Balloon angioplasty of popliteal and crural arteries in elderly with critical chronic limb ischemia

OBJECTIVE: Elderly patients with extensive infrainguinal peripheral vascular disease and critical chronic limb ischemia (CCLI) are poor surgical candidates. Our purpose was to evaluate angiographic and clinical results of popliteal, infrapopliteal, and multi-level disease percutaneous transluminal angioplasty (PTA) in such patients. DESIGN: Retrospective study of angiographic and clinical files in selected group. MATERIALS AND METHODS: Between 1996 and 2002, 38 elderly patients aged 80-94 years old (mean age 83.3) with critical leg ischemia were treated with PTA. All patients were at high surgical risk. 31/38 (81.5%) patients had chronic non-healing wounds, and 14/38 (37%) had multi-level disease of superficial femoral, popliteal and crural arteries. One hundred and two lesions were treated by angioplasty. Immediate angiographic and 1 year clinical results were retrospectively analyzed. RESULTS: The overall procedural success rate was 32/38 (84.2%). There were three major complications (7.9%), but no deaths, and three technical failures, all were of infrapopliteal lesions. After 1 year, 27 patients could be followed, five patients died during the first year of unrelated causes. Twenty-three patients (85.2%), were clinically re-occluded within 1 year, but complete and partial wound healing was achieved in 80% (16/20) and rest pain improvement in 57% (4/7), so that overall limb salvage was 74% (20/27). CONCLUSIONS: Elderly patients with multi-level CCLI have a short patency term following angioplasty of 14.8% after 1 year. Nevertheless, this temporary vascular patency enables wound healing or improvement in 74% of these patients, thus such endovascular interventions are recommended in this age group.     

Defective enamel ultrastructure in diabetic rodents

We investigated six different types of diabetic rodents. Four expressed a genetic obesity resulting in diabetes. One developed diabetes induced by a diet-dependent obesity, and one with genetic diabetes received anti-diabetic medication. The tooth samples were examined under a scanning electron microscope and with an energy dispersive microanalysis (EDX). The electron micrographs showed severe, varying degrees of damage within the six different diabetic animal types, such as irregular crystallite deposition and prism perforations in genetically obese animals compared to less-disordered prism structures in diet-dependent obesity. Anti-diabetic medication resulted in normal enamel ultrastructure. The EDX analysis revealed a reduction in the amount of calcium and phosphorus in all regions affected by diabetes. Based on these animal studies, we suggest that both juvenile diabetes type I (in infants) and adult diabetes type II (in pregnant mothers, affecting the developing foetus) may affect the normal development of teeth in humans.     

Hospital preparedness for possible nonconventional casualties: an Israeli experience

Since 9/11, hospitals and health authorities have been preparing medical response in case of various mass terror attacks. The experience of Tel Aviv Sourasky Medical Center in treating suicide-bombing mass casualties served, in the time leading up to the war in Iraq, as a platform for launching a preparedness program for possible attacks with biological and chemical agents of mass destruction. Adapting Quarantelli's criteria on disaster mitigation to the "microinfrastructure" of the hospital, and including human behavior experts, we attempted to foster an interactive emergency management process that would deal with contingencies stemming from the potential hazards of chemical and biological (CB) weapons. The main objective of our work was to encourage an organization-wide communication network that could effectively address the contingent hazards unique to this unprecedented situation. A stratified assessment of needs, identification of unique dangers to first responders, and assignment of team-training sessions paved the way for program development. Empowerment through leadership and resilience training was introduced to emergency team leaders of all disciplines. Focal subject matters included proactive planning, problem-solving, informal horizontal and vertical communication, and coping through stress-management techniques. The outcome of this process was manifested in an "operation and people" orientation supporting a more effective and compatible emergency management. The aim of article is to describe this process and to point toward the need for a broad-spectrum view in such circumstances. Unlike military units, the civilian hospital staff at risk, expected to deal with CB casualties, requires adequate personal consideration to enable effective functioning. Issues remain to be addressed in the future. We believe that collaboration and sharing of knowledge, information, and expertise beyond the medical realm is imperative in assisting hospitals to expedite appropriate preparedness programs.     

Acetazolamide-enhanced neuroSPECT scan reveals functional impairment after minimal traumatic brain injury not otherwise discernible

A patient suffering from aggressive personality changes and cognitive impairment following head trauma, without neurological or anatomical imaging findings, underwent neuroSPECT scans with and without acetazolamide injection, both before treatment and during treatment with valproate. Acetazolamide injection induced increased prefrontal perfusion not evident at baseline. Valproate treatment was associated with increased prefrontal perfusion concomitant with clinical improvement and abolished response to acetazolamide challenge.     

