Dan Justo

Introduction: Unprovoked pulmonary embolism (UPE) is not rare and it is associated with an unfavorable prognosis in adults. However, the incidence and the prognosis of UPE in older adults have never been studied.Material and methods: This was a historical prospective study. We reviewed all the medical charts of all older adults (aged 70 years or more) with UPE, provoked pulmonary embolism (PPE), and malignancy-associated PE (MAPE), admitted to a tertiary medical center between 2010 and 2012. The all-cause 3-year mortality rates and cumulative survival following admission were compared between the groups.Results: The final cohort included 249 patients with PE: 161 (64.7%) were women; the mean age was 79.8 ±5.7 years. Overall, 36 (14.5%) patients had UPE, 81 (32.5%) patients had MAPE, and 132 (53.0%) patients had PPE. Overall, 39 (15.7%) patients died within 30 days, 76 (30.5%) patients died within 6 months, 101 (40.6%) patients died within 1 year, and 136 (54.6%) patients died within 3 years of admission. Relative to PPE and MAPE patients, the cumulative survival was significantly higher in UPE patients at each time point within 1 year of admission (p < 0.05 and p < 0.001, respectively). However, 3 years after admission, the cumulative survival was comparable between PPE patients and UPE patients, and was significantly lower in MAPE patients (p < 0.001).Conclusions: UPE is not rare in older adults with PE, and it is associated with a favorable prognosis within 1 year of admission in this population.

To study which laboratory malnutrition markers best predict 1-year mortality in hospitalized older adults as well as among patients at risk for malnutrition.

Infection might be associated with increased risk of venous thromboembolism (VTE) and arterial thrombosis. Specific hypotheses have been raised regarding the procoagulant response induced by acute cytomegalovirus (CMV) infection. Accordingly, we investigated the 6-month incidence of VTE and/or arterial thrombosis in patients that had been tested positive for CMV-IgM antibodies in a large health maintenance organization. Logistic regression analysis was used to identify independent risk factors for VTE and arterial thrombosis. Among 90,515 patients eligible for the VTE analysis and 90,805 patients eligible for the arterial thrombosis analysis, 6,205 (6.9 %) and 6,222 (6.9 %) patients were tested positive for CMV-IgM antibodies, respectively. During 6 months of follow-up from index date, the incidence rates per 1,000 capita of VTE among CMV-IgM seropositive and CMV-IgM seronegative patients were 3.06 (19 patients) and 1.36 (115 patients), respectively (odds ratio (OR) 2.25; 95 % confidence intervals (95 % CI) 1.38–3.66; p = 0.003). CMV-IgM seropositivity was independently associated with VTE appearance (OR 2.49; 95 % CI 1.53–4.06; p < 0.0001) following adjustment for age, sex, and other confounders. The incidence rates per 1,000 capita of arterial thrombosis among CMV-IgM seropositive and CMV-IgM seronegative patients were 1.12 (7 patients) and 1.06 (90 patients), respectively (OR 1.06; 95 % CI 0.49–2.28; p = 0.840). CMV-IgM seropositivity was not associated with arterial thrombosis. We conclude that acute CMV infection might be associated with an increased short-term VTE risk. To the best of our knowledge, this is the largest study ever to confirm this association.

Little is known about the time-course of the postprandial appearance of macronutrient-induced inflammatory response. Our aim was to investigate the postprandial inflammatory and metabolic response following high fat, high caloric popular meals in apparently healthy participants. Fifty four apparently healthy normal weight volunteers (BMI of 25.9±0.9) were given two iso-caloric meals with similar amounts but different composition of fats: a meal high in monounsaturated fats (MUFA), and a meal high in saturated fat (SFA). Three main effects and the interactions between them were analyzed: the time (before and 2 and 4 hours following the meals), the meal (MUFA or SFA) and the gender. The effect of time from the meal on hs-CRP level was highly significant (p=0.004). The highest responses were observed 2 hours after the meal (p=0.002). A statistically significant interaction was found between the time and the meal (p≤0.0001), which reflects the higher increase in hs-CRP values 2 hours after the SFA meal, with no effect by the MUFA meal. The white blood cell counts were affected significantly by the time (p≤0.0001) however, other inflammatory markers (fibrinogen, IL-6, TNFα, ICAM and VICAM) were not. All the metabolic markers (insulin, glucose, HOMA-R, QUICKI and triglycerides) were affected by the time (p≤0.0001), with no interactions observed. Metabolic and modest inflammatory changes occur within a few hours after the ingestion of a high SFA meal in apparently healthy adults.

