Gideon Koren

Bio: Gideon Koren is an academic researcher from Ariel University. The author has contributed to research in topics: Pregnancy & Population. The author has an hindex of 129, co-authored 1994 publications receiving 81718 citations. Previous affiliations of Gideon Koren include McGill University Health Centre & University of Western Ontario.

A Double-Blind, Placebo-Controlled Trial of Transdermal Fentanyl After Abdominal Hysterectomy: Analgesic, Respiratory, and Pharmacokinetic Effects

Abstract: BackgroundA randomized, double-blind, placebo-controlled trial was conducted to assess the analgesic, pharmacokinetic, and clinical respiratory effects of 72-h application of two transdermal fentanyl (TTSF) patch sizes in patients undergoing abdominal hysterectomy. MethodsTTSV patches releasing 50 μg/h (TTSF-50) or 75 μg/h (TTSF-75) fentanyl or placebo patches were applied to 120 women 2 h before abdominal hysterectomy under general anesthesia. Postoperatively, all patients had access to supplemental morphine using patient-controlled analgesia pumps. Each patient was attended continuously by a research nurse for 8 h on the night before surgery and for 84 h after patch application. The following data were collected: visual analog scale pain scores, supplementary analgesia, fentanyl plasma concentration (4-h intervals), continuous hemoglobin saturation (pulse oximetry), respiratory pattern (continuous respiratory inductive plethysmography), and adverse effects (nausea, vomiting, pruritus). Data analysis included analysis of variance, Kruskal-Wallis, and chi-squared. P < 0.05 was considered significant. ResultsThere were no demographic differences among groups. Visual analog scale pain scores were significantly lower for the TTSF-75 group, and supplemental morphine was significantly decreased in the TTSF-75 group in the postanesthesia care unit and for both the TTSF-50 and the TTSF-75 group for 8–48 h postoperatively. Between 5 and 36 h, the TTSF groups had significantly increased abnormal respiratory pattern including apneic episodes (tidal volume of less than 100 ml for more than 15 s) and episodes of slow respiratory rate (less than 8 breaths/min persisting for more than 5 min) and significantly increased requirement for oxygen supplementation. Nine patients in the TTSF groups were withdrawn because of severe respiratory depression compared to none in the placebo group. No significant between-group differences were present in the incidence of nausea, vomiting, or pruritus. Although fentanyl plasma concentration was higher in the TTSF-75 group than in the TTSF-50 group, the differences were not significant. Fentanyl plasma concentration decreased significantly 48 h after patch application. ConclusionsApplication of TTSF patches 2 h preoperatively is associated with moderate supplementary opioid requirements for analgesia in the early postoperative period and ongoing opioid supplementation for at least 72 h. Although good analgesia is the result of this combination therapy, it is associated with a high incidence of respiratory depression requiring Intensive monitoring, oxygen supplementation, removal of the TTSF patches in approximately 11% of the patients, and opioid reversal with naloxone in approximately 8% of the patients.

Thrombocytopenia and megakaryocyte dysplasia: an adverse effect of valproic acid treatment.

Abstract: We describe a 10-year-old girl with thrombocytopenia for 5 months. She has severe cerebral palsy, quadriplegia, developmental delay, and a seizure disorder. She had been treated with valproic acid (Depakene) 53 mg/kg/day t.i.d. for 2 years before presentation. Her platelet count decreased to 28 × 10/L a short time before presentation. Five months ago she was admitted for severe pneumonia; her laboratory values were as follows: platelet count 38 × 10/L, fibrinogen 6.37 (normal 1.60–4.0) g/L, DDI >7,000 (normal 0–449) ng/mL, and International Normalized Ratio 1.6 (normal 0.9–1.1). Other hematologic findings included hemoglobin 66 (normal 120–160) g/L, absolute reticulocyte count 517 (normal 10–100) × 10/L, mean corpuscular volume 98 (normal 80–94) fL, erythrocyte sedimentation rate 130 mm/h, and negative direct antiglobulin test. Vitamin B12 and folate levels were normal. She was successfully treated for pneumonia and did not require platelet transfusions. With the improvement of her clinical condition, her complete blood count and coagulation screen returned to normal except for prolonged thrombocytopenia with limited response to intravenous immunoglobulin. Therefore, a bone marrow aspiration was performed (Fig. 1). This case illustrates one of the hematologic adverse effects of valproic acid, namely thrombocytopenia with megakaryocytic dysplasia. The long-standing thrombocytopenia with valproic acid levels up to 1,115 (normal 350–700) mmol/L before bone marrow aspiration and the improvement after dose reduction of valproic acid, resulting in levels of 517 mmol/l, strongly suggest that they are related to

