Yoav Rosenthal, Amir Arami, Yona Kosashvili, Nir Cohen, Eli Sidon and Steven Velkes
Background: Bisphosphonates reduce the overall risk of fractures among patients with osteoporosis, and this beneficial effect is long-lasting. However, since bisphosphonates inhibit bone remodeling, they may enhance the formation and propagation of micro-cracks over time and patients may therefore be prone to atypical fatigue fractures, mainly in the subtrochanteric region and femoral shaft.
Objectives: To present two cases of subtrochanteric fractures related to bisphosphonate treatment and review of the current literature.
Conclusions: Despite the overall beneficial effect of bisphosphonates, further research is required to prevent this significant complication.
Noam Rosen, Roy Gigi, Amir Haim, Moshe Salai and Ofir Chechik
Background: Above-the-knee amputations (AKA) and below-the-knee amputations (BKA) are commonly indicated in patients with ischemia, extensive tissue loss, or infection. AKA were previously reported to have better wound-healing rates but poorer rehabilitation rates than BKA.
Objectives: To compare the outcomes of AKA and BKA and to identify risk factors for poor outcome following leg amputation.
Methods: This retrospective cohort study comprised 188 consecutive patients (mean age 72 years, range 25–103, 71% males) who underwent 198 amputations (91 AKA, 107 BKA, 10 bilateral procedures) between February 2007 and May 2010. Included were male and female adults who underwent amputations for ischemic, infected or gangrenotic foot. Excluded were patients whose surgery was performed for other indications (trauma, tumors). Mortality and reoperations (wound debridement or need for conversion to a higher level of amputation) were evaluated as outcomes. Patient- and surgery-related risk factors were studied in relation to these primary outcomes.
Results: The risk factors for mortality were dementia [hazard ratio (HR) 2.769], non-ambulatory status preoperatively (HR 2.281), heart failure (HR 2.013) and renal failure (HR 1.87). Resistant bacterial infection (HR 3.083) emerged as a risk factor for reoperation. Neither AKA nor BKA was found to be an independent predictor of mortality or reoperation.
Conclusions: Both AKA and BKA are associated with very high mortality rates. Mortality is most probably related to serious comorbidities (renal and heart disease) and to reduced functional status and dementia. Resistant bacterial infections are associated with high rates of reoperation. The risk factors identified can aid surgeons and patients to better anticipate and possibly prevent severe complications.
Arnon D. Cohen MD MPH PhD, Israel D. Andrews MD, Evgeny Medvedovsky MD, Roni Peleg MD, and Daniel A.Vardy MD MSc
Background: Localized itch of non-pruritoceptive origin is often neuropathic and may be referred to as neuropathic itch syndrome.
Objectives: To describe the results of nerve conduction studies in patients with anogenital pruritus, brachioradial pruritus and scalp dysesthesia, and compare these sites to typical sites of lichen simplex chronicus (LSC).
Methods: The study summarizes previously published data combined with unpublished data of patients with scalp dysesthesia. Nerve conduction studies included measurements of distal sensory and motor latency, conduction velocity and F-responses.
Results: A neuropathy was demonstrated in 29 of 36 patients with anogenital pruritus (80.5%), 8/14 with brachioradial pruritus (57.1%) and 4/9 with scalp dysesthesia (44.4%). The typical sites overlapped with some but not all LSC sites.
Conclusions: A considerable proportion of patients with brachioradial pruritus, anogenital pruritus and scalp dysesthesia have abnormal nerve conduction findings, suggesting a neuropathic origin. The skin sites overlap with some common LSC sites, suggesting that in some cases of LSC a local neuropathy could be a possible cause.
Itai Gat, Mordechai Dulitzki, Eyal Schiff, Eyal Sivan and Michal J. Simchen
Background: Homozygous carriers of factor V Leiden (FVL) have an up to 80-fold increased risk of venous thrombosis, but the risk of obstetric complications in FVL homozygosity is unclear.
Objectives: To compare obstetric and thromboembolic complications among factor V Leiden (FVL) homozygous and heterozygous carriers treated with prophylactic dose anticoagulation during pregnancy.
Methods: In this retrospective case-control study we performed a chart review for the years 2004–2010 of homozygous and heterozygous FVL carriers who were treated with low molecular weight heparin (LMWH) at a dose of 0.6 mg/kg/day during pregnancy. Adverse outcomes included thromboembolic and obstetric complications. A composite adverse obstetric outcome was defined as the presence of at least one of the following: late intrauterine fetal demise, severe intrauterine growth restriction (< 5th percentile), preeclampsia, placental abruption. Pregnancy outcomes of homozygous and heterozygous FVL carriers were compared.
Results: We compared the pregnancies of 13 homozygous FVL women with those of 82 heterozygous FVL carriers. Thromboembolic events occurred only in heterozygous FVL controls. Gestational age and birth weight were similar. The composite adverse obstetric outcome rate was higher for homozygous compared with heterozygous FVL carriers (23.1% vs. 11%, respectively), although not statistically significant. A trend for prematurity among homozygous FVL patients was evident, with 2/13 women (15.3%) in the homozygous FVL group giving birth before 34 weeks gestation, compared with only 2/82 (2.3%) in the heterozygous group.
Conclusions: Pregnancy outcome was similar for homozygous and heterozygous FVL carriers on LMWH thromboprophylaxis. The overall likelihood of thromboembolic complications was low. Thromboprophylaxis may decrease the risk for placental and thromboembolic complications in homozygous FVL patients to a similar level as in heterozygotes.
Chrystalleni Mylonas, Shifra T. Zwas, Galina Rotenberg, Gal Omry and Ohad Cohen
Background: To prevent the unwarranted effects of post-thyroidectomy hypothyroidism prior to radiodine (RAI) ablation, patients with well-differentiated thyroid cancer can currently undergo this treatment while in a euthyroid state. This is achieved with the use of recombinant human thyroid-stimulating hormone (rhTSH) injections prior to the ablation.
Objectives: To demonstrate the efficacy of rhTSH in radioiodine thyroid ablation in patients with differentiated thyroid cancer.
Methods: We conducted a retrospective study of patients who underwent total thyroidectomy for well-differentiated thyroid cancer with different levels of risk, treated with rhTSH prior to remnant ablation with radioiodine.
Results: Seventeen patients with thyroid cancer were studied and followed for a median of 25 months (range 8–49 months). Ablation (defined as stimulated thyroglobulin < 1 mg/ml, negative neck ultrasonography, and radioiodine scan) was successful in 15 patients (88.2%). One of the patients was lost to follow-up.
Conclusions: The use of rhTSH with postoperative radioiodine ablation may be an efficient tool for sufficient thyroid remnant ablation, avoiding hypothyroidal state in the management of thyroid cancer patients.
Hefziba Green, Noa Eliakim-Raz, Yael Zimra and Anat Gafter-Gvili