Hyperglycaemia in patients with no history of diabetes presenting to Internal Medicine Departments.

AIMS: Stress hyperglycaemia during hospitalisation may be the first sign of diabetes mellitus (DM). Most hospitals routinely measure blood glucose, which may enable early diagnosis. This study measured the prevalence of hyperglycaemia in hospitalised adults with no history of diabetes, and whether the discharge summary recommended work-up. METHODS: Files with at least one random blood glucose (RBG) sample were included and reviewed for specific discharge recommendations concerning elevated blood glucose. Hyperglycaemia was defined as serum glucose > 200 mg/dl. Length of stay, in-hospital mortality and 3-year mortality were examined. RESULTS: Among 5274 discharged patients, 1479 had DM. They were older and had a higher incidence of cerebrovascular risk factors. Among 3714 patients without known DM, 211 (5.7%) had at least one RBG > 200 mg/dl. Of these patients, 31 died and 24 left against medical advice. Of the remaining 156, 25(16%) files included instructions to the family physician. These patients were younger, more overweight and less frequently diagnosed with dementia or other mental illness. Patients with RBG > 200 mg/dl had prolonged hospital stay (6.5 ± 5.3 vs. 4.0 ± 4.8; p < 0.001). In-hospital mortality and 3-year mortality were increased by 5.1 and 1.89, respectively (p < 0.001 for both parameters) compared to those without RBG ≤ 200 mg/dl. RBG > 200 mg/dl emerged as a significant, independent predictor of prolonged hospital stay and death. CONCLUSIONS: Random blood glucose > 200 mg/dl is common in medical departments and is associated with increased in-hospital and 3-year out-hospital mortality.

Inpatient hyperglycaemia improvement quality program.

BACKGROUND: Poorly controlled hyperglycaemia is associated with increased morbidity and mortality in hospitalised patients. Based on the view that hospitalisation provides a window of opportunity to improve patient quality of care and health status, a comprehensive program for treating hospitalised diabetic patients was initiated. This study assessed the effectiveness of the Inpatient Hyperglycaemia Improvement Quality Program (IHIQP) over a 4-year period. METHODS: Pre-test post-test design. In the pre-intervention period (August-December 2007), an institution-wide blood glucose monitoring system was introduced in August 2007. The remaining program components were introduced in January 2008, including implementing a hospital care protocol based on the 2007 American Diabetes Association Standards, a multidisciplinary team that participates in patient care and arranges continuing care after discharge and comprehensive patient education prior to discharge. Program results from January 2008 through October 2011 were evaluated. RESULTS: During follow-up, more than 600,000 blood glucose tests were performed. Blood glucose values declined from 196.4 ± 98.4 mg/dl pre-IHIQP (August-December 2007) to 174.5 ± 82.0 mg/dl post-IHIQP (January-October 2011) (p < 0.0001). Prevalence of glucose values lower than 60 mg/dl declined from 2% to 1.3% (p < 0.004). Prevalence of glucose values ≥ 300 mg/dl declined from 13.6% to 8.4% (p < 0.0001). Concomitantly, the proportion of in-target values of 80-180 mg/dl increased from 47.7% to 58.1% (p < 0.0001). CONCLUSION: This in-patient hyperglycaemia quality improvement program led to improvements in-patient glycaemic control, which continued over time. The effect of this improvement on in-patient mortality and morbidity needs additional follow-up.

Opinion and knowledge among hospital medical staff regarding diagnosis of diabetes and proper usage of a specific test tube for glucose analysis.

