Development and Validation of a Colorectal Cancer Prediction Model: A Nationwide Cohort-Based Study

BACKGROUND

Early diagnosis of colorectal cancer (CRC) is critical to increasing survival rates. Computerized risk prediction models hold great promise for identifying individuals at high risk for CRC. In order to utilize such models effectively in a population-wide screening setting, development and validation should be based on cohorts that are similar to the target population.

AIM

Establish a risk prediction model for CRC diagnosis based on electronic health records (EHR) from subjects eligible for CRC screening.

METHODS

A retrospective cohort study utilizing the EHR data of Clalit Health Services (CHS). The study includes CHS members aged 50-74 who were eligible for CRC screening from January 2013 to January 2019. The model was trained to predict receiving a CRC diagnosis within 2 years of the index date. Approximately 20,000 EHR demographic and clinical features were considered.

RESULTS

The study includes 2935 subjects with CRC diagnosis, and 1,133,457 subjects without CRC diagnosis. Incidence values of CRC among subjects in the top 1% risk scores were higher than baseline (2.3% vs 0.3%; lift 8.38; P value < 0.001). Cumulative event probabilities increased with higher model scores. Model-based risk stratification among subjects with a positive FOBT, identified subjects with more than twice the risk for CRC compared to FOBT alone.

CONCLUSIONS

We developed an individualized risk prediction model for CRC that can be utilized as a complementary decision support tool for healthcare providers to precisely identify subjects at high risk for CRC and refer them for confirmatory testing.

Chronic health conditions among long-term survivors of adolescent and young adult (AYA) cancer: A comparison of outcomes in Israel and the United States

BACKGROUND

There is a paucity of information on health outcomes of adolescent and young adult (AYA) cancer survivors living outside North America and Europe. This study compared outcomes in AYA cancer survivors in Israel with individuals without cancer and similar demographics and access to health care, and to AYA cancer survivors living in the United States.

METHODS

This study included 12,674 2-year survivors of AYA (aged 15-39 years) cancer diagnosed between 2000 and 2018 at Clalit Health Services (CHS) in Israel. CHS participants without cancer (N = 50,696) were matched 4:1 to survivors on age, sex, ethnicity, and membership duration. Poisson regression was used to determine incidence rate ratios (IRRs) for chronic conditions. The US Kaiser Permanente Southern California AYA cohort (N = 6778) was used to estimate weighted (age, sex) standardized incidence ratios (SIRs) for CHS survivors.

RESULTS

CHS AYA cancer survivors were more likely to have any chronic condition (IRR, 1.6 95% CI, 1.5-1.7), compared with participants without cancer. Survivors had an increased risk across nearly all conditions examined, with especially elevated risks for osteoporosis (IRR, 4.7; 95% CI, 4.1-5.5) and cardiomyopathy (IRR, 4.2 95% CI, 3.4-5.3). Compared with the Kaiser Permanente Southern California cohort, CHS survivors had an overall lower (SIR, 0.68; 95% CI, 0.65-0.72) incidence of developing any health condition, with noticeably lower incidence of hyperlipidemia (SIR, 0.7; 95% CI, 0.64-0.75).

CONCLUSION

AYA cancer survivors in Israel are at increased risk for developing chronic conditions compared with individuals without cancer, but the overall incidence was lower than in US survivors. These findings may allow for refinement of surveillance recommendations for AYA survivors, taking into consideration regional differences in sociodemographic characteristics and cancer care.

PLAIN LANGUAGE SUMMARY

The burden of chronic conditions was consistently greater in Israeli adolescent and young adult cancer survivors compared with individuals without cancer, with clear differences in risk of specific conditions by cancer diagnosis. However, the overall incidence of chronic conditions in Israeli survivors was generally lower than in US survivors.

Systematic Review of Functional Outcomes in Cancer Rehabilitation

OBJECTIVE

To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019.

STUDY SELECTION

Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion.

DATA EXTRACTION

Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV).

DATA SYNTHESIS

Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome.

CONCLUSIONS

These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

The burden of long-term complications among adolescent and young adult cancer survivors: An international comparison of two large cohorts

e24059

Background: There is a paucity of information on health outcomes of adolescent and young adult (AYA) cancer survivors outside of Northern Europe or North America. We compared long-term health outcomes of Israeli AYA cancer survivors to non-cancer individuals with similar demographics and access to healthcare, estimated the risk of developing chronic health conditions by cancer type, and compared the comorbidity burden in Israeli AYA survivors to AYA cancer survivors from the U.S. Methods: This was a retrospective cohort of 2-year cancer survivors diagnosed with invasive cancer between 15 to 39 years of age from 2000 to 2018 in Clalit Health Services (CHS), the largest payer-provider healthcare organization in Israel. Non-cancer CHS participants were matched 4:1 to cancer survivors on age, sex, ethnicity, and membership duration. Health conditions were limited to those requiring medical intervention. Incidence rates for health conditions were determined for the two cohorts, and Poisson regression was used to determine the incidence rate ratio (IRR) with associated 95% confidence intervals (CI). A sub-population of CHS AYA survivors was used to compare the incidence of chronic health conditions from the Israeli cohort to AYA cancer survivors from Kaiser Permanente Southern California (KPSC), using Standardized Incidence Rate (SIR). Results: There were 12,674 CHS AYA cancer survivors and 50,696 non-cancer participants. Among survivors, the mean age at diagnosis was 31.02 years (SD: 6.2), 61.7% were female, and 78.4% were Jewish. The most common cancer diagnoses were lymphoma (16.5%), breast (16.4%), and thyroid (14.0%). Cancer survivors were significantly more likely to have any (IRR 1.60 95%CI: 1.54-1.67) or multiple (IRR 1.82 95%CI: 1.72-1.94) chronic health conditions compared to non-cancer participants. Survivors had an increased risk across nearly all examined outcomes, with an especially higher risk for premature ovarian failure (IRR 6.02 95%CI: 2.14-16.91), osteoporosis (IRR 4.74 95%CI: 4.06-5.53), and cardiomyopathy (IRR 4.20 95%CI: 3.35-5.27). We also found clear differences in the risk of specific health conditions by cancer type. Compared to the KPSC cohort, CHS cancer survivors had an overall lower (SIR 0.82 95%CI: 0.79-0.84) incidence of developing any health condition, with noticeably lower incidences of hypertension, hyperlipidemia, chronic liver disease, but higher incidences of cardiopulmonary diseases and osteoporosis. Conclusions: AYA cancer survivors in Israel are at increased risk for developing chronic conditions, compared matched non-cancer individuals, but the overall incidence of was lower when compared to survivors living in the U.S. These findings may allow for refinement of surveillance recommendations for AYA survivors, taking into consideration regional differences in socio-demographics and cancer care.

