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עמוד בית
Sun, 14.07.24

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September 2017
Basheer Karkabi MD, Ronen Jaffe MD, David A. Halon MD, Amnon Merdler MD, Nader Khader MD, Ronen Rubinshtein MD, Jacob Goldstein MD, Barak Zafrir MD, Keren Zissman MD, Nissan Ben-Dov MD, Michael Gabrielly MD, Alex Fuks MD, Avinoam Shiran MD, Salim Adawi MD, Yaron Hellman MD, Johny Shahla, Salim Halabi MD, Shai Cohen MD, Irina Bergman MD, Sameer Kassem MD PhD MPH, Chen Shapira MD and Moshe Y. Flugelman MD

Background: Outcomes of patients with acute ST-elevation myocardial infarction (STEMI) are strongly correlated to the time interval from hospital entry to primary percutaneous coronary intervention (PPCI). Current guidelines recommend a door to balloon time of < 90 minutes. 

Objectives: To reduce the time from hospital admission to PPCI and to increase the proportion of patients treated within 90 minutes. 

Methods: In March 2013 the authors launched a seven-component intervention program: 


  1. Direct patient evacuation by out-of-hospital emergency medical services to the coronary intensive care unit or catheterization laboratory

  2. Education program for the emergency department staff

  3. Dissemination of information regarding the urgency of the PPCI decision

  4. Activation of the catheterization team by a single phone call

  5. Reimbursement for transportation costs to on-call staff who use their own cars

  6. Improvement in the quality of medical records

  7. Investigation of failed cases and feedback 



Results: During the 14 months prior to the intervention, initiation of catheterization occurred within 90 minutes of hospital arrival in 88/133 patients(65%); during the 18 months following the start of the intervention, the rate was 181/200 (90%) (P < 0.01). The respective mean/median times to treatment were 126/67 minutes and 52/47 minutes (P < 0.01). Intervention also resulted in shortening of the time interval from hospital entry to PPCI on nights and weekends. 

Conclusions: Following implementation of a comprehensive intervention, the time from hospital admission to PPCI of STEMI patients shortened significantly, as did the proportion of patients treated within 90 minutes of hospital arrival. 

 

May 2016
Dan Levin, Salim Adawi MD, David A Halon MBChB, Avinoam Shiran MD, Ihab Asmer, Ronen Rubinshtein MD and Ronen Jaffe MD

Background: Radial artery occlusion (RAO) may occur following transradial catheterization, precluding future use of the vessel for vascular access or as a coronary bypass graft. Recanalization of RAO may occur; however, long-term radial artery patency when revascularization is more likely to be required has not been investigated. Transradial catheterization is usually performed via 5-Fr or 6-Fr catheters. Insertion of 7-Fr sheaths into the radial artery enables complex coronary interventions but may increase the risk of RAO. 

Objective: To assess the long-term radial artery patency following transradial catheterization via 7-Fr sheaths.

Methods: Antegrade radial artery blood flow was assessed by duplex-ultrasound in 43 patients who had undergone transradial catheterization via a 7-Fr sheath. 

Results: All patients had received intravenous unfractionated heparin with a mean activated clotting time (ACT) of 247 ± 56 seconds. Twenty-four patients (56%) had received a glycoprotein IIbIIIa inhibitor and no vascular site complications had occurred. Mean time interval from catheterization to duplex-ultrasound was 507 ± 317 days. Asymptomatic RAO was documented in 8 subjects (19%). Reduced body weight was the only significant univariate predictor of RAO (78 ± 11 vs. 89 ± 13 kg, P = 0.031). In a bivariate model using receiver operator characteristic (ROC) curves, the combination of lower weight and shorter ACT offered best prediction of RAO (area under the ROC curve 0.813). 

Conclusions: Asymptomatic RAO was found at late follow-up in approximately 1 of 5 patients undergoing transradial catheterization via a 7-Fr sheath and was associated with lower body weight and shorter ACT. 

 

June 2015
Yacov Shacham MD, Eran Leshem-Rubinow MD, Arie Steinvil MD, Gad Keren MD, Arie Roth MD and Yaron Arbel MD

Abstract

Background: In the era of primary percutaneous coronary intervention (PPCI), information on the incidence and prognostic significance of high degree atrioventricular block (AVB) in ST elevation myocardial infarction (STEMI) patients is limited.

Objectives: To assess the incidence, time of onset, predictors and prognostic significance of high degree AVB in a large cohort of consecutive STEMI patients undergoing PPCI.

