Israel Medical Association Journal

Background: In recent years there has been an increase in endovascular repair of thoracic aortic aneurysms. In cases of insufficient neck length, occlusion of left subclavian artery achieves proper sealing and is usually well tolerated. Selected cases require revascularization of the left subclavian artery, including patients after coronary bypass surgery (left internal mammary to left anterior descending) and those with arm claudication or subclavian steal syndrome.

Objectives: To evaluate the tolerability of left subclavian artery occlusion by stent graft without revascularization.

Methods: Thirty patients with thoracic aortic aneurysms underwent endovascular repair between July 2000 and November 2004. Eleven of them had occlusion of the left subclavian artery that required revascularization in two. Follow-up (average 3 years) included a) blood pressure measurements of both arms at rest, after effort and pulse palpation, and b) vertebral blood flow by duplex scan.

Results: Of nine patients with no revascularization, 8 (89%) tolerated left subclavian artery occlusion with no claudication or steal syndrome; one (11%) suffered mild claudication only after effort and required no intervention. No left radial pulses were palpated in the nine patients. Blood pressure measurements in the left arm showed an average decrease of 40%, which remained constant after induced effort in all patients and was clinically insignificant. Duplex scan demonstrated reverse flow in the left vertebral artery in 8 of 9 patients (89%) and occlusion in 1 (originating in the arch and covered by the stent graft) with no clinical symptoms.

Conclusions: Left subclavian artery occlusion by stent graft is a tolerable procedure in the long term. In most cases, the constant decrease in blood pressure remained unchanged during follow-up and had no significant adverse affects. Most patients do not require revascularization prior to the endovascular procedure.
 

Background: Arabs in Israel have high morbidity and mortality from diabetes and cardiovascular disease. Obesity is a risk factor for both conditions.

Objectives: To investigate the prevalence of obesity (body mass index > 30 kg/m²), subjects' knowledge and behaviors, and their reports on practices of health-care professionals regarding body weight among Arabs and Jews.

Methods: The study participants (n=880) were randomly sampled from the urban population of the Hadera district in Israel. Data on demographic, socioeconomic and lifestyle characteristics; reports on height, current body weight and body weight at the age of 18 years; knowledge and behavior; and health-care professionals' practices with regard to body weight were obtained by interview. Anthropometric measurements were performed subsequently.

Results: Information on BMI[1] was available on 868 participants (49% Arabs, 49% women, median age 46 years). Although the median BMI did not differ significantly between Arabs and Jews at age 18, the prevalence of current obesity was 52% in Arab women compared to 31% in Jewish women (P < 0.001), and 25% in Arab men compared to 23% in Jewish men (P = 0.6). On multivariate analysis, obesity was significantly associated with age, BMI at the age of 18 years, leisure time physical activity and cigarette smoking, but not with ethnicity. Fewer Arabs reported measuring their body weight and Arab women were less frequently advised to maintain an active lifestyle.

Conclusions: The high prevalence of obesity among Arab women may be explained by lifestyle characteristics. Prevention of obesity in Arabs should be directed at women and should start preferably before adulthood.

Background: The rate of trauma in the elderly is growing.

Objectives: To evaluate the characteristics of non-hip fracture-associated trauma in elderly patients at a level I trauma center.

Methods: The study database of this retrospective cohort study was the trauma registry of a level I trauma center. Trauma patients admitted from January 2001 to December 2003 were stratified into different age groups. Patients with the diagnosis of hip fracture were excluded.

Results: The study group comprised 7629 patients. The non-hip fracture elderly group consisted of 1067 patients, 63.3% women and 36.7% men. The predominant mechanism of injury was falls (70.5%) and most of the injuries were blunt (94.1%). Injury Severity Score was found to increase significantly with age. The average mortality rate among the elderly was 6.1%. Age, ISS[1], Glasgow Coma Score on admission, and systolic blood pressure on admission were found to be independent predictors of mortality.

Conclusions: Falls remain the predominant cause of injury in the elderly. Since risk factors for mortality can be identified, an effective community prevention program can help combat the future expected increase in morbidity and mortality associated with trauma in the elderly.

Background: The contribution of drugs and alcohol to current trauma‑related morbidity and mortality in Israel is not known. Identification of these factors in the fast-changing demographics of the Israeli population might lead to better care and, no less importantly, to targeted prevention measures.

Objectives: To determine the incidence of alcohol‑related trauma, and to specify the time of day, the cause of trauma, and the morbidity and mortality rates as compared to non-alcohol‑associated trauma in the tertiary trauma unit of a large medical center in Tel Aviv.

Methods: Data were obtained from the Israel National Trauma Registry, based on patient records in our institution (Tel Aviv Sourasky Medical Center) from January 2001 to December 2003.

Results: Of the 5,529 patients who were enrolled in the study, 170 had high alcohol blood levels (> 50 mg/dl). Patients intoxicated with alcohol had higher rates of road accident injuries (35% versus 24% non‑intoxicated) and stab wounds (29% vs. 7%). The Injury Severity Score of the alcohol‑intoxicated patients was higher (32% ³ 16 vs. 12% ³ 16). The alcohol‑intoxicated patients were more likely to be non-Jewish (34% vs. 9%), young (82% aged 15–44 years) and males (91%). Most of the alcohol‑related injuries occurred during the weekend (47%) and during evening‑late night hours (from 7 a.m. to 11 p.m.; 55%).

