion was more common in the 1980s group of patients (22%) than in the 1970s group (6%, p less than 0.01); (2) no significant difference was found in the occurrence of pathogens between the 1970s and the 1980s groups of patients; (3) in most patients (17 of 19) with MVP, the organisms isolated were Streptococci viridans; (4) most patients (15 of 17) with MVP had undergone a dental procedure without prior antibiotic treatment in the two months prior to admission. Prophylactic antibiotic treatment is suggested in patients with MVP undergoing dental procedure, especially in a subset of patients with flail or redundant valve leaflet as 16 of our MVP patients (out of 17) had this pathology on echocardiogram.

A method for the determination of circulating aggregated platelets and its application to patients in the course of unstable angina.

A method for the quantitative and qualitative determination of the number of aggregated platelets is described. One milliliter of venous blood was separated equally into two solutions. One solution composed of EDTA (ethylenediaminetetraacetic acid) and formaldehyde (solution F) contained reversibly and irreversibly aggregated platelets, and the second solution, composed of EDTA alone (solution E), contained irreversibly aggregated platelets. By microscopic readings, the percentage of platelets forming aggregates was determined. Reversibly aggregated platelets were estimated by subtracting the percentage of aggregated platelets in solution E from that in solution F. The average amount of platelets per aggregate was calculated by dividing the number of aggregated platelets in solution F by the number of aggregates per 1000 platelets counted. The reference ranges (means +/- SDs) established in 100 healthy persons were 5.8% +/- 2.4% (1% to 9%) for solution F, 3.9% +/- 1.8% (0% to 7%) for solution E, and 2.2 +/- 0.18 (2.0 to 2.5) for the average number of platelets per aggregate. Twenty hospitalized patients without heart disease had values similar to those of 100 normal subjects. In 50 patients with acute myocardial infarction, the percentage of aggregated platelets in solution F was 23.8% +/- 10.3%; in solution E, 4.0% +/- 3.0%; and the average number of platelets per aggregate, 2.9 +/- 0.7. The mean variance for five daily consecutive measurements was 0.52% for solution F, 0.63% for solution E, and 0.002 for the average number of platelets per aggregate. An even lesser mean variance was observed when the interobserver-vs-intraobserver and the intersmear-vs-intrasmear variations were tested. In patients with acute myocardial infarction, the interobserver-vs-intraobserver variance was 5.6% for solution F, 2.2% for solution E, and 0.005 for the average number of platelets per aggregate. The parameters studied were unaffected by different blood drawings, assay tubes, or venous stasis. In 80 patients with unstable angina, the studied parameters as well as the percentage of "big" platelets were measured on hospital days 1, 2, and 5. In 25 patients in whom acute myocardial infarction developed during hospitalization, the percentage of aggregated platelets was 28.1% +/- 8.3%. Most of them (71%) were reversibly aggregated and did not change during hospitalization. The average number of platelets per aggregate was 3.9 +/- 1.6, and the percentage of big platelets was 12.5% +/- 7.2%, both values not undergoing subsequent changes. In patients in whom acute myocardial infarction did not develop, the percentage of aggregated platelets decreased to 14.2% +/- 6.1% on day 5. Most aggregated platelets (58.8% to 90%) were irreversibly aggregated.(ABSTRACT TRUNCATED AT 400 WORDS)

Drug-related syncope.

The records of 483 patients admitted to the emergency room because of syncope were reviewed. Forty-one patients were found to have drug-related syncope. Thirty-nine experienced syncope related to drugs administered for cardiovascular disease. The most frequently associated diseases were anginal syndrome (22 patients), hypertension (13 patients), and a history of myocardial infarction (6 patients). Thirty-eight patients experienced symptomatic orthostatic hypotension following drug taking (nitrates in 19 patients, beta blockers in 10 patients, nifedipine in 3 patients, prazosin and quinidine in 2 patients each, methyldopa and verapamil in 1 patient each). One patient developed complete heart block as a result of digoxin intoxication. Two patients developed the characteristic picture of anaphylactic reaction (1 with ampicillin, 1 with dipyrone). During one-year follow-up, without the offending medications, no further syncopal episodes were reported by these patients. We conclude that drug-related syncope was more common among our patients with syncope than had been reported previously. It is suggested that drug-related syncope should be taken into consideration in any patient with syncope who is treated by any of the above-mentioned drugs.

Lactate dehydrogenase isoenzyme patterns in serum of patients with metastatic liver disease.