Indirect protection of children from SARS-CoV-2 infection through parental vaccination

Children not vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may still benefit from vaccines through protection from vaccinated contacts. We estimated the protection provided to children through parental vaccination with the BNT162b2 vaccine. We studied households without prior infection consisting of two parents and unvaccinated children, estimating the effect of parental vaccination on the risk of infection for unvaccinated children. We studied two periods separately-an early period (17 January 2021 to 28 March 2021; Alpha variant, two doses versus no vaccination) and a late period (11 July 2021 to 30 September 2021; Delta variant, booster dose versus two vaccine doses). We found that having a single vaccinated parent was associated with a 26.0 and a 20.8% decreased risk in the early and late periods, respectively, and having two vaccinated parents was associated with a 71.7 and a 58.1% decreased risk, respectively. Thus, parental vaccination confers substantial protection on unvaccinated children in the household.

Concordance between Self-reported Symptoms and Clinically Ascertained Peripheral Neuropathy among Childhood Cancer Survivors: the St. Jude Lifetime Cohort Study

BACKGROUND

Childhood cancer survivors are at elevated risk for motor and/or sensory neuropathy. The study aims to evaluate the concordance between self-report peripheral neuropathy compared with clinically ascertained peripheral neuropathy, and to identify factors associated with misclassification of peripheral neuropathy among survivors.

METHODS

The concordance between self-report and clinically ascertained peripheral neuropathy was evaluated among 2,933 5+ years old childhood cancer survivors (mean age 33.3, SD = 8.9). The sensitivity, specificity, and accuracy of self-report peripheral motor neuropathy (PMN) and peripheral sensory neuropathy (PSN) were calculated with reference to clinically assessed peripheral neuropathy.

RESULTS

Female survivors were more likely than male survivors to have clinically ascertained PMN (8.4% vs. 5.6%, P = 0.004). For females, having either PSN or PMN the most sensitive, specific, and accurate self-reported symptom was endorsing ≥2 symptoms on the self-report questionnaire (43.2%, 90.3%, and 85.2%, respectively), with kappa of 0.304. For males, having either PSN or PMN the most sensitive, specific, and accurate self-reported symptom was endorsing ≥2 symptoms on the self-report questionnaire (38.8%, 90.5%, and 86.3%, respectively) with kappa of 0.242. Age at diagnosis, emotional distress, and reporting pain in legs in the past 4 weeks were associated with an increased risk for false-positive reporting of peripheral neuropathy. Race (White), age at assessment, and emotional distress were associated with increased risk for false-negative reporting of peripheral neuropathy.

CONCLUSIONS

Agreement between self-report and clinically ascertained peripheral neuropathy was poor in survivors. Choosing self-report versus clinical ascertained peripheral neuropathy should be carefully considered.

IMPACT

The current study identifies the need for a self-report questionnaire that accurately assesses symptoms of peripheral neuropathy among cancer survivors.

Cardiovascular effects of chimeric antigen receptor t-cell therapy for refractory or relapsed non-hodgkin lymphoma

Purpose

Cardiovascular complications of chimeric antigen receptor T-cell (CAR T-cell) therapy are poorly understood. We examined the incidence, predictors and impact of new or worsening cardiomyopathy in patients undergoing CAR T-cell therapy.

Methods

All patients with refractory or relapsed non-Hodgkin's lymphoma, undergoing CAR T-cell therapy at collaborative institutes underwent serial echocardiograms at baseline and within 7 days after developing high-grade cytokine release syndrome (CRS), and were followed for all-cause mortality. New or worsening cardiomyopathy was defined as a reduction in left ventricular ejection fraction (LVEF) &gt;10% from baseline to &lt;50% during the index hospitalization.

Results

Among 187 consecutive CAR T-cell therapy patients, 116 (50 Grade ≤1 CRS, 66 Grade ≥2 CRS) had &gt;1 echocardiogram performed and were included in this analysis. The median age was 63 (range 19–80) years, 42% were women, 91% were Caucasian. A total of 12 (10.3%) patients developed new or worsening cardiomyopathy with a decline in LVEF from 58±6% to 36±7% within a median of 12.5 (range 2–24) days of CAR T-cell infusion. In multivariable analyses, older age, prior stem cell transplantation, baseline angiotensin-converting enzyme inhibitor use and CRS grade ≥2 were associated with the development of cardiomyopathy. Patients who developed cardiomyopathy were more likely to require vasopressor support (p=0.004) and mechanical ventilation (p=0.014). LVEF improved in 9/12 (75%) patients. CAR T-cell associated cardiomyopathy did not impact overall mortality or cancer response to CAR-T cell therapy.

Conclusions

Patients undergoing CAR T-cell therapy are at risk of developing cardiomyopathy and hemodynamic instability. Pre-CAR T-cell therapy cardiovascular risk stratification and echocardiogram surveillance during therapy should be considered for prompt identification and mitigation of cardiac complications.

Predictors of Cardiomyopathy Development

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Anju Nohria, MD is supported by the Gelb Master Clinician Award at Brigham and Women's Hospital.

Association of Exercise Intolerance With Emotional Distress, Attainment of Social Roles, and Health-Related Quality of Life Among Adult Survivors of Childhood Cancer

Importance

Exercise intolerance is associated with increased risk for morbidity and mortality in childhood cancer survivors. However, an association between exercise intolerance and psychosocial outcomes has not been fully explored.

Objective

To examine the associations between exercise intolerance and emotional distress, attainment of social roles, and health-related quality of life in childhood cancer survivors.

Design, Setting, and Participants

A cross-sectional study including 1041 adult survivors of childhood cancer and 286 community controls in the St Jude Lifetime Cohort was conducted at St Jude Children's Research Hospital. The study was performed from April 1, 2012, to March 15, 2020.

Exposures

Exercise intolerance was defined as relative peak oxygen uptake less than 85% of age- and sex-estimated levels from maximal cardiopulmonary exercise testing.

Main Outcomes and Measures

Emotional distress was measured with the 18-item Brief Symptom Inventory-18, which includes overall Global Severity Index and depression, anxiety, and somatization subscales. Participants with T scores greater than or equal to 63 were classified as having elevated levels of distress. Social attainment was evaluated using patient-reported educational, employment, and marital status. Health-related quality of life was examined with the Medical Outcomes Survey Short Form-36. Participants with T scores less than or equal to 40 were classified as reporting poor health-related quality of life.

Results

Of the 1041 participants, 528 were women (50.7%). The prevalence of exercise intolerance among survivors (mean [SD] age, 35.5 [9.2] years) was higher than that among controls (age, 34.5 [10.0] years) (survivors: 634 [60.9%] vs controls: 75 [26.2%], P < .001). After adjusting for age at diagnosis and cardiopulmonary exercise testing, sex, race/ethnicity, smoking, physical activity, and exercise intolerance were associated with an increased risk for anxiety (prevalence rate ratio [PRR], 1.95; 95% CI, 1.20-3.16), somatization (PRR, 1.86; 95% CI, 1.23-2.80), and unemployment (PRR, 1.76; 95% CI, 1.23-2.52); an inverse association was noted with having a college degree (PRR, 0.67; 95% CI, 0.50-0.88). Exercise intolerance was associated with an increased the risk for scoring less than or equal to 40 on the physical component summary of the Medical Outcomes Survey Short Form-36 (PRR, 3.69; 95% CI, 2.34-5.84). These associations persisted when either cancer treatment exposures or chronic health conditions were added to the model.

