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Biomedical subjects

I Shapira

Publications and source records attributed to I Shapira.

At least 91 records · Page 5Linked to original sources
PubMed2000

Emergency myocardial revascularization for acute myocardial infarction: survival benefits of avoiding cardiopulmonary bypass.

OBJECTIVE: Emergency coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) is associated with increased operative mortality. It has been suggested that this mortality might be reduced by performing the operation without cardiopulmonary bypass (CPB). METHODS: Between January 1992 and April 1998, 77 patients underwent emergency CABG within 48 h of AMI. Thirty seven were operated on with CPB, and 40 without CPB. The two groups were similar regarding age, gender, left-ventricular ejection fraction (EF) and preoperative use of intra-aortic balloon pump (IABP; 50%). The mean number of grafts/patient was 3 in the CPB group, and 1.9 in the No-CPB group (P<0.0001). RESULTS: Operative mortality in the CPB group was 24% (nine of 37) compared to 5% (two of 40) without CPB (P=0.015). Follow-up ranged between 6 and 66 months. There were no late deaths in the CPB group compared to nine (22%) in the No-CPB group (P<0.0066). Patients operated on with CPB had lower rates of recurrent angina (0 versus 15%; P=0.04) and re-interventions (0 versus 15%; P=0.04). CONCLUSIONS: Our experience suggests that CABG without CPB is the preferred method of myocardial revascularization, due to the fact that it carries lower mortality than CABG with CPB. The trade-off includes increased rates of recurrent angina, re-interventions and late mortality.

Aged↗
PubMed2000

Combined repair of pectus excavatum and coronary artery bypass grafting.

Coronary artery bypass grafting (CABG) in patients with severe pectus excavatum is a surgical challenge. A two-stage correction of sternal deformities and cardiac lesions has been described and myocardial revascularization through a left lateral thoracotomy is a valid alternative in urgent situations. We report a one-stage repair of severe pectus excavatum and CABG with the use of bilateral internal thoracic arteries in a young patient requiring urgent myocardial revascularization. The technical aspects and operative consideration are discussed.

Coronary Artery Bypass↗
PubMed2000

Bezafibrate and simvastatin combination therapy for diabetic dyslipidaemia: efficacy and safety.

OBJECTIVE: To determine the efficacy and safety of a statin-fibrate combination in diabetes patients. DESIGN.: An open 21-month trial in which each patient first received the single drug for 6 months and then a combination of the two for 1 year. SETTING: Three lipid clinics in university-based tertiary care hospitals. PATIENTS: One hundred and forty-eight patients with type 2 (non-insulin-dependent, NIDDM) diabetes mellitus under stable control for 3 months by means of diet and oral hypoglycaemic medication. INTERVENTION: Patients from one clinic (n = 48) received bezafibrate slow release (400 mg day-1), and patients from the other two clinics (n = 100) received simvastatin 20 mg day-1. Six months later, all patients were switched to a daily combination of 400 mg bezafibrate slow release and 20 mg simvastatin for 1 year. RESULTS: The combination of statin and fibrate led to a 23% reduction in total cholesterol, 42% reduction in triglycerides, 29% reduction in LDL-c, 25% increase in HDL-c, 10% decrease in fibrinogen and 19% reduction of Lp(a) levels, and a decrease in the cholesterol/HDL-c ratio (from 8.9 to 5.4) in all 148 patients. Cardiovascular (CV) event rate was significantly reduced from 9.5% during the first 6 months of the study to less than 2% during the last year of the study (whilst on combination Rx). Side-effects with all treatments included only two patients who developed myopathy when on the combined regimen and one on the single statin regimen. However, plasma creatinine phosphokinase (CPK) levels doubled (but remained within the normal range) in most of the patients on combination therapy, compared with only a mild increase in patients receiving a single medication. CONCLUSIONS: The statin and fibrate combination was found to be more efficacious than a single medication for treatment of diabetic dyslipidaemia, as evidenced by improvement in the lipoprotein profile, reductions in Lp(a), fibrinogen and CV event rate, and almost no clinically significant side-effects.

Aged↗
PubMed2000

Risk factor clustering in hypertensive patients: impact of the reports of NCEP-II and second joint task force on coronary prevention on JNC-VI guidelines.