Hair cortisol as a biomarker of stress in the 2011 Libyan war.

Abstract: Purpose: There is a substantial body of research that utilizes saliva cortisol levels to examine wartime stress; however, there is a paucity of literature that utilizes hair cortisol levels, which allows for long-term assessment of chronic stress, to investigate the stress of war. The present study aimed to evaluate changes in hair cortisol concentrations before, during, and after the 2011 Libyan war. Methods: This study examined hair cortisol concentrations of young adult women who were living in Tripoli, Libya during the 2011 war. The participants were recruited at the campus of Tripoli University. Participants needed to have at least 24 cm of hair and to have resided in Tripoli before, during and after the 2011 Libyan war. Hair was sectioned to reflect 3 month windows of cortisol exposure corresponding to periods before, during and after the war. Hair cortisol concentrations were quantified using a modified salivary ELISA test. The women were also asked to complete the Perceived Stress Scale pertaining to the post-war period. Results: Median hair cortisol concentrations in the post-war period (226.11 ng/g; range 122.95-519.85 ng/g) were significantly higher than both the pre-war (180.07 ng/g; 47.13-937.85 ng/g) and wartime (186.65 ng/g; 62.97-771.79 ng/g) periods (P<0.05). The mean PSS score (24) was in the range of “much higher than the mean” for this test and the vast majority of participants were either in the “much higher than the mean” or “slightly higher than the mean” ranges. Hair cortisol determination suggests that in Tripoli, the post-war period appears to have been more stressful than the war itself. This is consistent with the fact that during the war the civilian participants were not directly involved with warfare, nor were they targeted by the international coalition fighting Gaddafi. In contrast, the post-war period was characterized by chaos and total lack of authority, with the participants exposed to injury, lack of food and destruction. Conclusion: This study documents the utility of hair cortisol levels to retrospectively assess stress before, during, and after an armed conflict.

New antidepressants in pregnancy.

Abstract: QUESTION: I have read that fluoxetine is the drug of choice for treating depression during pregnancy. One of my patients, who did not respond to the "old" selective serotonin reuptake inhibitors, is doing well on venlafaxine and is now 6 weeks pregnant. What advice should I give her? ANSWER: Fluoxetine is recommended because to date it has the most evidence of its safety. It is important that women be treated appropriately for depression during pregnancy, and some research on the newer antidepressants, such as venlafaxine, will be useful to you and your patient in making an informed decision regarding treatment.

Effect of Lidocaine-Prilocaine Cream (EMLA®) on Pain of Intramuscular Fluzone® Injection