Conclusions and Relevance

The findings of this study suggest that exercise intolerance is independently associated with emotional distress, attainment of social roles, and health-related quality of life of long-term survivors of childhood cancer. The results also suggest that improving physiologic capacity may benefit general health and wellness, as well as emotional health, ability to participate in social roles, and health-related quality of life.

Patient satisfaction with primary care physician performance in a multicultural population

BACKGROUND

A key component of the quality of health care is patient satisfaction, particularly in regard to Primary Care Physician (PCP), which represents the first contact with health care services. Patient satisfaction is associated with ethnic, regional and socio-demographic differences, due to differences in service quality, patient-doctor communication, and the patient's perceptions. The aim of this study was to evaluate patients' satisfaction related to primary care physicians' (PCP) performance and to explore potential differences by ethnicity in a multicultural population.

METHODS

A national cross-sectional telephone survey was conducted, among a random sample of the Israeli population aged ≥25 years. Satisfaction level from performance of PCP was assessed using a validated questionnaire (30 items; 6 different domains).

RESULTS

The final sample included (n = 827 Jews; n = 605 Arabs, mean age 54.7(±14.9). In the adjusted logistic regression models, Arabs reported lower general satisfaction related to PCPs' performance as compared to Jews (adjusted odds ratio (AOR), 0.63; (95% CI: 0.40-0.98). Arabs reported lower satisfaction related to PCPs' performance across the following domains: communication skills (AOR, 0.42; 95% CI, 0.22-0.82); interpersonal manners (AOR, 0.37; 95% CI, 0.24-0.58); and time spent with the patients (AOR, 0.60; 95% CI, 0.43-0.85).

CONCLUSIONS

Jews and Arabs were very satisfied with PCPs' performance. However, there are ethnic differences in the extent of satisfaction level related to the performance of PCP. Satisfaction from PCPs' performance may be achieved by improving the communication skills of the PCP, encouraging interpersonal interaction between the PCP and the patient, and devoting more time to the patient during the visits.

Prevalence and Predictors of Frailty in Childhood Cancer Survivors and Siblings: A Report From the Childhood Cancer Survivor Study

PURPOSE

To estimate the prevalence of frailty among childhood cancer survivors and to determine the direct and indirect effects of treatment exposures, lifestyle factors, and severe, disabling, and life-threatening chronic condition on frailty.

METHODS

Childhood cancer survivors (≥ 5 years since diagnosis), treated between 1970 and 1999 when < 21 years old (n = 10,899; mean age, 37.6 ± 9.4 years; 48% male, 86% white) and siblings were included (n = 2,097; mean age, 42.9 ± 9.4 years). Frailty was defined as ≥ 3 of the following: low lean mass, exhaustion, low energy expenditure, walking limitations, and weakness. Generalized linear models were used to evaluate direct and indirect associations between frailty and treatment exposures, sociodemographic characteristics, lifestyle factors, and chronic condition.

RESULTS

The overall prevalence of frailty among survivors was 3 times higher compared with siblings (6.4%; 95% CI, 4.1% to 8.7%; v 2.2%; 95% CI, 1.2% to 3.2%). Survivors of CNS tumors (9.5%; 95% CI, 5.2% to 13.8%) and bone tumors (8.1%; 95% CI, 5.1% to 11.1%) had the highest prevalence of frailty. Survivors exposed to cranial radiation, pelvic radiation ≥ 34 Gy, abdominal radiation > 40 Gy, cisplatin ≥ 600 mg/m², amputation, or lung surgery had increased risk for frailty. These associations were partially but not completely attenuated when sociodemographic characteristics, lifestyle factors, and chronic conditions were added to multivariable models. Cranial radiation (prevalence ratio [PR], 1.47; 95% CI, 1.20 to 1.76), pelvic radiation ≥ 34 Gy (PR, 1.46; 95% CI, 1.01 to 2.11), and lung surgery (PR, 1.75; 95% CI, 1.28 to 2.38) remained significant after sociodemographic, lifestyle, and chronic conditions were accounted for.

CONCLUSION

Childhood cancer survivors reported a higher prevalence of frailty compared with siblings. Radiation and lung surgery exposures were associated with increased risk for frailty. Interventions to prevent, delay onset, or remediate chronic disease and/or promote healthy lifestyle are needed to decrease the prevalence of frailty and preserve function in this at-risk population.

Fear of catastrophic health expenditures and unrealistic expectations from supplementary health insurance: ethnic differences

BACKGROUND

In Israel, the whole population is covered by comprehensive universal health insurance. Despite that, most of the population purchases supplementary health insurance (SHI). It has been shown that individuals purchase more health insurance and preventive medicine when they are uncertain of their state of health, while a majority may not fully understand basic concepts in their health insurance coverage. The purpose of this study was to examine the role of fear of catastrophic health expenditures and unrealistic expectations in purchasing SHI, which does not cover expenses for life-threatening illnesses.

METHODS

A cross-sectional survey was conducted among random samples of 814 Jews and 800 Arabs in Israel. A structured questionnaire was administered by telephone using random digit dialling. Log-linear regression was used to identify factors associated with reasons for purchasing SHI and expectations from SHI.

RESULTS

The most common reason for purchasing SHI was fear of catastrophic health-related expenditures (41%). The most important service expected from SHI was 'cancer medications' (mean 4.68 [standard deviation 0.87]). Differences in the reasons for purchasing SHI and in expectations from SHI were found according to population group, age, gender and education.

CONCLUSIONS

Consumers' misconceptions and fear of catastrophic health expenditures are major factors leading to the purchase of SHI, despite universal health coverage. Improved and accessible information should help consumers make informed decisions as to whether or not to purchase SHI.

Frailty among childhood cancer survivors: A report from the Childhood Cancer Survivor Study (CCSS)

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Background: Childhood cancer survivors are at increased risk for frailty, which is a loss of physiological capacity that is typically observed among older adults. Aims: Estimate the prevalence of frailty among survivors, and examine direct and indirect effects of treatment, lifestyle, and chronic disease factors on frailty. Methods: CCSS participants who were > 5-year survivors of childhood cancer, diagnosed between 1970-1999 at <21 years of age (n=10,899, 48% male), and siblings (n=2,097, 42% male) were included. Frailty was defined from self-reported data at mean ages of 37.6±9.4 and 42.9±9.8 years for survivors and siblings, respectively, as ≥3 of the following: low lean mass, exhaustion, low energy expenditure, slow walking, and weakness. Results: The prevalence of frailty among survivors was higher compared to siblings (5.8%, 95% CI: 5.4-6.3% vs. 1.9%, 95% CI 1.4-2.5%). Prevalence was highest in survivors of CNS tumors (9.5%, 5.2-13.8%), bone sarcomas (8.1%, 5.1-11.1%) and Hodgkin lymphoma (7.5%, 4.9-10.1%). In models adjusted for sex, age at assessment, and race/ethnicity, treatment exposures were associated with frailty (Table). After adjusting for the presence of chronic diseases and lifestyle factors, these associations were attenuated. Conclusions: The prevalence of frailty among survivors (6.0% at 38 years of age) was similar to the general population aged ≥65 years (9.0%). Radiation, platinum, amputation and thoracotomy increased risk for frailty. Findings suggest interventions to prevent, delay onset, or remediate chronic disease and/or promote healthy lifestyle are needed to preserve function in this population. [Table: see text]

Do Israeli health promoting schools contribute to students' healthy eating and physical activity habits?