Total lactate dehydrogenase (LD, EC 1.1.1.27) and LD isoenzymes were determined in serum of 170 patients with metastatic liver disease, 35 of whom had multiple metastatic sites. Overall, values of LD were above normal for 78% of the 170 patients. Half of the patients had an isomorphic pattern of LD isoenzymes (i.e., relative increase in all five isoenzymes); the other half had an increased LD-4,5 pattern, mostly a solitary increase in LD-5 only. Of those patients with normal LD values, 92% had the increased LD-4,5 pattern, whereas 70% of patients with LD values greater than 350 U/L had an isomorphic pattern of LD isoenzymes. All 35 patients with multiple metastatic sites had LD activity greater than 350 U/L; in the majority of them (74%) it was greater than 500 U/L; in 31 (89%), the increase was isomorphic. The diagnostic efficiency of the combined LD greater than 225 U/L (upper limit of normal) and increased LD-4,5 test results was much better than that of LD greater than 225 U/L alone (93% vs 74%). We conclude that serum LD and LD isoenzymes should be determined in every patient with suspected liver metastatic disease. The isomorphic pattern of LD isoenzymes is apparently associated with higher values for total LD and was common among the patients with multiple metastatic sites.

Diagnosis and characteristics of lone atrial fibrillation.

Thirty-two patients with LAF were studied. Nineteen (59 percent) were male subjects. Mean age was 46.8 years. They were followed up for 2 to 16 years. On admission, most patients (94 percent) were symptomatic and had palpitations, nine had nonspecific chest pain, and five had syncope or near syncope. Left atrial size measured by echocardiography was less than 40 mm in all patients. During the follow-up period, only one patient had a complication, ie, cerebral embolism. We conclude that LAF may be regarded as a relatively benign form of AF. According to our study, one of its features is left atrial size not larger than 40 mm in echocardiography.

Changes in creatine kinase activity in the course of acute myocardial infarction.

Peak activity of creatine kinase (CK; EC 2.7.3.2) and its decline were determined in 380 patients with acute myocardial infarction (AMI) whose CK values had peaked after admission to the hospital. During hospitalization, 26 patients either died (14 patients) or experienced nonfatal re-infarction (12 patients). In 22 of these 26 patients CK activity decreased by less than 50% within 48 h after the peak value was measured. In all patients who did not die or develop re-infarction, CK activity decreased by greater than 50% during the 48 h after the peak. Evidently the rate of decline of CK (i.e., whether more than or less than 50%) from its peak value during the 48 h after AMI may be helpful in assessing which patients are at high risk for developing re-infarction or dying.

Patterns of lactate dehydrogenase isoenzymes 1 and 2 in serum of patients performing an exercise test.

Values for total lactate dehydrogenase (LD, EC 1.1.1.27) activity and LD isoenzymes were determined in serum from 56 patients and 40 healthy subjects before and 24, 48, and 72 h after they performed an exercise test. The mean (for all four times) total LD activity concentration and proportion of LD-2 were within the normal range for all 96 subjects. Mean LD-1 values for serum, although within the normal range in all subjects, were significantly higher in patients with positive exercise test results than in subjects with negative results: 75 (SD 12) U/L in 35 patients with ST depression greater than 2 mm; 63 (SD 14) U/L in 16 patients with ST depression of 1-2 mm; 43 (SD 11) U/L in subjects with negative test results, by 48 h after the test. The LD 1:2 ratio was also markedly higher in the group of patients with positive test exercise results, especially in those with ST depression greater than 2 mm (1.02, SD 0.06), compared with those subjects with negative results (0.60, SD 0.04). A similar trend was also found 24 and 72 h after the exercise test. We conclude that exercise-myocardial ischemia may lead to an increased LD 1:2 ratio in serum, and demonstrate a correlation between the degree of ischemia and the LD 1:2 ratio. Determination of the LD 1:2 ratio, even in the presence of normal total LD activity, may assist in the clinical evaluation of patients performing an exercise test.

Atrial fibrillation. Cause and time of onset.

To characterize groups of patients presenting at the emergency room with atrial fibrillation (AF) according to the various causes of AF and the time of its onset, 704 medical files from the Beilinson Medical Center (Petah Tikva, Israel), during an eight-year period, were reviewed. Two thirds of all patients converted to sinus rhythm (SR) within a seven-day in-hospital treatment. The most frequent causes associated with AF were atherosclerotic cardiovascular disease, 55%; rheumatic heart disease, 22.8%; chronic obstructive pulmonary disease, 2.8%; Wolf-Parkinson-White syndrome, 2.6%; and thyrotoxicosis, 2.6%. There was a relatively large group of idiopathic AF (4.5%). Best convertors to SR were patients with idiopathic AF (93.9%), then patients with Wolf-Parkinson-White syndrome (88.8%), followed by atherosclerotic cardiovascular disease (71.6%), and thyrotoxicosis (63.2%). Patients with rheumatic heart disease and chronic obstructive pulmonary disease had the lowest percentage of successful conversion to SR--46% and 55%, respectively. We conclude that there are differences regarding gender, age, and possible conversion of AF to SR according to the different causes of AF.