BACKGROUND: Accuracy of blood sugar values, as examined by glucose analysis, has significant importance on the diagnosis of diabetes and follow up of diabetes treatment. Usage of a designated test tube significantly improves the accuracy of measurement. Knowledge of the medical staff is a major determinant in the current usage of such a technology. The aim of the study was to assess the level of knowledge exhibited by medical staff in the diabetes field and specifically for the usage of a designated tube to test blood glucose level. METHODS: A prospective study. The staff of the internal and surgical departments and outpatient clinics at the Wolfson Medical Center completed a questionnaire that assessed the level of knowledge about the designated glucose test tube, other randomly used test tubes, the parameters that influence the blood glucose values in a non-designated tube and the diagnosis of diabetes. RESULTS: A number of 160 questionnaires (50% from internal departments, 36% from surgical departments and 14% from outpatient clinics) were analysed. The majority of the staff members (65%) knew that diabetes is diagnosed by glucose levels in blood. Of the 35% that did not know, 91% were nurses. The majority (75%) knew that diabetes is diagnosed during fasting conditions; however, most of the staff indicated that 12 h is needed. Only 25% knew of the designated test tube, and most of the staff indicated that a regular chemistry tube was the tube of choice for them. The staff exhibited poor level of knowledge regarding the parameters that influence the quality of the test. CONCLUSIONS: Staff members are not aware of the various aspects of diabetes diagnosis and the designated test tube for glucose measurements, and most of them use a tube that gives inaccurate measurements, therefore there is an urgent need to improve diabetes knowledge among staff members.

Parental sleep quality and continuous glucose monitoring system use in children with type 1 diabetes.

To compare sleep quality and sleep-wake patterns in parents of children with type 1 diabetes before routine use of the continuous glucose monitoring system (CGMS) and while using it. Thirteen parents completed the Pittsburg Sleep Quality Index (PSQI), a 7-day sleep diary, and wore an actigraph (a wristwatch-size motion detector) during the night for 1 week before pediatric use of CGMS and 4-8 weeks after initiating routine use of the CGMS. Mean age of parents (ten mothers, three fathers) was 39 (range 32-47) years; mean age of children was 9.3 years (range 5.5-16.5 years); mean disease duration was 3.4 (range 0.6-11.2) years. PSQI total score demonstrated similar quality of sleep with and without use of the CGMS (4.6 and 4.9, respectively, p = 0.45). Six of the 13 parents reported severe sleep problems (PSQI ≥ 5) with and without the CGMS. The sleep diary indicated a greater number of awakening episodes during CGMS use than without the CGMS (1.6 and 1, respectively, p = 0.03), and actigraphy documented an increase in the number of wake bouts (22.9 and 19.7, p = 0.03) as well as in total wake time (48.3 and 42.2 min, p = 0.03) during CGMS use as compared with the period prior to CGMS use. Although self-perception of sleep quality remained unchanged, CGMS use appeared to affect actual parental sleep continuity somewhat negatively. This should be made clear to parents who may hold expectations of improvement in sleep quality following initiation of CGMS use.

Relationship between equipment and infrastructure for pandemic influenza and performance in an avian flu drill.

BACKGROUND: Effective preparedness for pandemic influenza necessitates acquisition and maintenance of vital equipment and infrastructure. The aim of this study was to investigate the relationship between the level of hospital preparedness relating to infrastructure and equipment and performance of the hospital in an avian flu drill. METHODS: The levels of preparedness of the infrastructure and equipment for pandemic influenza of all 24 general hospitals were evaluated using a tool developed for this purpose. The hospital evaluation scores were then compared with the scores obtained by the hospitals in a simulated avian flu drill. RESULTS: The overall scores of equipment and infrastructure for pandemic influenza of general hospitals ranged from 67% to 100%. Comparison of the overall level of preparedness of equipment and infrastructure for pandemic influenza with the overall scores achieved in the avian flu drill revealed a medium correlation. A medium correlation was also found between stockpiling of medications and performance in the avian flu drill. No correlations were found between operating infrastructure, availability of protective measures and medical forms and performance in the avian flu drill. CONCLUSIONS: This study has identified benchmarks of infrastructure and equipment required for managing a pandemic influenza event and evaluating the level of emergency preparedness of the hospital. The significant relationship between maintaining stockpiles of antiviral medications for patients and staff and performance in an avian flu drill emphasises its importance in the process of maintaining emergency preparedness for a pandemic influenza outbreak.

A single, improvised "Kassam" rocket explosion can cause a mass casualty incident: a potential threat for future international terrorism?