The Israeli Health Promoting School Network (HPSN) is actively committed to enhancing a healthy lifestyle for the entire school population. This study aimed to explore the contribution of school participation in the HPSN and students' individual characteristics to healthy eating and physical activity habits among Israeli school children aged 10-12 years. A cross-sectional survey was conducted among 4166 students in grades 4-6 from 28 schools. The schools were selected from a sample of HPSN affiliated and non-HPSN schools. The contribution of individual characteristics (grade, gender and subjective self-reported health education activities at school) and school characteristics (school type, population group, deprivation score) to healthy eating and physical activity habits was analyzed using multi-level hierarchical models. Multi-level analysis indicated that student's individual characteristic was significantly associated with healthy eating and physical activity habits. The subjective self-reported health education received at school was statistically significant factor associated with students' health behaviors. The school's affiliation with the HPSN was not associated with higher healthy eating and physical activity scores after adjusting for individual factors. These findings suggest that Israeli HPSN schools do not contribute to children's health behaviors more than other schools. Therefore, health promoting activities in HPSN schools need to be improved to justify their recognition as members of the HPS network and to fulfill their mission.

Risk of second primary neoplasm and mortality in childhood cancer survivors based on a national registry database

OBJECTIVE

Although overall childhood cancer survival has improved, survivors may still have an elevated risk for second primary neoplasm (SPN) and excess mortality. The aim of the current study was to estimate the risks for SPN and mortality in childhood cancer survivors in Israel as compared to the general population.

METHODS

All children aged 0-19 diagnosed with primary neoplasm between 1980-2007 who survived at least 5 years following diagnosis were included in the study. Follow-up continued until December 31st, 2013, or diagnosis of SPN, or death due to any cause (the earliest of these events). Standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) were calculated. Cox proportional hazards regression was employed to assess predictors of SPN and mortality.

RESULTS

The cohort consisted of 6637 childhood cancer survivors. A total of 244 all-site SPN cases were observed. Compared to the general population, the risks for SPN and for mortality were significantly increased (SIR = 5.48; 95%CI: 4.82-6.22 and SMR = 13.99; 95%CI = 12.54-15.56, respectively). Factors predicting SPN were sex (female), older age at first diagnosis, and initial cancer diagnosis (lymphomas). Factors predicting mortality were older age at first diagnosis, initial cancer diagnosis (myeloproliferative diseases) and earlier years, according to calendar period of initial diagnosis.

CONCLUSIONS

Although 5-year childhood cancer survival is high, survivors are at elevated risk for SPN and mortality, and the risks are associated with baseline characteristics of the patients. The increased risks should be considered when planning treatment, follow-up and surveillance of the survivors.

Prevalence, Correlates, and Time Trends of Multiple Chronic Conditions Among Israeli Adults: Estimates From the Israeli National Health Interview Survey, 2014-2015

INTRODUCTION

Chronic diseases constitute a major public health challenge. The prevalence of multiple chronic conditions (MCC) has increased. The objective of our study was to describe the prevalence, correlates, and time trends of MCC in the Israeli population and among the nation's 2 main population groups (Jewish and Arab).

METHODS

To describe the prevalence of correlates of MCC, we used data from the 2014-2015 Israeli National Health Interview Survey-III (INHIS-III). MCC was defined as having 2 or more of the following 10 self-reported physician-diagnosed chronic conditions: asthma, arthritis, cancer, diabetes, dyslipidemia, heart attack, hypertension, migraine, osteoporosis, or thyroid disease. For trend analysis, we used data from INHIS-I (2003-2004) and INHIS-II (2007-2010). Logistic regression was used for multivariate analysis. Estimates were weighted to the 2014 Israeli population. P for trend was calculated by using the Cochran-Armitage test for proportions.

RESULTS

In 2014-2015, the prevalence of MCC was 27.3% (95% confidence interval, 25.7%-28.8%). In multivariate analysis, MCC was associated with older age, female sex, a monthly household income of USD$3,000 or less, current and past smoking, and overweight or obesity. After adjusting for age, sex, income, smoking status, and body mass index, differences in MCC between Jewish and Arab populations disappeared. Dyslipidemia and hypertension were the most prevalent dyad among both men and women. Dyslipidemia, hypertension, and diabetes were the most prevalent triad among both men and women. The age-adjusted prevalence of MCC increased by 6.7% between 2003-2004 and 2014-2015.

CONCLUSION

With the increase in the prevalence of MCC, a comprehensive approach is needed to reduce the burden of chronic conditions. Of special concern are the groups most prone to MCC.

Despite awareness of recommendations, why do health care workers not immunize pregnant women?

Studies indicate uncertainty surrounding vaccination safety and efficacy for pregnant women, causing a central problem for health authorities. In this study, approximately 26% of participants do not recommend the tetanus, diphtheria, and acellular pertussis and influenza vaccines to their patients, although being aware of the health ministry recommendations. We found significant statistical discrepancies between the knowledge about the recommendations and their actual implementation, revealing the concerns of health care workers regarding vaccine safety.

Centers for Disease Control and Prevention Funding for HIV Testing Associated With Higher State Percentage of Persons Tested

OBJECTIVES

To assess the association between state per capita allocations of Centers for Disease Control and Prevention (CDC) funding for HIV testing and the percentage of persons tested for HIV.

SETTING AND PARTICIPANTS

We examined data from 2 sources: 2011 Behavioral Risk Factor Surveillance System and 2010-2011 State HIV Budget Allocations Reports. Behavioral Risk Factor Surveillance System data were used to estimate the percentage of persons aged 18 to 64 years who had reported testing for HIV in the last 2 years in the United States by state. State HIV Budget Allocations Reports were used to calculate the state mean annual per capita allocations for CDC-funded HIV testing reported by state and local health departments in the United States.

DESIGN

The association between the state fixed-effect per capita allocations for CDC-funded HIV testing and self-reported HIV testing in the last 2 years among persons aged 18 to 64 years was assessed with a hierarchical logistic regression model adjusting for individual-level characteristics.

MAIN OUTCOME

The percentage of persons tested for HIV in the last 2 years.

RESULTS

In 2011, 18.7% (95% confidence interval = 18.4-19.0) of persons reported being tested for HIV in last 2 years (state range, 9.7%-28.2%). During 2010-2011, the state mean annual per capita allocation for CDC-funded HIV testing was $0.34 (state range, $0.04-$1.04). A $0.30 increase in per capita allocation for CDC-funded HIV testing was associated with an increase of 2.4 percentage points (14.0% vs 16.4%) in the percentage of persons tested for HIV per state.

