Alexander Guber, MD, Eyal Morris, MD, Baruch Chen MD and Shaul Israeli, MD
Background: Ventilator-dependent patients represent an increasing clinical, logistic and economic burden. An alternative solution might be monitored home care with high-tech ventilatory support systems.
Objectives: To explore the implications of such home-care management, such as its impact on quality of life and its cost-effectiveness, and to assess the practical feasibility of this mode of home care in Israel.
Methods: We surveyed 25 partly or fully home-ventilated patients (17 males and 8 females), average age 37.6 years (range 1–72), who were treated through a home-care provider during a 2 year period.
Results: Most patients (n=18) had a neuromuscular respiratory disorder. The average hospital stay of these patients prior to entry into the home-care program was 181.2 days/per patient. The average home-care duration was 404.9 days/per patient (range 60–971) with a low hospitalization rate of 3.3 ± 6.5 days/per patient. The monthly expenditure for home care of these patients was one-third that of the hospital stay cost ($3,546.9 vs. $11,000, per patient respectively). The patients reported better quality of life in the home-care environment, as assessed by the Sickness Impact Profile questionnaire.
Conclusions: Home ventilation of patients in Israel by home-care providers is a practical and attractive treatment modality in terms of economic benefits and quality of life.
Ahmet Ege, MD, Ibrahim Tuncay, MD and Omer Ercetin, MD,
Background: Coverage of part of a soft tissue defect in the thumb, without bone shortening and without long-lasting immobilization in an inappropriate position leading to stiffness, is difficult to achieve.
Objectives: To report our experience using Foucher’s modification of the first dorsal metacarpal artery flap for thumb reconstruction in 21 cases.
Methods: Foucher’s flap is based on the neurovascular structures of the first dorsal metacarpal artery flap and radial nerve-sensitive branches on the dorsum of the second metacarpal and proximal phalanx. The cause of injury was work-related in all 21 cases. The patients' mean age was 37 (range 17–68 years), and mean follow-up was 19 months (range 12–31). Emergency surgery was performed in 13 patients, with a time delay after injury of 4–12 hours. The minimum defect was 12–18 mm and the maximum 20–40 mm. Pedicular length was 55–95 mm. A skin bridge was left intact in 16 cases. In two cases of early postoperative venous congestion and flap loss, a cross-finger flap was performed as a salvage procedure.
Results: Subjective satisfaction score was 8.37/10 (range 4–10); cold intolerance was experienced in 60% and dysesthesia in 33%. All except one patient are able to use their thumb in daily activity. Loss of mobility in the proximal interphalangeal joint of the index finger was less than 20 degrees. Semmes-Weinstein sensitivity evaluation score was 3.61–4.31 on the flap and 0–6.65 on the donor site. Two-point discrimination was 10.8 mm (range 8–20). Grip strength was reduced by 15% compared to the unaffected hand (hand dominance was not taken into consideration). Rehabilitation was not consistent as almost all the patients were living in another location.
Conclusions: First DMCA pedicle flap is a successful thumb reconstruction method, especially in patients not disturbed by its cosmetic appearance.
__________________________
DMCA = dorsal metacarpal artery
Eliezer Golan, MD, Bruria Tal, PhD, Yossef Dror, PhD, Ze’ev Korzets, MBBS, Yaffa Vered, PhD, Eliyahu Weiss, MSc and Jacques Bernheim, MD
Background: Multiple factors are involved in the pathogenesis of hypertension in the obese individual.
Objective: To evaluate the role of a decrease in sympathetically mediated thermogenesis and the effect of the correlation between the plasma leptin and daily urinary nitric oxide levels on obesity-related hypertension.
Methods: We evaluated three groups: 25 obese hypertensive patients (age 45.7±1.37 years, body mass index 34.2±1.35 kg/m2, systolic/diastolic blood pressure 155±2.9/105±1.3, mean arterial pressure 122±1.50 mmHg); 21 obese normotensive patients (age 39.6±1.72, BMI 31.3±0.76, SBP/DBP 124±2.1/85.4±1.8, MAP 98.2±1.80); and 17 lean normotensive subjects (age 38.1±2.16, BMI 22.1±0.28, SBP/DBP 117±1.7/76.8±1.5, MAP 90.1±1.50). We determined basal resting metabolic rates, plasma insulin (radioimmunoassay), norepinephrine (high performance liquid chromatography) in all subjects. Thereafter, 14 obese hypertensives underwent a weight reduction diet. At weeks 6 (n=14) and 14 (n=10) of the diet the above determinations were repeated. Plasma leptin (enzyme-linked immunosorbent assay) and UNOx (spectrophotometry) were assayed in 17 obese hypertensives and 17 obese normotensives, and in 19 obese hypertensives versus 11 obese normotensives, respectively.
Results: Obese hypertensive patients had significantly higher basal RMR and plasma NE levels. Insulin levels were lower in the lean group, with no difference between the hypertensive and normotensive obese groups. At weeks 6 and 14, BMI was significantly lower, as were insulin and NE levels. RMR decreased to values of normotensive subjects. MAP normalized but remained significantly higher than that of obese normotensives. Leptin blood levels and the leptin/UNOx ratio were significantly higher in the obese hypertensive compared to the obese normotensive patients. Both these parameters were strongly correlated to BMI, MAP5, RMR, and plasma NE and insulin .Obese hypertensive patients excreted less urinary NO metabolites. A strong correlation was found between MAP and the leptin/UNOx ratio.
Conclusions: A reduction of sympathetically mediated thermogenesis, as reflected by RMR, results in normalization of obesity-related hypertension. In contrast, insulin does not seem to play a major role in the pathogenesis of hypertension associated with obesity. Increased leptin levels in conjunction with decreased NO production in the presence of enhanced sympathetic activity may contribute to blood pressure elevation in the obese.