Successful treatment of infective endocarditis with recombinant tissue plasminogen activator

OBJECTIVES: In a prospective study, we examined the effect of treatment with recombinant tissue plasminogen activator (r-TPA) on survival and morbidity in a series of high-risk children with infectious endocarditis (IE) after prolonged treatment with indwelling catheters. We hypothesized that r-TPA is an adjunctive therapy for dissolution of infected thrombi in drug-resistant IE. STUDY DESIGN: In the prospective 3-year study (1998-2001), we identified high-risk children with chronic illness and prolonged treatment with indwelling catheters who developed IE and overwhelming sepsis. Patients were allocated to receive r-TPA after persistent and enlarging intracardiac vegetations and failure to respond to conventional medical management. Complications associated with treatment, survival, and cardiac morbidity were observed. RESULTS: Seven infants were treated prospectively with r-TPA. All infants responded promptly to treatment, with resolution of the intracardiac vegetations within 3 to 4 days of commencement and without any adverse complications. All patients survived without long-term cardiac morbidity. CONCLUSION: Recombinant tissue plasminogen activator may offer a safe alternative to surgical intervention in the high-risk infant with IE.     

Bone ultrasound velocity curves of newly born term and preterm infants

BACKGROUND: Ultrasound velocity (speed-of-sound [SOS]) has been proposed as a non-invasive method of evaluation of bone status in infants. We hypothesized that SOS correlates with both gestational age and birth weight. METHODS: We measured SOS within the first 96 hours of life at the right tibial midshaft location in 73 neonates ranging in gestational age from 25 to 41 weeks, and in birth weight from 825 to 3880 grams. We used the Sunlight Omnisense 7000p device (Tel Aviv, Israel). Results are expressed as meanS +/- 1 SD; statistical analyses included linear regression and computation of 95% CI regression lines; p<0.05 was considered significant. RESULTS: There was, as hypothesized, a significant correlation between gestational age (or birth weight) and SOS. There were no significant differences between males and females. Ninety-five percent confidence intervals were established. CONCLUSIONS: These data may be used as reference ranges for further studies.     

Nucleated red blood cells in polycythemic infants

OBJECTIVE: This study was undertaken to evaluate whether the absolute nucleated red blood cell (RBC) count is elevated in term, appropriate-for-gestational-age (AGA) polycythemic infants. STUDY DESIGN: We compared absolute nucleated RBC counts taken during the first 12 hours of life in term, AGA infants with neonatal polycythemia (n = 29), and in control, nonpolycythemic infants (n = 37). We excluded infants of women with diabetes, hypertension, and alcohol, tobacco, or drug abuse, and those with fetal heart rate abnormalities or low Apgar scores, hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no differences between groups in birth weight, gestational age, or other demographic or perinatal factors. The hematocrit, RBC count, and absolute nucleated RBC counts were significantly higher and the platelet counts significantly lower in the polycythemic group. Regression analysis that included Apgar scores and gestational age showed a significant correlation of absolute nucleated RBC count with the polycythemia status only (P =.017). CONCLUSION: At birth, term AGA polycythemic infants have increased indices of active erythropoiesis. We speculate that this finding is suggestive of subtle fetal hypoxemia.     

Massage therapy by mothers and trained professionals enhances weight gain in preterm infants

BACKGROUND: The method of "massage therapy" has consistently shown increased weight gain in preterm infants. The weight gain was apparent during massages administered by professionals. AIMS: To replicate the results of increased weight gain in the course of "massage therapy" in preterm infants, and utilize a new, cost-effective application of this method by comparing maternal to nonmaternal administration of the therapy. STUDY DESIGN: Random cluster design. SUBJECTS: The study comprised 57 healthy, preterm infants assigned to three groups: two treatment groups--one in which the mothers performed the massage, and the other in which a professional female figure unrelated to the infant administered the treatment. Both these groups were compared to a control group. RESULTS: Over the 10-day study period, the two treatment groups gained significantly more weight compared to the control group (291.3 and 311.3 vs. 225.5 g, respectively). Calorie intake/kg did not differ between groups. CONCLUSIONS: Mothers are able to achieve the same effect size as that of trained professionals, allowing cost-effective application of the treatment within the neonatal intensive care unit.