CONCLUSIONS

Providing HIV testing resources to health departments was associated with an increased percentage of state residents tested for HIV.

A national survey of ethnic differences in knowledge and understanding of supplementary health insurance

Background

Knowledge and understanding of what health insurance covers is an important public health issue. In Israel, whereas national health insurance covers all residents, optional supplemental health insurance (SHI) can be purchased from the healthcare providers, for additional, special services. The purpose of this study was to identify disparities between Jews and Arabs in their knowledge and understanding of SHI.

Methods

National, cross-sectional, telephone survey using a structured questionnaire, among random samples of 814 Jews and 800 Arabs. Knowledge and understanding of health insurance was assessed by a score based on correct answers to 8 questions. Log-linear regression was used to estimate association between health insurance knowledge and population group, after controlling for potential confounding independent variables.

Results

Ninety one percent of Jews and 62% of Arabs reported owning SHI. Among both groups, knowledge levels were low on a 0–8 scale. However, the average score for Jews was statistically higher (Mean = 3.50, S.D = 1.69) as compared with Arabs (Mean = 2.78, S.D = 1.70) (p < 0.001). The adjusted health insurance knowledge score was significantly higher among Jews than Arabs (Prevalence ratio = 1.10; 95% CI = 1.06–1.13), indicating that differences remain even after controlling for socio-demographic characteristics and SHI ownership.

Conclusions

There is a large gap between the public’s understanding of what is covered by SHI and the services that it covers in practice. Low SHI knowledge and understanding may lead to frustration, and limit access to additional health care among populations that suffer from socio-economic inequalities. These findings emphasize the need to provide clearer and more culturally sensitive information on health insurance coverage.

Electronic supplementary material

The online version of this article (doi:10.1186/s13584-017-0137-4) contains supplementary material, which is available to authorized users.

Receiving family physician's advice and the 'stages of change' in smoking cessation among Arab minority men in Israel

BACKGROUND

Receiving physician advice (PA) can increase patient's willingness to quit smoking and influence the 'stages of change' in quitting. However, less is known about this association among minority groups for whom cessation is more challenging.

OBJECTIVE

We examined whether receiving advice on smoking cessation from a family physician is associated with the 'stages of change' in quitting smoking-i.e. pre-contemplation, contemplation, preparation or action-among Arab minority men in Israel with high smoking prevalence.

METHODS

In 2011-12, a stratified random sample of 964 Arab men current and past smokers, aged 18-64, were interviewed face-to-face. We used ordered logistic regression models to examine the association between PA and stages of quitting smoking, adjusted for socioeconomic status, health status, sociodemographics, Health Maintenance Organizations (HMO) and smoking-related variables.

RESULTS

About 40% of Arab men reported ever receiving PA to quit smoking. Participants with chronic disease(s) and higher nicotine dependence were more likely to receive PA. PA was significantly associated with the stages of change, but not with actual quitting. In multivariable analysis, receiving PA was associated with a greater likelihood of being at the contemplation or preparation stages of cessation, compared to pre-contemplation; odds ratio (OR) and 95% confidence interval (CI) were 1.95 (95% CI = 1.34-2.85) and 1.14 (95% CI = 1.09-2.076), respectively.

CONCLUSIONS

Receiving PA among minority men is associated with advanced motivational stages of change in quitting smoking, but not with actual smoking cessation. Culturally, sensitive interventions and involvement of other health care providers may be considered for more comprehensive smoking cessation, in addition to PA.

Stages of change of the readiness to quit smoking among a random sample of minority Arab male smokers in Israel

BACKGROUND

Despite advanced smoking prevention and cessation policies in many countries, the prevalence of cigarette smoking among indigenous and some ethnic minorities continues to be high. This study examined the stages of change (SOC) of the readiness to quit smoking among Arab men in Israel shortly after new regulations of free-of-charge smoking cessation workshops and subsidized medications were introduced through primary health care clinics.

METHODS

We conducted a countrywide study in Israel between 2012-2013. Participants, 735 current smokers; 18-64 years old; were recruited from a stratified random sample and interviewed face-to-face using a structured questionnaire in Arabic. We used ordered regression to examine the contribution of socio-economic position (SEP), health status, psychosocial attributes, smoking-related factors, and physician advice to the SOC of the readiness to quit smoking (pre-contemplation, contemplation and preparation).

RESULTS

Of the current smokers, 61.8% were at the pre-contemplation stage, 23.8% were at the contemplation stage, and only 14.4% were at the preparation stage. In the multinomial analysis, factors significantly (P < 0.05) contributing to contemplation stage compared to pre-contemplation stage included [odds ratio (OR), 95% confidence interval (CI)]: chronic morbidity [0.52, (0.31-0.88)], social support [1.35, (1.07-1.70)], duration of smoking for 11-21 years [1.94, (1.07-3.50)], three or more previous attempts to quit [2.27, (1.26-4.01)], knowledge about smoking hazards [1.75, (1.29-2.35)], positive attitudes toward smoking prevention [1.44, (1.14-1.82)], and physician advice to quit smoking [1.88, (1.19-2.97)]. The factors significantly (P < 0.05) contributing to preparation stage compared to pre-contemplation stage were [OR, (95 % CI)]: chronic morbidity [0.36, (0.20-0.67)], anxiety [1.07, (1.01-1.13)], social support [1.34, (1.01-1.78)], duration of smoking 5 years or less [2.93, (1.14-7.52)], three or more previous attempts to quit [3.16, (1.60-6.26)], knowledge about smoking hazards [1.57, (1.10-2.21)], and positive attitudes toward smoking prevention [1.34, (1.00-1.82)].

CONCLUSIONS

Most Arab men who currently smoke are in the pre-contemplation stage, indicating low readiness to quit smoking. New policies of free-of-charge smoking-cessation group sessions and subsidized medications introduced through primary health care clinics in Israel may be less effective among Arab men. For these policies to promote cessation more successfully, tailored interventions and campaigns may be needed to increase the readiness to quit smoking in this population, especially for those at the pre-contemplation stage.

What does the public know about Ebola? The public's risk perceptions regarding the current Ebola outbreak in an as-yet unaffected country

BACKGROUND

The unexpected developments surrounding the Ebola virus in the United States provide yet another warning that we need to establish communication preparedness. This study examines what the Israeli public knew about Ebola after the initial stages of the outbreak in a country to which Ebola has not spread and assesses the association between knowledge versus worries and concerns about contracting Ebola.

METHODS

Online survey using Google Docs (Google, Mountain View, CA) of Israeli health care professionals and the general public (N = 327).

RESULTS

The Israeli public has knowledge about Ebola (mean ± SD, 4.18 ± 0.83), despite the fact that the disease has not spread to Israel. No statistically significant difference was found between health care workers versus non-health care workers in the knowledge score. Additionally, no statistically significant association was found between knowledge and worry levels. The survey indicated that Israelis expect information about Ebola from the health ministry, including topics of uncertainty. More than half of the participants thought the information provided by the health ministry on Ebola and Ebola prevention was insufficient (50.5% and 56.4%, respectively), and almost half (45.2% and 41.1%, respectively) were unsure if the information was sufficient.