Methods: We retrospectively studied 1244 consecutive STEMI patients undergoing PPCI. Patient records were reviewed for the presence of high degree AVB, its time of occurrence and relation to in-hospital complications, as well as long-term mortality over a 5 year period.

Results: High degree AVB was present in 33 patients (3.0%), in 25 (76%) of whom the conduction disorder occurred prior to PPCI. Twelve patients (36%) required temporary pacing, all prior to or during coronary intervention, and all AVB resolved spontaneously before hospital discharge. AVB was associated with a significantly higher 30 day (15 % vs. 2.0%, P = 0.001) and long-term mortality rate (30% vs. 6.0%, P < 0.001). Time of AVB had no effect on mortality. In a multivariate regression model, AVB emerged as an independent predictor for long-term mortality (hazard ratio 2.8, 95% confidence interval 1.20–6.44, P = 0.001).

Conclusions: High degree AVB remains a significant prognostic marker in STEMI patients in the PPCI era, albeit transient.

Amnon Y. Zlotnick MD ,Tamar Gaspar MD, Ronen Rubinshtein MD, David Halon MD and Amir Elami MD
April 2015
Eran Leshem-Rubinow MD, Shani Shenhar-Tsarfaty PhD, Assi Milwidsky MD, Sharon Toker PhD, Itzhak Shapira MD, Shlomo Berliner MD, Yael Benyamini PhD, Samuel Melamed PhD and Ori Rogowski MD

Abstract

Background: A single self-rated health (SRH) assessment is associated with clinical outcome and mortality, but the biological process linking SRH with immune status remains incompletely understood.

Objectives: To examine the association between SRH and inflammation in apparently healthy individuals.

Methods: Our analysis included 13,773 apparently healthy individuals attending the Tel Aviv Sourasky Medical Center for periodic health examinations. Estimated marginal means of the inflammation-sensitive biomarkers [i.e., highly sensitive C-reactive protein (hs-CRP) and fibrinogen] for the different SRH groups were calculated and adjusted for multiple potential confounders including risk factors, health behavior, socioeconomic status, and coexistent depression.

Results: The group with the lowest SRH had a significantly higher atherothrombotic profile and significantly higher concentrations of all inflammation-sensitive biomarkers in both genders. Hs-CRP was found to differ significantly between SRH groups in both genders even after gradual adjustments for all potential confounders. Fibrinogen differs significantly according to SRH in males only, with low absolute value differences.

Conclusions: A valid association exists for apparently healthy individuals of both genders between inflammation-sensitive biomarker levels and SRH categories, especially when comparing levels of hs-CRP. Our findings underscore the importance of assessing SRH and treating it like other markers of poor health.

January 2015
Udit Gibor MD, Zvi H. Perry MD, Uri Netz MD, Yair Glazer MD, Lia Laufer MD and Boris Kirshtein MD
Avi Rubinov MD, Nir Seider MD, Eedy Mezer MD, Liron Berkovitz MD, Eytan Z. Blumenthal MD and Imad R. Makhoul MD PhD
August 2014
Avi Rubinov MD, Eitan Z. Blumenthal MD and Itzchak Beiran MD
May 2014
Bonaguri Chiara PHD, Orsoni Jelka Gabriella MD, Russo Annalisa PHD, Rubino Pierangela MD, Bacciu Salvatore MD, Lippi Giuseppe MD Melegari Alessandra PHD, Zavota Laura MD, Ghirardini Stella AO and Mora Paolo MD

Background: Cogan’s syndrome (CS) is a rare autoimmune vasculitis characterized by ocular inflammation and sensorineural hearing loss. CS is divided into a “typical” form with non-syphilitic interstitial keratitis and audiovestibular symptoms, and an “atypical” form with ocular involvement affecting structures other than the cornea. Anti-Hsp70 antibodies were found at variable levels in patients presenting with various forms of autoimmune sensorineural hearing loss (ASNHL).

Objectives: To assess the correlation between anti-Hsp70 antibodies and specific ASNHL subgroups.

Methods: We divided 112 subjects into four groups: 14 subjects with typical CS, 24 with atypical CS, 55 with ASNHL, and 19 control subjects (healthy subjects and patients with systemic autoimmune diseases but no sensorineural hearing or audiovestibular alterations). Patients were tested for serological autoimmunity markers including anti-Hsp70.

Results: Positivity of the anti-Hsp70 antibody test was highest in the typical CS group (92.9%) and lowest in the control group (5.2%). The test was positive in 52.7% of patients in the ASNHL group and 16.6% in the atypical CS group. The paired comparison analysis between groups showed that sensitivity of anti-Hsp70 in the typical CS group was significantly higher, as compared to the other three study groups.