INTRODUCTION: Over 2000 improvised rockets (called "Kassam" rockets) have been targeted at the south of Israel from the Gaza strip since 2001. Most of them have injured relatively few people. The first known case of a multicasualty incident (MCI) caused by the landing of a single, improvised rocket is described. METHODS: The event is described according to the disastrous incidents systematic analysis through components, interactions and results methodology (DISAST-CIR). RESULTS: The rocket hit a military training tent camp in the south of Israel at 01:18 hours. At that time, all soldiers were in bed and were not using any protective gear. A total of 76 soldiers was injured (three severe, eight moderate and 65 mild). The most prevalent types of injuries were upper extremity (33%) and lower extremity (30%) trauma, tinnitus (30%) and acute stress reactions (32%). A total of 67 casualties was evacuated to the nearest level two hospital, Barzilai, in a two-phase distribution characterised by different patterns of injury severity and type. All urgent casualties arrived at hospitals within 1 h 24 minutes, whereas most stress casualties arrived in the later phase. Seven casualties were secondarily transported to level one trauma centres. 42 of the casualties were hospitalised and 17 needed urgent surgery. None has died. CONCLUSIONS: A single low-tech mortar with poor accuracy and small warhead (estimated weight of 10 kg only) can cause a large-scale MCI. As international terrorist organisations can easily gain access to improvised rockets, the latter may become a threat in many countries. Emergency systems should thus be prepared for that adverse possibility.

Prevalence of central nervous system diseases--a large retrospective cohort study of adolescents.

At age sixteen, most Israeli nationals must undergo medical evaluation for compulsory military duty. All potential conscripts are referred to the Israel Defense Forces (IDF) recruiting office. Therefore, medical screening of a vast number of adolescents is performed, offering a unique opportunity to study the prevalence of neurological diseases in an entire age cohort. Hence, screening is not affected by diagnostic or methodological bias. We performed a retrospective neuroepidemiological large cohort study of adolescents from the database of the Israel Defense Forces recruiting office during the years 1998-2002. The survey included 409 492 adolescents, among them 162 079 (39.5%) females. The most prevalent diagnoses were: headache (754 per 10 000 adolescents), permanent brain damage (197 per 10 000), epilepsy (167 per 10 000) and movement and coordination disorders (36 per 10 000). These were followed by cranial nerve disorders, sleep disorders, cranio-spinal bone defects, and chronic progressive CNS disorders. The relative risk for male adolescents within the specific disease groups was higher for movement-coordination, sleep and cranial nerve disorders. Multivariate analysis revealed gender and severity prevalence and sex-grade, or year-grade interactions in the distinct groups of diseases. This study provides important information on the prevalence of neurological diseases in adolescents and demonstrates some significant epidemiological trends.

Injury patterns in clashes between citizens and security forces during forced evacuation.

INTRODUCTION: Clashes between state security forces and civilian populations can lead to mass casualty incidents (MCI), challenging emergency medical service (EMS) systems, hospitals and medical management systems. In January 2006, clashes erupted between Israeli security forces and settlers, around the forced evacuation of the Amona outpost. METHODS: Data collected during the events and in subsequent formal debriefings were processed to identify the specifics of an MCI caused by forced evacuation. Pre-event preparedness, time and types of injuries encountered were evaluated among evacuated civilians and security forces members, their transport to hospitals, care received and follow-up. The event is described according to DISAST-CIR methodology. Data were entered on MS Excel (2003) and analysis was carried out using SPSS version 12. RESULTS: 4000 police personnel (backed by army forces) clashed for 12 h with approximately 5000 settlers. 229 injured (174 settlers and 55 security personnel) were cared for at six receiving hospitals. A total of 16 were evacuated by aeromedical evacuation, including one severely head-injured policeman. Settlers used sticks, stones and cement blocks, whereas police used mounted riders, batons and shields. Head injuries were the most common injuries among settlers (50%), whereas extremity injuries dominated among security forces members (72.7%). CONCLUSION: Large-scale clashes between state security forces and citizens may cause numerous injuries, even if firearms and explosives are not used. Despite the fact that almost all injuries were mild, the incident burdened local medical teams, EMS and Jerusalem hospitals. A predominance of head injuries was found among injured settlers and extremity injuries among injured security forces.

