Heart failure with reduced ejection fraction (HFrEF) is an increasing global pandemic affecting more than 30 million individuals worldwide. Importantly, HFrEF is frequently accompanied by the presence of cardiac and non-cardiac comorbidities that may greatly influence the management and prognosis of the disease. In this review article, we will focus on three important comorbidities in HFrEF; atrial fibrillation (AF), advanced renal disease, and elderly, which all have a paramount impact on progression of the disease, management strategies, and response to therapy. AF is very common in HFrEF and shares many risk factors. AF aggravates heart failure and contributes to HFrelated adverse clinical outcomes; hence it requires special consideration in HFrEF management. The kidney function is largely affected by the reduced cardiac output developed in the setting of HFrEF, and the neurohormonal feedback effects create a complex interplay that pose challenges in the management of HFrEF when renal function is significantly impaired. Cardiorenal syndrome is a challenging sequela with increased morbidity and mortality thereby reflecting the delicate and complex balance between the heart and the kidney in HFrEF and renal failure conditions. Furthermore, patients with advanced renal failure have poor prognosis in the presence of HFrEF with limited treatment options. Finally, aging and frailty are important factors that influence treatment strategies in HFrEF with greater emphasis on tolerability and safety of the various HFrEF therapies in elderly individuals.
CONTEXT Thyroid hormones play a key role in systemic metabolism, yet the relationship between thyroid dysfunction and risk for type 2 diabetes is unclear. OBJECTIVE To assess type 2 diabetes risk in adulthood among adolescents with thyroid disorders. DESIGN AND SETTING A nationwide, population-based study of Israeli adolescents who were examined before military recruitment during 1988–2007, and were followed until December 31, 2016. PARTICIPANTS 1,382,560 adolescents (mean age 17.3 years). INTERVENTIONS The diagnosis of thyroid disorders was based on recent thyroid function tests. Data were linked to the Israeli National Diabetes Registry. Cox proportional hazard models were applied. MAIN OUTCOME MEASURES Type 2 diabetes incidence. RESULTS During a mean follow-up of 18.5 years, 1.12% (69 of 6,152) of adolescents with thyroid disorders were diagnosed with type 2 diabetes vs. 0.77% of adolescents without thyroid disorders. The HR for type 2 diabetes was 2.3 (95%CI, 1.8–2.9) among those with thyroid disorders, after adjustment for sex, birth-year, BMI and sociodemographic confounders. The increased diabetes risk was observed in both men and women, presence or absence of obesity, in the absence of other health conditions, and was associated with different types of thyroid disorders. It was also similar when the outcome was defined as type 2 diabetes diagnosed at or before the age of 30 years (HR 2.3; 95%CI, 1.5–3.5). CONCLUSIONS Thyroid disorders diagnosed in adolescence are a risk factor for early-onset type 2 diabetes in both men and women.
Hypovolemic shock is the leading cause of preventable death on the battlefield. Remote damage control resuscitation has evolved dramatically in the past decade by introducing novel treatments and approaches to bleeding in the prehospital setting. This report presents a case of a casualty who sustained multiple gunshot wounds to the chest and gluteal regions and suffered from hemorrhagic shock with an Injury Severity Score of 34. The casualty was treated at the point of injury and during evacuation according to the IDF’s remote damage control resuscitation algorithm utilizing the range of blood products available in the IDF. Prompt identification of the mechanism of injury, clinical and tactical decision-making, and immediate advanced medical care through several prehospital medical evacuation platforms culminated in this casualty’s survival. This case emphasizes the importance of medical advancements in prehospital field care and guideline-directed treatment to improve casualty survival.
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