Conclusions: Anti-Hsp70 antibodies can be considered a serological marker of “typical” CS. “Atypical” CS is conceivably a sort of “melting pot” of different forms of autoimmune diseases still characterized by ocular inflammation and sensorineural hearing loss but whose antigenic characteristics need to be further defined.

December 2013
Yacov Shacham, Eran Leshem-Rubinow and Arie Roth
 Studies on trials conducted before the use of thrombolysis demonstrated both short- and long-term benefits of beta-blockers, and one meta-analysis of those trials showed a 25% reduction in 1 year mortality. Treatment with beta-blockers was and continues to be recommended for patients following ST elevation myocardial infarction (STEMI), but many patients failed to receive these agents, mostly because physicians were unconvinced of their benefit. A similar analysis of the studies in STEMI patients treated with thrombolysis also showed an overall 23% reduction in mortality associated with β-blocker use in the era of primary percutaneous coronary intervention (PCI). In the present review, we examine the relationship between the pharmacology of β-blockers and their potential utility in order to review early trials on their post-infarct efficacy and to place these findings in the context of this specific patient population in the era of primary PCI.

October 2013
A. Finkelstein, E.Y. Birati, Y. Abramowitz, A. Steinvil, N. Sheinberg, S. Biner, S. Bazan, Y. Ben Gal, A. Halkin, Y. Arbel, E. Ben-Assa, E. Leshem-Rubinow, G. Keren and S. Banai
 Background: Transcatheter aortic valve implantation (TAVI) has recently become an alternative to surgical aortic valve replacement in selected patients with high operative risk.

Objectives: To investigate the 30 day clinical outcome of the first 300 consecutive patients treated with transfemoral TAVI at the Tel Aviv Medical Center.

Methods: The CoreValve was used in 250 patients and the Edwards-Sapien valve in 50 patients. The mean age of the patients was 83 ± 5.3 years (range 63–98 years) and the mean valve area 0.69 ± 0.18 cm2 (range 0.3–0.9 cm2); 62% were women.

Results: The procedural success rate was 100%, and 30 day follow-up was done in all the patients. The average Euro-score for the cohort was 26 ± 13 (range 1.5–67). Total in-hospital mortality and 30 day mortality were both 2.3% (7 patients). Sixty-seven patients (22%) underwent permanent pacemaker implantation after the TAVI procedure, mostly due to new onset of left bundle brunch block and prolonged PR interval or to high degree atrioventricular block. The rate of stroke was 1.7% (5 patients). Forty-one patients (13.7%) had vascular complications, of whom 9 (3%) were defined as major vascular complications (according to the VARC definition).

Conclusions: The 30 day clinical outcome in the first 300 consecutive TAVI patients in our center was favorable, with a mortality rate of 2.3% and low rates of stroke (1.7%) and major vascular complications (3%).

 

 







 VARC = Valve Academic Research Consortium


July 2013
A. Tal, G. Rubin and N. Rozen
 Background: Hip fractures are common in the elderly population, but surgical treatment of these fractures within the first 48 hours decreases morbidity and mortality. The management of patients with hip fracture requiring surgery who are taking warfarin anticoagulation is unclear.

Objectives: To determine the effect of vitamin K on hip fracture patients treated with warfarin.

Methods: We retrospectively examined the management of 21 patients with hip fractures who were being treated with warfarin at the time of admission. Vitamin K was given to 11 of the 21 patients. A third group, which served as a control, consisting of 35 hip fracture patients who were not being treated with anticoagulants was also evaluated.

Results: Patients who received vitamin K took fewer days to reach target international normalized ratio (INR) (1.73 ± 0.90 vs. 4.30 ± 1.89, P < 0.001) and had less preoperative time (2.64 ± 1.12 vs. 5.10 ± 2.42 days, P < 0.008) when compared with patients who did not receive vitamin K. In addition, these patients had statistically significantly shorter hospitalization stays (9.4 ± 1.9 and 13.2 ± 4.9 days, one-sided P < 0.06). There was no difference in the amount of blood found in the wound drains (111.8 ± 68.5 vs. 103.0 ± 69.4 ml) or the number of blood units administered (1.45 ± 1.29 vs. 2.00 ± 2.75 units).

Conclusions: Treatment with vitamin K for hip fracture patients who receive warfarin shortens preoperative time, reduces the length of hospitalization and probably reduces morbidity and mortality.

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