Israel Medical Association Journal

Background: Surgical repair of tetralogy of Fallot may leave the patient with pulmonary regurgitation causing eventual right ventricle dilatation and dysfunction. Predicting clinical deterioration may help to determine the best timing for intervention.

Objectives: To assess whether the clinical and humoral status of patients in the second decade after repair of ToF[1] is worse than that of patients in the first decade after repair.

Methods: Twenty-one patients with repaired ToF underwent clinical assessment, electrocardiogram, echocardiogram and measurement of plasma B-type natriuretic peptide and N-terminal pro-BNP[2] as well as the 6 minute walk distance test. Patients were divided into two groups: group A – less than 10 years after repair (n=10, age < 12 years old), and group B – more than 10 years after repair (n=11, age > 12 years old). The age at repair was similar in both groups.

Results: In all but one patient the distance in the 6 min walk test was less than the minimum for age. RV[3] end-diastolic volume and the 6 min walk test correlated with age. NT-proBNP[4] levels were significantly higher in the ToF group compared to 26 healthy controls (P < 0.0001) and were inversely correlated with RV ejection fraction. Comparison of the two groups showed no difference in RV end-diastolic volume indexed for body surface area, pulmonary regurgitation severity, right or left ventricular myocardial performance index, RV ejection fraction, QRS duration, or 6 min walk indexed to minimum for age.

Conclusions: In this group of patients with similar age at operation and pulmonary regurgitation severity, most clinical, echocardiographic and humoral parameters were not worse in the second decade after repair of ToF. These data suggest that very early pulmonary valve replacement may not be of benefit.

Background: The Pittsburgh Sleep Quality Index is a standardized self-administered questionnaire for the assessment of subjective sleep quality. It has been translated into several languages and is widely used in clinical research studies.

Objectives: To assess the reliability and validity of the Pittsburgh Sleep Quality Index Hebrew translation in a sleep clinic sample and in comparison with the Technion Mini Sleep Questionnaire.

Methods: The PSQI[1] was translated into Hebrew based on standard guidelines. The final Hebrew version (PSQI-H) was administered to 450 patients from two sleep clinics and to 61 healthy adults from the community as a non-clinical control sample. The MSQ[2] was administered to 130 patients in one sleep clinic.

Results: For the PSQI-H[3], Cronbach's-alpha scores for sleep clinic and non-clinical samples were 0.70 and 0.52 respectively and 0.72 combined. Clinical sample scores were significantly higher than the non-clinical group, indicating lower sleep quality for the former. Significant correlations were found between the MSQ subscores and PSQI-H component scores for common underlying constructs.

Conclusions: The PSQI-H differentiated between clinical and non-clinical samples and showed adequate reliability and good validity. It may be used as a standardized tool for the assessment of subjective sleep quality in clinical research studies conducted in the Hebrew-speaking population.

Background: Common peroneal neuropathies, usually located at the fibular head, are one of the causes of drop foot, a condition often evaluated in the electromyography laboratory.

Objectives: To study the motor conduction properties of the common peroneal nerve and its branches of distribution in patients with paralyzed drop foot, several weeks after their first stroke, assuming that its inversion position can cause neuropathy around the fibular neck.

Methods: We performed peroneal nerve conduction study on 76 legs of 38 patients, 12–73 days after their first stroke. All the patients had flaccid drop foot on the involved side. The stimulating electrode was placed at the postero-lateral aspect of the fibular neck. Motor nerve conduction latency and compound muscle action potential amplitude were measured along the proximal part of the deep and the superficial peroneal nerve, comparing the paralyzed to the sound leg. Paired sample t-test and paired t-test were used to compare the nerve conduction properties between the sound and the paralytic leg. The linear liaison between the two legs was determined by Pearson coefficient and the test based on it.