Acute illness and prolonged bed rest might be associated with loss of muscle mass and significant decline in functional ability and mobility, regardless of a specific neurological or orthopedic insult. This condition is commonly termed hospital-associated deconditioning (HAD). To the best of our knowledge to date, acute inpatient rehabilitation length and outcome for HAD in the elderly have never been studied in Israel. To study which variables are independently associated with the length and mobility outcome of acute inpatient rehabilitation for HAD in the elderly. A retrospective cross-sectional study was conducted during 2009 at the departments of Geriatric Medicine in the Tel-Aviv Medical Center The medical charts of consecutive elderly (< 65 years) patients admitted for rehabilitation due to HAD were studied for the following measurements: demographics, co-morbidities, causes of HAD, admission albumin serum levels, Mini-Mental Status Examination (MMSE) scores, admission transfer and walking Functional Independence Measure (FIM) scores, discharge transfer and walking FIM scores, and rehabilitation length. The cohort included 103 patients: 57 (55.3%) females and 46 (44.7%) males. The mean age for the entire cohort was 83.6 +/- 6.0 years. The three most common causes of HAD were pneumonia, craniotomy due to intracranial bleeding without neurological insults, and congestive heart failure exacerbation. The mean discharge transfer and walking FIM scores were 5.3 +/- 0.9 and 5.2 +/- 0.8, respectively. The mean length of rehabilitation was 20.4 +/- 13.9 days. Linear regression analysis showed that discharge transfer FIM scores, discharge walking FIM scores, and rehabilitation length were all independently associated with mobility upon admission to rehabilitation (p < 0.0001, p < 0.0001, p = 0.024, respectively). Rehabilitation length was also associated with admission albumin serum levels (p = 0.008). The length and mobility outcomes of acute inpatient rehabilitation for HAD in the elderly are associated with mobility upon admission to rehabilitation. Acute inpatient rehabilitation length is also associated with admission albumin serum levels.

We studied the prevalence of erectile dysfunction (ED) in elderly men, aged 65 years or above, with coronary artery disease (CAD) documented by coronary angiography. A total of 123 men (112 men with CAD and 11 men without CAD), mean age 74.6±5.9 years, was included. To detect ED and assess its severity, all participants were asked to complete the Sexual Health Inventory for Males (SHIM) questionnaire. Lack of sexual activity was more prevalent among men with CAD relative to men without CAD (31.3 vs 0.0%). Among the sexually active men, ED was more prevalent among men with CAD relative to men without CAD (85.7 vs 72.7%). A general linear model showed that age was the only factor associated with SHIM scores among the sexually active men with CAD (P=0.001). Other factors, such as the number of occluded coronary arteries, diabetes mellitus, hypertension, smoking, various medications and marital status, were not associated with SHIM scores in elderly men with CAD. We conclude that lack of sexual activity and ED are very common in elderly men with CAD. Among the sexually active men with CAD, ED severity is associated only with age.

The prevalence of sexual dysfunction in adult women with coronary artery disease (CAD) has seldom been studied, and the association between sexual dysfunction severity and with CAD severity has never been studied. To study the prevalence of sexual dysfunction and its severity by CAD severity in adult women. Adult women undergoing coronary angiography at the Tel Aviv Medical Center completed a sexual questionnaire titled Female Sexual Function Index (FSFI). Scores of 23 or lower in this questionnaire were consistent with sexual dysfunction. The cohort was divided into three groups: 1. Women without CAD. 2. Women with one vessel disease. 3. Women with two or more vessel disease. CAD was defined as one or more coronary artery stenosis of 50% or more, and/or history of myocardial infarction. The prevalence of sexual dysfunction and cardiovascular risk factors was compared between these groups. The study included 104 adult women (age range: 42-92 years; mean age: 11.2 +/- 68.7 years). Sixty-five (62.5%) ,women had one-vessel disease (n = 27) or more (n = 38). Overall, 39 (37.5%) women had no coronary stenosis and/or history of myocardial infarction. Most women (n = 68; 65.4%) had no sexual activity. Among the 36 sexually active women, 11 (30.6%) women had a normal sexual function. Normal sexual function was two-times more prevalent in women without CAD relative to women with CAD (7.7% vs. 15.4%; p = 0.049). These findings were not statistically significant following adjustment for age. The odds for normal sexual function were low as more coronaries were stenotic, but these findings were not statistically significant. A trend towards association between CAD severity and sexual dysfunction severity in adult women has been demonstrated for the first time. Sexual dysfunction and lack of sexual activity are very common among adult women with CAD. There is a negative association between the number of coronary arteries involved and normal sexual function, but this trend should be studied in a larger cohort.

Erectile dysfunction (ED) is the inability to attain and/ or maintain an erection sufficient for satisfactory sexual performance. The prevalence of ED among elderly men is 52%, and it is associated with preventable and treatable cardiovascular conditions, such as diabetes mellitus, hyperlipidemia, hypertension and smoking. Treating these conditions may prevent cardiovascular diseases and ED. Nevertheless, large-scale studies regarding the prevalence of ED among young men has never been conducted, although prevention should be performed in younger ages. A unique screening examination, including a sexual questionnaire has been conducted in Israel since 2001. Men who are suspected of ED, according to this questionnaire, are referred to a sexual clinic for consultation and treatment. In this review, we present several studies based on this database. Our main findings: ED is prevalent in young men and is associated with diabetes mellitus, hypertriglyceridemia, sleeping disorders and periodontal diseases. These findings stress the importance of incorporating a sexual questionnaire in screening examinations.