CONCLUSION

The greatest challenges that the organizations face is not only to convey knowledge, but also to find ways to convey comprehensive information that reflects uncertainty and empowers the public to make fact-based decisions about health.

A randomised controlled double-blind clinical trial of 17-hydroxyprogesterone caproate for the prevention of preterm birth in twin gestation (PROGESTWIN): evidence for reduced neonatal morbidity

OBJECTIVE

To determine whether 17 alpha-hydroxyprogesterone caproate (17OHPC) prolongs gestation beyond 37 weeks of gestation (primary outcome) and reduces neonatal morbidity (secondary outcome) in twin pregnancy.

DESIGN

Randomised controlled double-blind clinical trial.

SETTING

Tertiary-care university medical centre.

POPULATION

Unselected women with twin pregnancies.

METHODS

Participants received weekly injections of 250 mg 17OHPC (n = 194) or placebo (n = 94), from 16-20 to 36 weeks of gestation. Randomisation was performed using the permuted-block randomisation method. Data were analysed on an intention-to-treat basis.

MAIN OUTCOME MEASURE

Preterm birth (PTB) rate before 37 weeks of gestation.

RESULTS

There were no significant differences in the average gestational age at delivery, or in the rates of PTB before 37, 32, and 28 weeks of gestation, between the two groups. The proportion of very-low-birthweight neonates (<1500 g) was significantly lower in the 17OHPC group (7.6%) compared with placebo (14.3%) (relative risk, RR 0.5; 95% confidence interval, 95% CI 0.3-0.9; P = 0.01). Progestogen-treated neonates had a significantly lower composite neonatal morbidity (19.1%) compared with placebo (30.9%) (odds ratio, OR 0.53; 95% CI 0.31-0.90; P = 0.02), with significantly lower odds for respiratory distress syndrome (14.4 versus 23.4%; OR 0.55; 95% CI 0.31-0.98; P = 0.04), retinopathy of prematurity (1.1 versus 4.6%; OR 0.21; 95% CI 0.05-0.96; P = 0.04), and culture-confirmed sepsis (3.4 versus 12.8%; OR 0.24; 95% CI 0.10-0.57; P = 0.00).

CONCLUSIONS

Intramuscular 17OHPC therapy did not reduce PTB before 37 weeks of gestation in unselected twin pregnancies. Nonetheless, 17OHPC significantly reduced neonatal morbidity parameters and increased birthweight.

Burn resuscitation: is it straightforward or a challenge?

Burn shock resuscitation has been extensively studied over the past four decades. Many formulas exist and many parameters have been suggested to assess the adequacy of resuscitation. The most commonly used formula is the Parkland formula, the most commonly used fluids are crystalloids, and the most commonly used parameter is urine output. However, until now, no conclusive evidence has suggested that one formula is superior to another or that one parameter is a better predictor than another. In this article we will review the updated information about the subject and we will look into new advancements in this field. We will pose some questions at the end that will help researchers concentrate their future efforts to solve this important challenge in burn care.

The effect of injections of botulinum toxin type A combined with casting on the equinus gait of children with cerebral palsy

Our aim was to evaluate the effect of adding inhibitory casting to the treatment of young children with cerebral palsy who received injections of botulinum neurotoxin A (BoNT-A) to gastrocnemius for equinus gait. Of the 20 patients in the series, 11 in group A had inhibitory casts applied on the day of the first set of BoNT-A injections and nine in group B did not have casting. Both groups received another BoNT-A injection four months later. The patients were followed for eight months and examined at five intervals. Both groups showed significant improvement in gait parameters and function (p < 0.0001) and selective motor control (p = 0.041, - 0.036) throughout the study. Group A had significantly better passive dorsiflexion of the ankle (p = 0.029), observational gait score (p = 0.006) and selective motor control (p = 0.036). We conclude that the addition of inhibitory casting enhances and prolongs the results of treatment and mainly influences the passive range of movement, while BoNT-A mostly influences the dynamic motion. The second injection further improved the results of most parameters. The gross motor function measure, the selective motor control test and the modified Tardieu scale correlated well with the results of treatment. We recommend the use of inhibitory casting whenever augmentation of the effect of treatment with BoNT-A is needed.

Burn wound cleansing - a myth or a scientific practice

Burn wound cleansing is an integral step in every wound management protocol. Yet a lot of this practice is based on myth rather than real scientific basis. The literature is poor in scientific papers comparing the outcome of patients who underwent wound cleansing to those who did not. A survey form was designed by the Mediterranean Council for Burns and Fire Disasters - MBC and sent by e-mail to its members as well as members of the European Burn Association and other burn specialists, and 76 replies were received. Responses showed wide inconsistencies in the methods of burn wound cleansing, the solutions used for cleansing, the added antiseptics or detergents used, and the frequency of cleansing. Wound cleansing and dressing is a process that should be based on evidence and not on a ritualistic behaviour or a personal preference. In order to optimize burn wound care and promote optimal healing, more clinical evidence-based studies are needed to confirm or negate the positive or negative effects of any topical solution currently in use for burn wound cleansing.

Perthes' disease and the search for genetic associations: collagen mutations, Gaucher's disease and thrombophilia

The role of heritable thrombophilic risk factors in the pathogenesis of the Perthes' disease is controversial. The clinical and radiological findings of Perthes' disease may be indistinguishable from those of Gaucher's disease, and the most common Jewish N370S Gaucher mutation is threefold greater in patients with Perthes' disease. Familial osteonecrosis of the femoral head is associated with variant mutations of collagen type II (COL2A1 mutations). We therefore studied the potential role of genetic thrombophilia and the Gaucher and COL2A1 mutations in children with Perthes' disease. Genomic DNA of 119 children with radiologically-confirmed Perthes' disease diagnosed between 1986 and 2005 was analysed for the thrombophilic polymorphisms Factor V Leiden, 677T-MTHFR and FIIG20210A. The results were compared with those of a group of 276 children without Perthes' disease. DNA was also analysed for the Gaucher mutations N370S, G insertion (84GG), L444P, Intron 2 (IVS2+1G>A) and R496H. Enzymic assays confirmed the Gaucher disease status. Collagen (COL2A1) mutations of the 12q13 gene were also analysed. The prevalence of thrombophilic markers was similar among the 119 patients with Perthes' disease and the 276 control subjects. The prevalence of the Gaucher mutation was consistent with Israeli population carriership data and did not confirm an earlier-claimed association with Perthes' disease. All 199 patients were negative for the studied COL2A1 mutations. We found no genetic association between Perthes' disease and either Gaucher's disease or COL2A1 mutations or increased genetic thrombophilia among our patients compared with the control group. A systematic review of case-control studies suggested that there was a positive association between Perthes' disease and Factor V Leiden. The impact of this association upon the disease, although not consistent across the studies, remains unclear.