Conclusions: Alcohol‑associated trauma differs from non-alcohol‑associated trauma in many ways. Since the population at risk can be identified, it is important that legislative, social, enforcement and educational measures be adopted to reduce the extent of alcohol abuse and thereby improve the level of public safety.
 

Background: Complementary medicine incorporates several methods of treatment, all of which aim to promote the health and quality of life of the patient. Public interest and demand for complementary medicine services have increased in recent years in Israel, as they have throughout the western world.

Objective: To characterize patients attending the Com­plementary Medicine Clinic in southern Israel at the completion of its first 2 years of operation.

Methods: Data for 398 patients selected at random from 4,400 patients treated in the clinic were collected retroactively from the patientsq' charts.

Results: Of those who visited the clinic, 68% were women with an average age of 49 years. Patients attending the clinic had higher rates of hypertension (20%), diabetes (6%) and heart disease (7%) than the general population of patients insured at the Clalit Health Services in the southern region. In addition to musculoskeletal problems (47%), the other most common complaint was emotional problems (13%) such as tension and anxiety. Acupuncture and Shiatsu were the most commonly used types of treatment (61%). Homeopathy was used by 7%. Among patients with musculoskeletal problems, there were significantly more men than women (P= 0.02). The mean age was higher (P= 0.07). And more of them were referred by friends or family (P= 0.06) than those with other problems.

Conclusions: Characterizing patients attending a com­plementary medicine clinic is imporant for the planning of marketing and resource management, and can assist primary care physicians in decisions regarding the referral of patients to this type of healthcare.

Background: Case-control and prospective studies indicate that an elevated plasma homocysteine level is a powerful risk factor for atherosclerotic vascular diseases. Certain medications can induce hyperhomocystinemia, such as methotrexate, trimethoprim and anti-epileptic drugs. There are few reports indicating an interaction between lipid-lowering drugs (cholestyramine and niacin) and homocysteine. Recently, an interaction was shown between fenofibrate and benzafibrates (a fibric acid derivative) and homocysteine plasma levels.

Objectives: To evaluate the effects of different fibrates on plasma homocysteine levels and to measure the reversibility of this effect.

Methods and Results: We investigated the effects of ciprofibrate and bezafibrate on homocysteine levels in patients with type IV hyperlipidemia and/or low high density lipoprotein levels. While a 57% increase in homocysteine was detected in the ciprofibrate-treated group (n=26), a 17% reduction n homocysteine was detected in the group treated with bezafibrate (n=12). The increase in homocysteine in the ciprofibrate-treated group was sustained for the 12 weeks of treatment and was partially reversible after 6 weeks of discontinuing the ciprofibrate therapy.

Conclusions: These results indicate that an increase In plasma homocysteine levels following administration of flbrates is not a class effect, at least in its magnitude. Moreover, it is reversible upon discontinuation of the treatment.
 

Background: The course and outcome of appendicitis in the elderly differs from that of the general population. The rates of perforated appendices, error in diagnosis, postoperative complications and mortality may be related to the time lapse between onset of symptoms and admission, and hence delay in surgery.

Objectives: To evaluate if these factors have improved in recent years.

Methods: A retrospective study was carried out of all 61 patients over age 60 who underwent appendectomies in a major metropolitan hospital during 1988-98.

Results: We found that most patients had appendectomies within the first 24 hours of admission and within 3 days of symptoms. Rate of perforation was 43%, error 5.6%, morbidity 41%, and mortality 3.2%.

Conclusions: The high rate of appendix perforation in the elderly is not due to delay. The literature reveals little improvement in the statistics of the disease over the last five decades, despite advances in imaging and surgical technique. This may be explained by the increasing inclusion of octogenarian patients.
 

Background: Bronchiolitis caused by respiratory syncytial virus is one of the major causes of hospitalization in young children, especially during the winter.  Recent evidence has shown that pharmacological treatment, especially nebulized epinephrine, in addition to the traditional supportive treatment, can alleviate symptoms and shorten hospitalization, but this approach is not yet widespread.

Objectives: To determine whether the management of bronchiolitis in Israel is moving toward a stronger emphasis on pharmacological care.

Methods: A questionnaire on the diagnosis and management of bronchiolitis was completed by 27 heads of pediatric departments throughout Israel.  The questionnaire dealt with the frequency of usage of diagnostic and selected therapeutic procedures.

Results: Chest X-ray and arterial blood gases are commonly used as a diagnostic aid in more than 75% of the departments, and antibiotics are prescribed routinely in 24%.  Corticosteroids are still in use: 48% use systemic steroids, and 19% nebulized steroids.  Nebulized epinephrine is used in 22% of the departments, while nebulized beta-agonists are used frequently in two-thirds of the departments.

Conclusions: Despite convincing data that beta-agonists and steroids have no positive effect on the outcome of bronchiolitis on the one hand, and that nebulized epinephrine has advantages in children on the other, we found significant use of the former two agents and sparse use of the latter.  Greater awareness is needed among pediatricians, and measures should be introduced to incorporate the new recommendations, with further study of the effect of the old and new drugs on bronchiolitis.