INTRODUCTION: Although the association of hypertension with established risk factors has been noted in several population studies, the recent redefinition of dyslipidaemia, hypertension and diabetes calls for reassessment of the prevalence and pattern of risk factor clusters in essential hypertension. OBJECTIVE: To analyse the risk factor profile of Israeli patients with essential hypertension seen by primary care physicians and in hypertension specialty clinics, based on current definitions of dyslipidaemia hypertension and diabetes and JNC-VI guidelines for the assessment of risk factors. DESIGN AND SETTING: We analysed the risk profile of 324 Israeli hypertensive subjects using the JNC-VI risk table and risk grouping. A total of 122 consecutive patients were recruited from primary care clinics and 212 consecutive patients were recruited from a hospital based hypertension clinic. RESULTS: Amongst hypertensive individuals with no known target organ damage, only 1.5% had no risk factors other than hypertension, whereas all hypertensives with coronary artery disease had additional risk factors. Of the six listed major JNC-VI risk factors (smoking, dyslipidaemia, diabetes, age, sex, family history of cardiovascular disease), hypertensive subjects without coronary artery disease (coronary artery disease-negative) had 3.02 +/- 0.10 risk factors, whereas hypertensive subjects with coronary artery disease (coronary artery disease positive) had 3.6 +/- 0.07 risk factors other than hypertension (P < 0.01). Dyslipidaemia defined by NCEP-II criteria was the most common associated risk factor identified in 93% of coronary artery disease-positive and 77% of the coronary artery disease-negative hypertensive subjects. The most common dyslipidaemic abnormality was an increased LDL cholesterol (79.2% of the cohort), followed by hypertriglyceridaemia (31.7%) and low HDL cholesterol (22.3%). Nevertheless, in nearly half of the coronary artery disease-negative patients, LDL cholesterol concentrations were within 30 mg dL-1 of the target levels. The most common dyslipidaemic variant was isolated hypercholesterolaemia (42%), whereas the syndrome X dyslipidaemic combination of hypertriglyceridaemia and low HDL was strikingly uncommon, observed in 2.8% of the coronary artery disease-positive and 0.8% of the coronary artery disease-negative patients. CONCLUSIONS: (i) JNC-VI group risk A patients (no risk factors) comprise a very small minority in this cohort (< 5%); (ii) dyslipidaemia is exceedingly common with mild hypercholesterolaemia being the most prevalent variant and hypertriglyceridaemia with low HDL the least common form.

Cardiovascular Diseases↗
PubMed2000

Medical history of hypercholesterolaemia adversely affects the outcome of out-of-hospital cardiopulmonary resuscitation; the 'Shahal' experience in Israel.

AIMS: To evaluate the impact selected risk factors for cardiac death may have on the success rate in a large cohort of subscribers to 'SHAHAL' who were resuscitated from out-of-hospital cardiac arrest. METHODS AND RESULTS: In this medical facility currently serving 50 000 subscribers, data were prospectively gathered from between 1987-1998. The information retrieved from the patients' medical records included a medical history of hypertension, diabetes, hypercholesterolaemia (>220.mg. dl(-1)) smoking, angina, previous myocardial infarction, and congestive heart failure. A total of 998 patients aged 74+/-12 years (mean+/-1 SD) were included. Death was announced at the scene for 659 (66%) victims, while 339 (34%) patients were taken to hospital. Of these 140 (14% of the total cohort) survived and were discharged from the hospital. A comparison of various selected parameters between survivors and non-survivors of resuscitation revealed that survivors were younger, had a higher rate of pulseless ventricular tachycardia/ventricular fibrillation, more were among the arrests witnessed by the 'SHAHAL' team, and that more had a shorter time lag to initiation of cardiopulmonary resuscitation than non-survivors. None of the studied risk factors predicted the outcome of cardiopulmonary resuscitation, with the exception of hypercholesterolaemia, which carried a significantly worse prognosis for cardiopulmonary resuscitation (P=0.009). CONCLUSIONS: A medical history of hypercholesterolaemia appears to be an important risk factor which adversely affects the outcome of cardiopulmonary resuscitation.

Aged↗
PubMed2000

Captopril and L-arginine have a synergistic cardioprotective effect in ischemic-reperfusion injury in the isolated rat heart.