Abstract: The efficacy of lidocaine-prilocaine cream (EMLA® — Eutectic mixture of Local Anesthetics) in alleviating the pain of intramuscular injections was investigated in a randomized, double-blind, placebo-controlled, parallel group trial. EMLA® or placebo cream was applied to the arms of 60 adult volunteers before receiving influenza virus vaccine (Fluzone®). Twenty-nine subjects received approximately 2.5 g of EMLA® cream and 31 subjects received approximately 2.5 g of an inert placebo cream under occlusion for 60-90 minutes. The cream was then removed and each subject received one 0.5 mL intramuscular injection of influenza virus vaccine using a 22 gauge one inch needle. Pain of needle puncture and pain of injection were both assessed by the subjects using a visual analog scale. EMLA® was associated with decreased needle puncture pain (p < 0.0002) and decreased pain of injection when compared to placebo (p = 0.0139). There was a significant correlation between scores of needle puncture pain and injection pain. Mild skin pallor was a common skin reaction from EMILA®· While the efficacy of EMLA® to alleviate pain of venipuncture is well documented, this is the first study to show the efficacy of EMLA ® for intramuscular injections. RESUME Une etude randomisee a double insu, en controle parallele avec placebo a permis d'evaluer la capacite de la Lidocaine-Prilocaine (creme EMLA® — melange eutectique d'anesthesiques locaux) a soulager la douleur causee par les injections intramusculaires. On a applique la creme EMLA® ou un placebo sur le bras de 60 volontaires adultes avant de leur injecter un vaccin viral contre la grippe (Fluzone®). Vingt-neuf (29) sujets ont ete traites avec la creme EMLA® et 31 avec le placebo. Tous ont recu une application d'environ 2,5 g de creme sous un pansement occlusif pendant 60 a 90 minutes. Apres l'elimination de la creme, on leur a injecte 0,5 mL de vaccin par voie intramusculaire au moyen d'une aiguille calibre 22 d'un pouce. Les sujets ont evalue la douleur causee par l’insertion de l'aiguille et par l'injection au moyen d'une echelle visuelle analogique. Comparativement au placebo, la creme EMLA® a attenue la douleur associee a l'insertion de l’aiguille (p < 0.0002) et a l’injection (P = 0,0139). On a note une correlation significative entre les cotes se rapportant a la douleur provoquee par l'insertion de l'aiguille et celles relatives a la douleur causee par l'injection. L'apparition d'une legere pâleur fut une reaction cutanee courante a l'application de la creme EMLA®. Il est bien etabli que cette derniere soulage la douleur due a la ponction veineuse, mais la presente etude est la premieree a demontrer son efficacite en cas d'injection intramusculaire.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Abstract: The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.

2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).

