Salman Zarka, Masad Barhoum, Tarif Bader, Itay Zoaretz, Elon Glassberg, Oscar Embon and Yitshak Kreiss
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.
Edward Koifman, Paul Fefer, Ilan Hay, Micha Feinberg, Elad Maor and Victor Guetta
Background: Percutaneous edge-to-edge mitral valve repair using the MitraClip® system has evolved as a new tool in the treatment of mitral regurgitation (MR).
Objectives: To present our initial experience with MitraClip implantation in 20 high risk patients at Sheba Medical Center.
Methods: Twenty high surgical risk patients with symptomatic significant MR underwent MitraClip implantation. Clinical and echocardiographic parameters were recorded at baseline and at follow-up.
Results: The patients’ mean age was 76 years and 65% were male. Coronary artery disease was present in 85% and 45% had previous bypass surgery. Renal failure was present in 65%, atrial fibrillation in 60%, and 30% had an implantable cardioverter defibrillator/cardiac resynchronization therapy device. Mean left ventricular ejection fraction was 36%. Grade III-IV MR was present in all patients with the vast majority suffering from functional MR secondary to ventricular remodeling. New York Heart Association (NYHA) class was III-IV in 90%. Patients were followed for a mean of 231 days. Acute reduction of MR grade to ≤ 2 was accomplished in 19 of the 20 patients (95%) with a 30 day mortality of 5%. At follow-up MR was reduced to ≤ 2 in 64% of patients, and NYHA class improved in 70% of patients. An additional 2 patients (11%) died during follow-up.
Conclusions: MitraClip implantation is feasible and safe in high risk highly symptomatic patients with significant MR. Acute and mid-term results are comparable to similar high risk patient cohorts in the literature. Continued surveillance and longer follow-up are needed to elucidate which patients are most likely to benefit from the procedure.
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.
Renata Faermann, Fani Sperber, Schlomo Schneebaum and Daphna Barsuk
Background: The surgical approach to breast cancer has changed dramatically in the past 20 years. The surgical objective today is to remove the tumor, ensuring negative margins and good cosmetic results, and preserving the breast when possible. Magnetic resonance imaging of the breast has become an essential imaging tool prior to surgery, diagnosing additional tumors and assessing tumor extent. Tumor-to-breast volume ratio, an important predictor of breast conservation, can be measured with MRI and may change the surgical decision.
Objectives: To measure the tumor-to-breast volume ratio using MRI in order to assess whether there is a correlation between this ratio and the type of surgery selected (breast-conserving or mastectomy).
Methods: The volumes of the tumor and the breast and the tumor-to-breast volume ratio were retrospectively calculated using preoperative breast MRI in 76 patients who underwent breast-conserving surgery or mastectomy.
Results: Breast-conserving surgery (lumpectomy) was performed in 64 patients and mastectomy in 12. The average tumor-to-breast volume ratio was 0.06 (6%) in the lumpectomy group and 0.30 (30%) in the mastectomy group (P < 0.0001).
Conclusion: The tumor-to-breast volume ratio correlated with the type of surgery. As measured on MRI, this ratio is an accurate means of determining the type of surgery best suited for a given patient. It is recommended that MRI-determined tumor-to-breast volume ratio become part of the surgical planning protocol for patients diagnosed with breast cancer.
Ibrahim Marai and Samia Massalha
Hefziba Green, Noa Eliakim-Raz, Yael Zimra and Anat Gafter-Gvili
Offer Amir, Yaron D. Barac, Arieh Eden, Shtiwi Sawaed, Victor Rubchevsky and Dan Aravot
Godfrey M. Rwegerera, Wahhab Chowdhury MPhil Path, Mpho A. Setime and Sandro Vento