_____________________
BMI = body mass index
SBP/DBP = systolic blood pressure/diastolic blood pressure
MAP = mean arterial pressure
UNOx = urinary nitric oxide
RMR – resting metabolic rate
NE = norepinephrine
Gregory Kouraklis, MD, Andromachi Glinavou, MD, Dimitrios Mantas, MD, Efstratios Kouskos, MD and Gabriel Karatzas, MD
Background: Small bowel diverticula are usually asymptomatic and rare. Their importance is based on the fact that they carry the risk of serious complications.
Objective: To study the implications and the therapeutic approach regarding small bowel diverticulosis.
Methods: The medical records of 54 patients with diverticular disease of the small bowel, including Meckel’s and duodenum diverticula, were retrospectively reviewed. The mean age of the 32 male and 22 female patients was 53.2 years.
Results: Diverticula were found in the duodenum in 11 cases, in the jejunum and ileum in 21 cases, and with Meckel’s diverticula in 22 cases. In 24% of the patients the diverticula were multiple. The most common clinical symptom was abdominal pain, in 44.4%. Most of the duodenum diverticula were asymptomatic; 47.6% of the patients with diverticular disease located in the jejunum and ileum presented with chronic symptoms. The overall diagnostic rate for symptomatic diverticula before surgery was 52.7%; in 33.3% diverticula were found incidentally during other diagnostic or therapeutic procedures. Forty-one patients were managed surgically: 15 patients were operated on urgently because of infection or rupture, 4 patients for bleeding, 5 patients for intestinal obstruction and one patient for jaundice.
Conclusions: The incidence of asymptomatic small bowel diverticula is difficult to ascertain. Patients with Meckel’s and duodenal diverticula are usually asymptomatic, while the majority of jejunal and ileal diverticula patients present with chronic symptoms. The preoperative diagnostic rate is higher for duodenal diverticula. Small bowel diverticula do not require surgical treatment unless refractory symptoms or complications occur.
Yoav Mattan, MD, Alice Dimant, MD, Rami Mosheiff, MD, Amos Peyser, MD, Steven Mendelson, MD and Meir Liebergall, MD
Background: Femoral hip fractures are a common occurrence in the elderly. Of the various fracture patterns, intertrochanteric injuries have the lowest rate of complications. Case reports of ensuing subcapital fracture have all been linked to incorrect placement of fixation devices or to osteomyelitis, while cases of avascular necrosis have only been reported rarely in the literature and are considered to occur at the rare rate of 0.8%.
Objectives: To check the incidence and outcome of AVN in intertrochanteric hip fractures.
Methods and Results: In a retrospective analysis of patients who had surgical treatment for intertrochanteric fractures, 10 patients (0.5%) underwent dynamic hip screw fixation for intertrochanteric fractures and subsequently developed painful AVN as their primary presentation. Three of these patients were also found to have subcapital fractures. On revision of the primary fixation no fault was found with nail placement.
Conclusions: The reported rate of AVN may be understated since many patients have limiting factors that prevent them from consulting a physician when in pain, and one-third of these patients die within 2 years. Therefore, we suggest that hip pain following fixation of an intertrochanteric fracture should prompt the clinician to consider the rare possibility of AVN or subcapital fracture.
___________________________
AV = avascular necrosis
Naomi B. Zak, PhD, Sagiv Shifman, MSc, Anne Shalom, PhD and Ariel Darvasi, PhD, MPH
The complex genetic nature of many common diseases makes the identification of the genes that predispose to these ailments a difficult task. In this review we discuss the elements that contribute to the complexity of polygenic diseases and describe an experimental strategy for disease-related gene discovery that attempts to overcome these factors. This strategy involves a population-based case-control paradigm and makes use of a highly informative, homogeneous founder population, many of whose members presently reside in Israel. The properties of single nucleotide polymorphisms, which are presently the markers of choice, are discussed, and the technologies that are currently available for SNP genotyping are briefly presented.
__________________________
SNP = single nucleotide polymorphism
Eduardo Garcua-Garcia, MD, Carlos A. Aguilar-Salinas, MD, Teresa Tusie-Luna, MD, PhD and Juan Antonio Rull-Rodrigo, MD
This review summarizes the clinical, metabolic and genetic characteristics of early-onset type 2 diabetes in Mexico. Early-onset type 2 diabetes is both a clinical challenge and a public health problem. It is calculated that almost 300,000 Mexican diabetics are diagnosed between the ages of 20 and 40. The large Mexican family structure and the high prevalence of the disease provide a unique opportunity to identify the genes and the metabolic abnormalities involved in this form of the disease. In a hospital-based population, our group found that insulin deficiency was the main defect in this form of diabetes. Mutations in the HNF-1α or HNF-4α genes or autoimmunity to the beta cell were found in a small proportion of cases, leaving unexplained the majority of cases. Also discussed are the epidemiologic and therapeutic implications of early-onset type 2 diabetes, and the possible role of genetic testing for prevention.
Ron Reshef, MD, Wisam Sbeit, MD and Jesse Lachter, MD
Gideon D. Charach, MD, Itamar Groskopf, MD, Dan Turner, MD, Michael Y. Barilan, MD, Chen Kugel, MD and Moshe S. Weintraub, MD
Yosefa Bar-Dayan, MD, MHA, Simon Ben-Zikrie, MD2, Gerald Fraser, MD, FRCP, Ziv Ben-Ari, MD, Marius Braun, MD, Mordechai Kremer, MD and Yaron Niv, MD
Lela Migirov, MD, Ana Eyal MD, and Jona Kronenberg, MD