OBJECTIVES: The present study was designed to evaluate the possible effect of the combined administration of both captopril (Cap) and L-arginine (L-a) in the isolated ischemic rat heart model. BACKGROUND: Recent studies suggest that L-arginine and angiotensin-converting enzyme (ACE) inhibitors possess independent cardioprotective effects in ischemic hearts. The pharmacological effect of the combination of both drugs has not yet been investigated in the ischemic myocardium. METHODS: Using the modified Langendorf model, rats were perfused with either Cap 360 micromol/L (n = 6) or (L-a) 3mmol/L (n = 6), both captopril and L-arginine (Cap+L-a) (n = 8), or saline control (Con) (n = 8). The study design included 30 minutes of perfusion, 30 minutes of global ischemia, and 30 minutes of reperfusion thereafter. RESULTS: Hearts treated with both Cap+L-a demonstrated an improved performance in all parameters. After 10 minutes of reperfusion, the P(max) in the Cap+L-a group was 98 +/- 8 mmHg (P <.001), 59 +/- 14 mmHg in the Cap group (P <.02), and 44.3 +/- 10 mmHg in the L-a group (P = NS), compared with only 42 +/- 8 mmHg in the control. After 10 minutes of reperfusion the dP/dt(min) was: in the Cap+L-a group: -1,650 +/- 223 mmHg/s (P <. 006); in the Cap group: -1,051 +/- 302 mmHg/s (P <.03); in the L-a group: -870 +/- 131 mmHg/s (P = NS), compared with only -487 +/- 131 mmHg/s in the control. Coronary flow was significantly increased in all 3 groups: Cap+L-a group: 22.3 +/- 1.5 mL/min (P <.001); Cap group: 18 +/- 1.6 mL/min (P <.01); L-a group: 19.8 +/- 0.9 mL/min (P <.02), compared with 12.6 +/- 0.9 mL/min in the Con group. Total NO level was significantly increased in the Cap+L-a group: 13.4 +/- 2 micromol (P <.03) vs. 6.1 +/- 1 micromol for the L-a group. NO levels of both the Cap group and the Con group were beneath detectable values. CONCLUSION: Combined administration of captopril and L-arginine has a synergistic, protective effect on heart function and coronary flow that may be mediated by enhanced NO production.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2000

Bilateral skeletonized internal thoracic artery grafting in 303 patients seventy years and older.

OBJECTIVES: Higher patency rates of the internal thoracic artery have led myocardial revascularization with bilateral internal thoracic arteries to be a procedure designated primarily for young patients. Fewer leg wound complications and sternal collateral flow preservation with the skeletonizing dissection technique can make bilateral internal thoracic artery grafting attractive also for elderly patients. METHODS: Between May 1996 and May 1998, 303 consecutive patients aged 70 years or older (mean age 75.5 years; range 70-92 years) underwent coronary artery bypass grafting with double skeletonized internal thoracic arteries. Forty-four (14.5%) patients were 80 years or older, and 89 (28%) had diabetes. The mean number of grafts was 3.1 per patient (2-6). RESULTS: Operative mortality was 2.6% (n = 8): it was higher for octogenarians (6.8%) than for younger patients (1.9%) (P =.06). The only significant preoperative predictors of early mortality were complicated percutaneous transluminal coronary angioplasty (P =.03) and preoperative use of intra-aortic balloon pumping (P =.03). Six patients (2%) had sternal wound infections for which chronic lung disease (P =.02) and emergency operation (P =.006) were the only significant predictors. Twenty-two (7.2%) late deaths occurred, and 1- and 3-year survivals were 93% and 90%, respectively. The 3-year survival of patients 80 years old or older was 92%. CONCLUSIONS: Bilateral grafting of the skeletonized internal thoracic artery carries relatively low morbidity and mortality in elderly patients and can be recommended for selected patients including octogenarians.

Aged↗
PubMed2000

Increased leukocyte aggregation induced by gamma-globulin: a clue to the presence of pseudoleukopenia.

BACKGROUND: Previous articles have reported the appearance of leukopenia after the administration of high-dose intravenous gamma-globulins. METHODS: A simple slide test was used to reveal the state of leukocyte aggregation (LA) in the peripheral blood as well as the absolute number of leukocytes in the slides. RESULTS: A significant (P < 0.00001) increment was noted in the state of LA, from 9 +/- 6% before to 25 +/- 11% after gamma-globulin administration. This was accompanied by a significant (P < 0.0004) reduction in the number of white blood cells in the peripheral blood (from 8433 +/- 3905 to 6550 +/- 3252 cells/mm3) but no significant change in the absolute number of the cells as determined by the leukocyte count per high power field in the peripheral slides. CONCLUSIONS: We raise the possibility that the leukopenia reported in some patients after the intravenous administration of high dose gamma-globulin is explained in part by the agglutination effect of the drug.

Adolescent↗
PubMed2000

Activated polymorphonuclear leukocytes and monocytes in the peripheral blood of patients with ischemic heart and brain conditions correspond to the presence of multiple risk factors for atherothrombosis.

