Decision-making algorithm for sequential treatment of diaphyseal bone gaps in war-wounded patients in the Middle East.

INTRODUCTION: Tibial bone gaps after war injuries are common and can be managed by different types of surgery, including compression, bone graft, tibialisation of fibula, bone transport, and free flaps. Here, we present an algorithm developed at a humanitarian surgical hospital to manage tibial bone gaps. We also identify some key factors affecting patient outcomes and describe some clinical considerations for choosing treatment strategy. METHOD: We performed retrospective data analysis on war-wounded adult patients with tibial injuries treated at our project according to the described algorithm. Patient outcomes were followed for at least four  years. Outcomes assessed were length of stay, complication rate, re-admission (late complications), and final discharge. RESULTS: Among the 200 included patients, 103 (51.5%) had bone gaps. Univariate analysis showed that the presence of a bone gap, but not its size, was associated with significantly increased risk of early complications, while type of surgery was significantly correlated with re-admission. Presence of a bone gap and type of surgery were each significantly associated with length of stay. Bone gap size showed no correlation with outcomes, an unexpected finding. DISCUSSION: Soft tissue damage with compromised vascularity may explain the lack of association between bone gap size and outcomes. Specialised centres using standardised approaches to complex surgical reconstruction can play an important role in expanding the evidence base needed to improve case management. CONCLUSIONS: Less invasive procedures may lead to better patient outcomes, although unfortunately may not always be possible given the nature of the injury and/or injury site.

Vitamin D Dosing Strategies Among Jordanians With Hypovitaminosis D.

OBJECTIVE: To compare between weekly and daily cholecalciferol in patients with hypovitaminosis D and to determine the optimal maintenance dose. METHODS: Seventy-one volunteers with hypovitaminosis D were randomly assigned to 2 dose regimens: cholecalciferol 50 000 IU weekly for 8 weeks, then 50 000 IU monthly for 2 months (group A) and 7000 IU daily for 8 weeks, then 12 500 IU weekly for 2 months (group B). Cholecalciferol was stopped for 2 months and reintroduced as 50 000 IU bimonthly for group A and 50 000 IU monthly for group B. RESULTS: Two months after therapy, the mean serum 25-hydroxyvitamin D (25(OH)D) level increased from 11.4 to 51.2 ng/mL and from 11.7 to 44.9 ng/mL in groups A and B, respectively ( P = .065). The levels of 25(OH)D declined similarly in both groups during maintenance and after holding therapy. After resuming cholecalciferol, 25(OH)D levels increased to 33.8 and 28.8 ng/mL in groups A and B, respectively ( P = .027). There was a negative correlation between serum 25(OH)D levels and body mass index (BMI; P = .040). CONCLUSION: Timing and frequency of the dosing (daily vs weekly) have no effect on the rise in serum 25(OH)D levels as long as the accumulative dose of cholecalciferol is similar. Cholecalciferol 50 000 IU bimonthly is required to maintain sufficient 25(OH)D levels.

Hypertension Prevalence, Awareness and Control Levels among Ghawarna: An African-Descendant Ethnic Minority in the Jordan Valley.

OBJECTIVE: Treatment and control of hypertension (HTN) is a challenging issue as undiagnosed HTN prevalence seems to be high among certain ethnic groups, such as African-descendant populations. The current study attempted to measure HTN prevalence, awareness and control levels among Ghawarna, an African-descendant ethnic group living in the Jordan Valley (Al-Ghawr). DESIGN SETTING AND PARTICIPANTS: A cross-sectional study was conducted in a community of Ghawarna between March and June 2013 in Ghawr Al-Mazraa Village in the southern part of the Jordan Valley. A total of 517 participants, aged >25 years, were randomly selected using cluster random sampling technique. MAIN MEASURES: Data were collected using an interviewer-administrated questionnaire and on-location measurement of blood pressure (BP), height, and weight. Prevalence rates were compared by sex and age groups using chi-square test while backward selection logistic regression analysis was used to identify predictors of HTN. RESULTS: We found 229 (44.3%) of the 517 participants had HTN. Of those 229 hypertensives, 146 (28.2%) participants were discovered to have HTN for the "first time." Only 23 of the 83 who were aware of their hypertension had their BP controlled. When we added the undiagnosed HTN (n=146) to the uncontrolled HTN (n=60), the prevalence of uncontrolled HTN became 90% (206/229). Older age, higher BMI, diabetes mellitus, and dyslipidemia were associated with having HTN. CONCLUSIONS: HTN prevalence, awareness and control levels are alarming among Ghawarna.

Permanent neonatal diabetes mellitus in Jordan.

OBJECTIVE: Permanent neonatal diabetes mellitus (PNDM) is a rare heterogeneous form of diabetes that develops within the first 6 months of life. The objective of this study is to define the genetic etiology and incidence of permanent neonatal diabetes mellitus in Jordan. METHODS: This study was conducted in Jordan at the National Center of Diabetes, Endocrinology and Genetics, Amman, between 2006 and 2012. The study included 22 cases diagnosed with diabetes within the first year of life. RESULTS: The incidence of PNDM in Jordan was calculated as one case for every 203,221 live births. Mutations were found in six out of ten cases diagnosed before 6 months and included one homozygous ABCC8 p.R826W mutation, three cases with a heterozygous KCNJ11 p.R201C mutation, and two cases with a homozygous EIF2AK3 splicing mutation. CONCLUSION: The genetic etiology of PNDM in Jordan is different from that seen in European countries and more similar to other Arab countries.