[Quality assurance in biometry before cataract surgery: which patients have an increased risk of aberrance from target refraction?]

BACKGROUND

An important factor for patient satisfaction after cataract surgery is the achievement of the planned target refraction. The formulae which are used to calculate the necessary refractive power of the intraocular lens (IOL) to be implanted have been improved over time in order to deliver exact predictions even in those cases in which the measurements of an eye deviate greatly from the norm. We examined which of the routinely measured biometric values have an influence on reaching target refraction.

PATIENTS AND METHODS

This retrospective investigation reports on a case series of 153 eyes of 146 patients within 6 months in which a cataract operation was performed. The average age at the time of operation was 73.5 years. Four measurements were taken preoperatively: refraction (Ref), axial length (AL), corneal refractive power (CR) and anterior chamber depth (ACD). Each of these measurements was examined regarding its influence on the refractive outcome. One of three end points was possible for each eye: achievement of target refraction within +/- 0.5 dpt, aberrance from target refraction by more than + 0.5 dpt and aberrance from target refraction by more than - 0.5 dpt. A multivariate regression analysis was performed in which aberrance from target refraction was defined as the dependent variable and the four mentioned measurements were set as independent variables.

RESULTS

Of the 153 eyes, in 91 eyes the target refraction was achieved within 0.5 dpt (group 1). In 37 eyes the aberrance from target refraction was more than - 0.5 dpt (group 2) and in 25 eyes it was more than + 0.5 dpt (group 3). The mean measurement values in groups 1, 2 and 3 were as follows: for preoperative refraction 0.0 dpt/0.5 dpt/0.625 dpt, for corneal refractive power 42.84 dpt/42.29 dpt/42.67 dpt, for axial length 23.41 mm/23.36 mm/23.73 mm and for anterior chamber depth 3.07 mm/3.00 mm/3.20 mm. No statistically significant relation between the respective measured values or a combination thereof and the refractive result could be demonstrated.

CONCLUSIONS

The formulae for calculating IOL power available today are highly developed and integrate preoperative biometries in a non-linear way, so that there is little difference between measurements within the norm and outlying ones concerning their influence on the refractive result. When conducting quality assurance efforts, we recommend to direct attention to factors influencing anterior chamber depth.

First Clinical Experience with Anecortave Acetate (Retaane®)

BACKGROUND

Anecortave acetate is an angiostatic cortisene which is injected as a posterior juxtascleral depot and has been shown to be effective in the treatment of exudative age-related macular degeneration (AMD). The compound is not yet approved in Switzerland but can be used as "compassionate use" in individual cases.

PATIENTS AND METHODS

An uncontrolled case series with standardised documentation of ETDRS visual acuity, near acuity, need for magnification and fluorescein angiography was performed.

RESULTS

22 eyes of 19 patients (8 male, 11 female, average age 78.8 years) were treated with a posterior juxtascleral depot injection (PJD) of 15 mg anecortave acetate. The mean change in visual acuity after 3 months in eyes treated with anecortave acetate was -2.6 ETDRS letters corresponding to 0.52 Snellen lines. 3/20 eyes gained more than 1 line. 11/20 eyes showed stable visual acuity (+/- 1 Snellen line, +/- 5 ETDRS letters). 5/20 eyes developed moderate vision loss (one to two Snellen lines, 6-10 ETDRS letters). 1/20 lost 18 ETDRS letters (> 3 Snellen lines). There were no moderate or severe adverse events.

CONCLUSIONS

A PJD of 15 mg anecortave acetate is safe and well tolerated. In eyes with occult CNV without recent progression or with residual neovascular activity after photodynamic therapy anecortave acetate may be an alternative therapeutic option before considering intravitreal anti-VEGF agents due to the much less invasive character and lower risk profile.

The 1226G (N370S) Gaucher mutation among patients with Legg-Calve-Perthes disease

Legg-Calve-Perthes disease (LCPD) is an avascular necrosis of the femoral head with an annual incidence of 5-15/100,000. The estimated incidence of Gaucher disease, a lysosomal recessive storage disease, is 1:850, with a carrier rate of 1:17.5 for the 1226G (N370S) mutation among Ashkenazi Jews in whom there is a predilection. Since clinical and radiological findings of avascular hip necrosis due to either Gaucher disease or LCPD may be indistinguishable, misdiagnosis may occur. The purpose of this study was to evaluate the incidence of 1226G Gaucher mutation in a cohort of radiologically confirmed LCPD patients (diagnosed 1986-2000) in Israel. Enzyme assay was performed for confirmation of affected versus carrier status in patients with the 1226G mutation. In all, 78 LCPD patients, 86% males, 51% with severe bone disease, were studied. Family history was negative for Gaucher disease. Ethnic origin was 39% Ashkenazi Jewish, 6% Arab, and 55% other ethnicities. One Ashkenazi Jewish LCPD patient was homozygous for the 1226G mutation, and 4 LCPD patients were carriers: 3 Ashkenazi Jewish and 1 Arab patient. The frequency of the 1226G mutation among the LCPD patients was increased relative to historical Ashkenazi Jewish Israeli controls (P = 0.01). Since Gaucher disease may be misdiagnosed as LCPD, glucocerebrosidase enzyme testing is recommended among Ashkenazi Jewish children diagnosed with LCPD.

Efficacy of prenatal ultrasonography in confirmed club foot

Club foot can be diagnosed by ultrasound of the fetus in more than 60% of cases. We have correlated the accuracy of the prenatal findings in 281 ultrasound surveys with the physical findings after birth and the subsequent treatment in 147 children who were born with club foot.

The earliest week of gestation in which the condition was diagnosed with a high degree of confidence was the 12th and the latest was the 32nd. Not all patients were diagnosed at an early stage. In 29% of fetuses the first ultrasound examination failed to detect the deformity which subsequently became obvious at a later examination. Club foot was diagnosed between 12 and 23 weeks of gestation in 86% of children and between 24 and 32 weeks of gestation in the remaining 14%. Therefore it can be considered to be an early event in gestation (45% identified by the 17th week), a late event (45% detected between 18th and 24th weeks) or a very late event (10% recognised between 25th and 32nd weeks). We cannot exclude, however, the possibility that the late-onset groups may have been diagnosed late because earlier scans were false-negative results. The prenatal ultrasonographic findings were correlated with the physical findings after birth and showed that bilateral involvement was more common than unilateral. There was no significant relationship between the prenatal diagnosis and the postnatal therapeutic approach (i.e., conservative or surgical), or the degree of rigidity of the affected foot.