OBJECTIVE: Risk factors like hypertension, diabetes mellitus, dyslipidemia and smoking contribute to the pathogenesis of atherothrombosis. We investigated whether the multiplicity of risk factors for atherothrombosis is associated with leukocyte activation. METHODS: We examined the availability of CD11b/CD18 antigen on the surface of peripheral blood polymorphonuclear leukocytes and monocytes in patients with acute ischemic heart and brain conditions. RESULTS: There was a highly significant (p<0.00001) increment in the availability of the CD11b/CD18 antigen on the surface of the polymorphonuclear leukocytes in patients with multiple (2 or more) vascular risk factors [mean fluorescence intensity (MFI) +/- SD, 210+/-102] as opposed to individuals with none or 1 risk factor for atherothrombosis (MFI 159+/-73). Similar results were observed on the monocytes: 309+/-151 and 235+/-97, respectively (p<0. 00001). CONCLUSION: The multiplicity of risk factors for atherothrombosis is associated with the up-regulation of CD11b/CD18 antigen on the surface of peripheral blood polymorphonuclear leukocytes and monocytes, suggesting the presence of an increased inflammatory response and leukocyte activation in these individuals.

Acute Disease↗
PubMed2000

The inflammation meter: novel technology to detect the presence of infection/inflammation in patients without leukocytosis but with increased leukocyte adhesiveness/aggregation.

OBJECTIVES: To reveal the presence of infection/inflammation in patients with relatively normal white blood cell count (WBCC) by using the leukocyte adhesiveness/aggregation test (LAAT). METHODS: The LAAT was performed by using a simple slide test and image analysis (Inflamet), the WBCC, by an electronic cell analyzer, C-reactive protein, by Laser nephelometry and CD11b/CD18 by whole blood flow cytometry. RESULTS: Forty out of a cohort of 121 patients with nonviral acute febrile illness had a WBCC within normal limits. The intensity of the inflammatory response in these individuals as judged by either C-reactive protein, or fibrinogen concentrations, erythrocyte sedimentation or polymorphonuclear leukocyte CD11b/CD18 expression was similar to that observed in patients with a leukocytic response. Our present finding that 63% out of the group with documented infection/inflammation and no leukocytosis had a significantly increased LAAT suggest that the lack of leukocytosis is in part a pseudoleukopenia, or is associated with some degree of uncompensated tissue leukostasis. CONCLUSIONS: The lack of a leukocytic response in a patient with nonviral infection/inflammation is by no means a sign of a less inflammatory response. The increased state of leukocyte adhesiveness/aggregation might help to disclose the presence of inflammation in these individuals.

Adult↗
PubMed2000

Long-term mortality rates reflect progressive prognostic benefits of thrombolysis in patients with first acute myocardial infarction.

This community nonrandomized study comprised a consecutive cohort of 1,545 (81% males) < or = 65-year-old patients who survived a first acute myocardial infarction (AMI). The all-cause 4- to 5-year mortality rate was 9% (80% cardiac). Univariate analysis revealed that older age, female gender, hypertension, diabetes, not undergoing thrombolysis, higher Killip class, preinfarction heart disease, peripheral vascular disease (PVD) and chronic obstructive lung disease (COLD) were significantly associated with increased mortality. Multivariate analyses disclosed the latter five parameters as being independent predictors of mortality. Our results show that patients undergoing thrombolysis enjoyed a progressive prognostic benefit over time. The independent contribution of PVD and COLD to long-term mortality is highlighted, in addition to the contribution of thrombolytic therapy, Killip class, and heart disease prior to infarction as being important predictors of long-term mortality in patients with a first AMI.

Female↗
PubMed2000

Fluid dynamics and atherosclerosis development in the human thoracic aorta: a transesophageal echocardiographic evaluation of protruding aortic plaque distribution and motion.