Abstract: ABCD : Appropriate Blood pressure Control in Diabetes ABI : ankle–brachial index ABPM : ambulatory blood pressure monitoring ACCESS : Acute Candesartan Cilexetil Therapy in Stroke Survival ACCOMPLISH : Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension ACCORD : Action to Control Cardiovascular Risk in Diabetes ACE : angiotensin-converting enzyme ACTIVE I : Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events ADVANCE : Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation AHEAD : Action for HEAlth in Diabetes ALLHAT : Antihypertensive and Lipid-Lowering Treatment to Prevent Heart ATtack ALTITUDE : ALiskiren Trial In Type 2 Diabetes Using Cardio-renal Endpoints ANTIPAF : ANgioTensin II Antagonist In Paroxysmal Atrial Fibrillation APOLLO : A Randomized Controlled Trial of Aliskiren in the Prevention of Major Cardiovascular Events in Elderly People ARB : angiotensin receptor blocker ARIC : Atherosclerosis Risk In Communities ARR : aldosterone renin ratio ASCOT : Anglo-Scandinavian Cardiac Outcomes Trial ASCOT-LLA : Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm ASTRAL : Angioplasty and STenting for Renal Artery Lesions A-V : atrioventricular BB : beta-blocker BMI : body mass index BP : blood pressure BSA : body surface area CA : calcium antagonist CABG : coronary artery bypass graft CAPPP : CAPtopril Prevention Project CAPRAF : CAndesartan in the Prevention of Relapsing Atrial Fibrillation CHD : coronary heart disease CHHIPS : Controlling Hypertension and Hypertension Immediately Post-Stroke CKD : chronic kidney disease CKD-EPI : Chronic Kidney Disease—EPIdemiology collaboration CONVINCE : Controlled ONset Verapamil INvestigation of CV Endpoints CT : computed tomography CV : cardiovascular CVD : cardiovascular disease D : diuretic DASH : Dietary Approaches to Stop Hypertension DBP : diastolic blood pressure DCCT : Diabetes Control and Complications Study DIRECT : DIabetic REtinopathy Candesartan Trials DM : diabetes mellitus DPP-4 : dipeptidyl peptidase 4 EAS : European Atherosclerosis Society EASD : European Association for the Study of Diabetes ECG : electrocardiogram EF : ejection fraction eGFR : estimated glomerular filtration rate ELSA : European Lacidipine Study on Atherosclerosis ESC : European Society of Cardiology ESH : European Society of Hypertension ESRD : end-stage renal disease EXPLOR : Amlodipine–Valsartan Combination Decreases Central Systolic Blood Pressure more Effectively than the Amlodipine–Atenolol Combination FDA : U.S. Food and Drug Administration FEVER : Felodipine EVent Reduction study GISSI-AF : Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation HbA1c : glycated haemoglobin HBPM : home blood pressure monitoring HOPE : Heart Outcomes Prevention Evaluation HOT : Hypertension Optimal Treatment HRT : hormone replacement therapy HT : hypertension HYVET : HYpertension in the Very Elderly Trial IMT : intima-media thickness I-PRESERVE : Irbesartan in Heart Failure with Preserved Systolic Function INTERHEART : Effect of Potentially Modifiable Risk Factors associated with Myocardial Infarction in 52 Countries INVEST : INternational VErapamil SR/T Trandolapril ISH : Isolated systolic hypertension JNC : Joint National Committee JUPITER : Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin LAVi : left atrial volume index LIFE : Losartan Intervention For Endpoint Reduction in Hypertensives LV : left ventricle/left ventricular LVH : left ventricular hypertrophy LVM : left ventricular mass MDRD : Modification of Diet in Renal Disease MRFIT : Multiple Risk Factor Intervention Trial MRI : magnetic resonance imaging NORDIL : The Nordic Diltiazem Intervention study OC : oral contraceptive OD : organ damage ONTARGET : ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial PAD : peripheral artery disease PATHS : Prevention And Treatment of Hypertension Study PCI : percutaneous coronary intervention PPAR : peroxisome proliferator-activated receptor PREVEND : Prevention of REnal and Vascular ENdstage Disease PROFESS : Prevention Regimen for Effectively Avoiding Secondary Strokes PROGRESS : Perindopril Protection Against Recurrent Stroke Study PWV : pulse wave velocity QALY : Quality adjusted life years RAA : renin-angiotensin-aldosterone RAS : renin-angiotensin system RCT : randomized controlled trials RF : risk factor ROADMAP : Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention SBP : systolic blood pressure SCAST : Angiotensin-Receptor Blocker Candesartan for Treatment of Acute STroke SCOPE : Study on COgnition and Prognosis in the Elderly SCORE : Systematic COronary Risk Evaluation SHEP : Systolic Hypertension in the Elderly Program STOP : Swedish Trials in Old Patients with Hypertension STOP-2 : The second Swedish Trial in Old Patients with Hypertension SYSTCHINA : SYSTolic Hypertension in the Elderly: Chinese trial SYSTEUR : SYSTolic Hypertension in Europe TIA : transient ischaemic attack TOHP : Trials Of Hypertension Prevention TRANSCEND : Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease UKPDS : United Kingdom Prospective Diabetes Study VADT : Veterans' Affairs Diabetes Trial VALUE : Valsartan Antihypertensive Long-term Use Evaluation WHO : World Health Organization ### 1.1 Principles The 2013 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology …

2007 Guidelines for the Management of Arterial Hypertension : The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).

Abstract: 2007 Guidelines for the Management of Arterial Hypertension : The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).

Standards of Medical Care in Diabetes

Abstract: XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.