Efficacy of prenatal ultrasonography in confirmed club foot

Club foot can be diagnosed by ultrasound of the fetus in more than 60% of cases. We have correlated the accuracy of the prenatal findings in 281 ultrasound surveys with the physical findings after birth and the subsequent treatment in 147 children who were born with club foot. The earliest week of gestation in which the condition was diagnosed with a high degree of confidence was the 12th and the latest was the 32nd. Not all patients were diagnosed at an early stage. In 29% of fetuses the first ultrasound examination failed to detect the deformity which subsequently became obvious at a later examination. Club foot was diagnosed between 12 and 23 weeks of gestation in 86% of children and between 24 and 32 weeks of gestation in the remaining 14%. Therefore it can be considered to be an early event in gestation (45% identified by the 17th week), a late event (45% detected between 18th and 24th weeks) or a very late event (10% recognised between 25th and 32nd weeks). We cannot exclude, however, the possibility that the late-onset groups may have been diagnosed late because earlier scans were false-negative results. The prenatal ultrasonographic findings were correlated with the physical findings after birth and showed that bilateral involvement was more common than unilateral. There was no significant relationship between the prenatal diagnosis and the postnatal therapeutic approach (i.e., conservative or surgical), or the degree of rigidity of the affected foot.

Primary chronic sclerosing (Garré's) osteomyelitis in children

Three children with unifocal nonpyogenic inflammatory bony lesions with a prolonged, fluctuating course are reported. The lesions were located at the metaphyseal region of long bones. Three was progressive sclerosis and hyperostosis in the tibia or femur, such as the changes described in Garré's osteomyelitis. No pus was released by exploration of the lesions. Tissue and blood cultures were negative. The histology was typical of chronic osteomyelitis: the symptoms returned intermittently over several years, together with the development of sclerosis but without disturbance of bone growth. It is not clear whether Garré's chronic sclerosing osteomyelitis is a different entity from chronic recurrent multifocal osteomyelitis.

Bilateral symmetric stress fractures in a toddler

Stress fractures are a common injury among adolescent athletes and military recruits. The increase in child participation in organized sport activities has contributed to the inclusion of the skeletally immature age group among those who may suffer from this problem. Bilateral simultaneous symmetric tibial stress fractures that are infrequent in older children are even more rare in toddlers. This entity may cause a diagnostic problem as it must be differentiated from infectious disease, acute trauma or even from the result of a battered child.

Spinal deformity in familial dysautonomia. Prevalence, and results of bracing

BACKGROUND

Familial dysautonomia (Riley-Day syndrome) is an autosomal recessive disorder primarily affecting individuals of Ashkenazi Jewish extraction. It affects the autonomic, central, and peripheral nervous systems. Spinal deformity (mainly scoliosis) is the most common orthopaedic problem in patients with familial dysautonomia. The objectives of our study were to document the prevalence of spinal deformity in a referral center for familial dysautonomia and to determine the effectiveness of bracing.

METHODS

We performed a retrospective radiographic and clinical study of 123 patients with familial dysautonomia who had survived to the age of twenty years or older.

RESULTS

One hundred and two (83 percent) of the 123 patients had spinal deformity: sixty-nine (56 percent) had scoliosis only, thirty-one (25 percent) had scoliosis as well as kyphosis, and two (2 percent) had kyphosis only. Scoliosis was diagnosed by the age of ten years in sixty-four (52 percent) of the patients. Of the sixty-five patients who were treated with bracing, fifty-eight (89 percent) had progression and twenty-four (37 percent) underwent spinal arthrodesis. No risk factors for the presence or progression of the curves could be found.

CONCLUSIONS

The prevalence of spinal deformity in patients with familial dysautonomia who had lived for at least twenty years was found to be 83 percent. By the age of ten years, 52 percent of the patients had scoliosis and 21 percent had kyphosis with or without scoliosis. Bracing was found to be of limited effectiveness as a definitive treatment for spinal deformity. The curve progressed despite bracing in fifty-eight (89 percent) of sixty-five patients.

Serrated W/M osteotomy. Results using a new technique for the correction of infantile tibia vara

The conventional osteotomies used to treat infantile tibia vara (Blount's disease) may require internal fixation and its subsequent removal. These techniques, which carry the risk of traction injury, and potential problems of stability and consolidation, do not always succeed in correcting the rotational deformity which accompanies the angular deformity. We have used a new surgical approach, the serrated W/M osteotomy of the proximal tibia, to correct infantile tibia vara in 15 knees of 11 patients. We present the results in 13 knees of nine patients who have been followed up for a mean of eight years. The mean angular correction achieved after operation was 18 +/- 5.8 degrees. The mean femorotibial shaft angle was corrected from 14.2 +/- 3.7 degrees of varus to 4.6 +/- 4.4 degrees of valgus. At the last follow-up, the mean angular correction had reduced to 1.3 +/- 4.9 degrees of valgus without compromising the rotational correction and the overall good clinical results. All the patients and parents were satisfied, rating the result as excellent or good. There were no major postoperative complications and no reoperations. Eight patients were free from pain and able to perform physical activities suitable for their age. One complained of occasional pain. This procedure has the advantage of allowing both angular and rotational correction with a high degree of success without the need for internal fixation.

Serrated W/M osteotomy

The conventional osteotomies used to treat infantile tibia vara (Blount’s disease) may require internal fixation and its subsequent removal. These techniques, which carry the risk of traction injury, and potential problems of stability and consolidation, do not always succeed in correcting the rotational deformity which accompanies the angular deformity.

We have used a new surgical approach, the serrated W/M osteotomy of the proximal tibia, to correct infantile tibia vara in 15 knees of 11 patients. We present the results in 13 knees of nine patients who have been followed up for a mean of eight years. The mean angular correction achieved after operation was 18 ± 5.8°. The mean femorotibial shaft angle was corrected from 14.2 ± 3.7° of varus to 4.6 ± 4.4° of valgus. At the last follow-up, the mean angular correction had reduced to 1.3 ± 4.9° of valgus without compromising the rotational correction and the overall good clinical results. All the patients and parents were satisfied, rating the result as excellent or good. There were no major postoperative complications and no reoperations. Eight patients were free from pain and able to perform physical activities suitable for their age. One complained of occasional pain. This procedure has the advantage of allowing both angular and rotational correction with a high degree of success without the need for internal fixation.

Rectus abdominis free-tissue transfer in lower extremity reconstruction: review of 40 cases

Forty patients who underwent rectus abdominis free-tissue transfer with split-thickness skin grafts for reconstruction of the lower extremity are reported. The procedures were performed between January, 1992 and December, 1998. Transfers were utilized for coverage of acute soft-tissue and bone defects (18 patients), defects following radical debridement of chronic osteomyelitis of the leg and foot (13 patients) or diabetic foot ulcers (eight patients), and for unstable scars (one patient). At a mean follow-up of 3.6 years, there was no donor-site morbidity; there were seven local complications--five superficial flap necroses and two flap congestions. Three flaps were totally lost. All patients but one were ambulatory and fully weight-bearing at the time of review, with consolidation of the fractures and bone defects and no evidence of recurrence of infection in the osteomyelitis or diabetic foot ulcer groups. The relatively high success rate (92.5 percent), the ease of surgical dissection, the consistency and size of the deep inferior epigastric pedicle, the absence of donor-site morbidity, and relatively low complication rates make the rectus abdominis muscle one of the preferable free-tissue transfers for these authors.