The pathogeneses of atherosclerosis in the thoracic aorta is heterogeneous and still incompletely elucidated. Protruding aortic plaques (PAP), reliable markers of atherosclerosis development and extension, could be easily identified by transesophageal echocardiography (TEE). A close relation between atherosclerosis development in the thoracic aorta, stroke and peripheral emboli were established. The purpose of this study was to use PAP distribution and motion on TEE to characterize atherogenesis in the human thoracic aorta. Out of 569 consecutive patients (age range 18-83 years), 108 were referred for TEE to evaluate recent embolism (Group I). The remaining 461 patients were referred for TEE for reasons unrelated to embolism (Group II). The plaque thickness was measured perpendicularly to the aortic wall. In the subgroup of patients with multiple mobile lesions, multiple vortices were suggested to be present when simultaneous rotations in different directions were found. The presence of a fixed PAP was associated with a statistically significant, albeit moderate, increase in the risk for embolism (adjusted odds ratio 4.1). The presence of mobile lesions was linked to an abrupt augmentation in this risk (adjusted odds ratio 30.1). Among the 35 patients in Group I there were 69 PAP: 8 (12%) in the ascending, 28 (41%) in the arch and 33 (48%) in the descending aorta. A total of 34 mobile lesions was detected: 1 (one patient) in the ascending aorta, 15 (10 patients) in the arch and 18 (11 patients) in the descending aorta. There was no significant difference between the arch and the descending aorta regarding the frequency of the plaques in these regions, whereas the ascending aorta presented the lowest prevalence for atheromatosis. Diastolic retrograde and rotational flows were observed in all patients. There were 16 multiple mobile PAP in 6 patients: in all these cases simultaneous rotations of mobile aortic plaques (MAP) in different directions (highly suggestive for the presence of multiple vortices and significant flow instability) were found in the arch and the descending but not the ascending aorta. Protruding aortic plaques and signs of relative aortic flow instability (presence of vortices) are mainly observed in the human arch and in the descending aorta, whereas the ascending aorta presented the lowest prevalence for atheromatosis. This issue may have significant implications in the study of atherosclerosis development in the human thoracic aorta and the pathogeneses of embolic events.

Adolescent↗
PubMed2000

Emergency room referral to internal medicine wards or to coronary care units of patients with first acute myocardial infarction. Israel Study Group on First Acute Myocardial Infarction.

The objective of the study was to assess factors associated with ward assignment in the emergency room for patients < or = 65 years old with first acute myocardial infarction. We analysed uni- and multivariate predictors for ward assignment (coronary care unit versus internal ward). Eight major centrally located Israeli hospitals provided data during one year. The study population included 1252 patients, of whom 83% were men, 37% were hypertensives, 22% were diabetics, and 14% had previous anginal syndrome. Most patients (83%) were admitted to the coronary care unit. Internal medicine ward assignment was significantly associated with advanced age, history of hypertension or diabetes, a longer time from appearance of symptoms to arrival at the hospital, and myocardial infarction type (non-Q-wave or non-anterior). The likelihood of medical ward referral increased stepwise with the increasing number of a patient's predictive factors: those with > or = 4 factors had a > 30% chance of being assigned to a medical ward compared to a < 10% chance when there were 0-3 risk factors. Exclusion of patients with thrombolysis had no effect on the results. The shortage of cardiac care unit beds apparently leads to emergency room selection acting in detriment of patients with poorest prognoses. Clear guidelines for decision making in the emergency room are needed to resolve this paradoxical situation.

Coronary Care Units↗
PubMed2000

Correlated expression of adhesive properties for both white and red blood cells during inflammation.

The state of leukocyte and erythrocyte adhesiveness/aggregation was determined in the peripheral blood of 382 patients with infection/inflammation as well as in 72 controls by using a simple slide test and image analysis. A highly significant correlation (r = 0.4, n = 455, p < 0.001) was found between the state of leukocyte and erythrocyte adhesiveness/aggregation. The extent of both leukocyte and erythrocyte aggregation correlated with the concentration of fibrinogen. Significant aggregation of leukocytes with erythrocytes was noted as well. We conclude that both leukocyte and erythrocyte aggregation occur in the peripheral blood of patients with infection/inflammation. Such cell aggregation, which might have detrimental rheological consequences, can be detected by using our novel technique.

Acute-Phase Reaction↗
PubMed2000

Anesthesia for victims of nerve agents undergoing surgery: establishment of a management protocol.

Awareness of the effects of nerve agents still being stocked around the world has led to the establishment of protocols for rapid evacuation and decontamination of large civilian areas. Perioperative care protocol and procedures for the administration of anesthesia in lifesaving surgical intervention for combined multiple trauma and intoxicated casualties have not been established. There are also no guidelines for anesthetizing those casualties who had already been medicated on site. The only exception to anecdotal reports and isolated communications on these issues is the organophosphate poisoning database of substances which act similarly to the nerve agents or their antagonists. We gathered the few reports existing on the subjects in the literature and extrapolated the knowledge of the nature and action of various anesthetic drugs. We applied it to biological and physiological conditions that exist in combined chemical and multiple trauma casualties and consolidated the data into two charts that may serve as guidelines for preventing the avoidable hazardous outcomes.

Anesthetics↗