Results: The differences between motor conduction latencies and between CMAP[1] amplitudes, comparing the paralyzed to the sound side, recorded in both the deep peroneal nerve and the superficial peroneal nerve, were statistically significant (P < 0.05).
Conclusions: It seems that the permanent equino-varus position of the paralyzed foot might affect common peroneal nerve conduction properties at the level of the fibular neck by demyelination, axonopathy, or both. Possible reasons for these pathological changes are nerve traction or nerve compression, but temperature changes in the paralytic leg should also be considered. Ankle-foot orthoses can be prescribed for prevention or correction of deformities of the foot and ankle and reduction of the weight-bearing forces

Background: Early detection of malignant melanoma of the skin is the most important factor in patient survival. Naked-eye diagnostic sensitivity and specificity are low. Patients with multiple nevi are at high risk to develop melanomas and the clinical follow-up of such patients is difficult, resulting in missed melanomas on the one hand and unnecessary biopsies on the other.

Objectives: To describe the set-up of a special clinic aimed at early detection of melanoma and follow-up of high risk patients and preliminary results from 20 months of operation.

Methods: We established a pigmented lesions clinic based on a digital photography studio enabling documentation and comparison over time of full body photography and dermoscopy.

Results: In the first 20 months of work, 895 patients were seen, 206 of them for follow-up visits. A total of 29,254 photos were taken. Altogether, 236 lesions were suspicious (either clinically or dermoscopically) and the patients were advised to excise them. Seven melanomas were found in this initial examination (which did not include long-term follow-up).

Conclusions: With multimode photographic cutaneous surveillance, early detection of melanoma in high risk patients has been reported. Our clinic utilizes the same techniques and diagnostic algorithm as other leading clinics throughout the world, thus enabling us to deliver better follow-up for those patients.
 

Background: Burns are a major public health problem, with long hospitalization stay in both intensive care units and general wards. In Israel about 5% of all hospitalized injuries are burn injuries. There are no long-term epidemiological studies on burn injuries in adults in Israel.

Objectives: To identify risk factors for burn injuries and provide a starting point for the establishment of an effective prevention plan.

Methods: We analyzed the demographic, etiologic and clinical data of 5000 burn patients admitted to the five major hospitals with burn units in Israel during a 7 year period (1997–2003). Data were obtained from the records of the Israeli National Trauma Registry. The differences between various groups were evaluated using the chi-square test.

Results: Male gender was twice as frequent as female gender in burn patients (68.0% vs. 31.9%), and Jewish ethnicity was more common than non-Jewish (62.3% vs. 36.8%). Second and third-degree burns with body surface areas less than 10% constituted the largest group (around 50%). The largest age group was 0–1 years, constituting 22.2% of the cases. Inhalation injury was uncommon (1.9%). The most common etiologies were hot liquids (45.8%) and open fire (27.5%). Children less than 10 years old were burnt mainly by hot liquids while the main cause of burns for adults > 20 years old was an open flame. The majority of burns occurred at home (58%); around 15% were work related. The mean duration of hospitalization was 13.7 days (SD 17.7); 15.5% were in an intensive care unit with a mean duration of 12.1 days (SD 17.1). Surgical procedures became more common during the period of the study (from 13.4% in 1998 to 26.59% in 2002, average 19.8%). The mortality rate was 4.4%. We found a strong correlation between burn degree and total body surface area and mortality (0.25% mortality for 2nd to 3rd-degree burns with less than 10% TBSA[1], 5.4% for 2nd to 3rd-degree burns with 20–39% TBSA, and 96.6% for burns > 90% TBSA). The worst prognosis was for those over the age of 70 (mortality rate 35.3%) and the best prognosis was for the 0–1 year group (survival rate 99.6%).

Conclusions: The groups at highest risk were children 0–1 years old, males and non-Jews (the incidence rate among non-Jews was 1.5 times higher than their share in the general population). Those with the highest mortality rate were victims of burns > 90% TBSA and patients older than 70. Most burns occurred at home.

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.