Mass casualty incident management, triage, injury distribution of casualties and rate of arrival of casualties at the hospitals: lessons from a suicide bomber attack in downtown Tel Aviv.

BACKGROUND: Terrorist attacks in Israel cause mass events with varying numbers of casualties. A study was undertaken to analyse the medical response to an event which occurred on 17 April 2006 near the central bus station, Tel Aviv, Israel. Lessons are drawn concerning the management of the event, primary triage, evacuation priorities and the rate and characteristics of casualty arrival at the nearby hospitals. METHODS: Data were collected both during and after the event in formal debriefings. Their analysis refers to medical response components, interactions and main outcomes. The event is described according to the DISAST-CIR methodology (Disastrous Incidents Systematic AnalysiS Through--Components, Interactions and Results). RESULTS: 91 casualties were reported in this event; 85 were evacuated from the scene including 3 already dead on arrival, 9 severely injured, 14 moderately injured and 59 mildly injured. Six were declared dead at the scene. Emergency medical service (EMS) vehicle accumulation was rapid. The casualties were distributed between five hospitals (three level 1 and two level 2 trauma centres). The first evacuated casualty arrived at the hospital within 20 min of the explosion and the last urgent victim was evacuated from the scene after 1 h 14 min. Evacuation occurred in two phases: the first, lasting 1 h 20 min, in which most of the patients with evident trauma were evacuated and the second, lasting 8 h 15 min, in which most patients presented with tinnitus and symptoms of somatisation. The most common injuries were upper and lower limb injuries, diagnosed in 37% of the total injuries, and stress-related disturbances (anxiety, tinnitus, somatisation) diagnosed in 41%. CONCLUSION: Rapid accumulation of EMS vehicles, effective primary triage between urgent and non-urgent casualties and primary distribution between five hospitals enabled rapid conclusion of the event, both at the scene and at the receiving hospitals.

Screening for common dermatologic disorders amongst Israeli adolescents.

BACKGROUND: Dermatologic disorders amongst adolescents tend to overlap with general adult dermatology, but specific data are scarce. This study was undertaken to assess the prevalence of common skin disorders in 17-year-old Israeli military conscripts. METHODS: Military recruits who underwent medical examination over approximately 1 year were included. Dermatology specialists evaluated and classified those with suspected skin disorders into categories of suitability for military tasks. Data were computerized for analysis of prevalences. Risk ratios for each category were determined for men and women. RESULTS: Of the 94,806 adolescents, 36,511 (38.5%) women and 58,295 (61.5%) men, the most prevalent diagnoses were hyperhidrosis, multiple nevi, atopic dermatitis, keratinization disorders (mostly psoriasis), and contact dermatitis. The most prominent gender differences were in hyperhidrosis, contact dermatitis, and collagen diseases. CONCLUSION: Major dermatologic problems in adolescents are documented, and the findings may be useful for the military, employers, and general health services.

Nonradiologist utilization of American College of Radiology Appropriateness Criteria in a preauthorization center for MRI requests: applicability and effects.

OBJECTIVE: The purpose of this study was to evaluate the effects and applicability of use of the American College of Radiology (ACR) Appropriateness Criteria by nonradiologist physicians in an MRI preauthorization center. MATERIALS AND METHODS: All MRI requests received at our preauthorization center during a 19-month period were included in the study. The study period was divided into preintervention and postintervention phases, indicating before and after introduction of the ACR criteria to the general practitioners staffing our center. ACR appropriateness values were classified into three groups: appropriate, indeterminate, and inappropriate. Requests for which a matching ACR value could not be assigned were labeled ACR-noncodable. Multiple parameters evaluated and compared for the two phases included rate of request receipt, total approval and denial rates, and approval and denial rates according to the ACR Appropriateness Criteria and by anatomic region to be evaluated. RESULTS: There was no significant change in rate of request receipt and total approval and denial rates. However, there was an increase in the rate of approval of appropriate requests (phase 1, 71/96 [74%]; phase 2, 74/76 [97%]; p < 0.001) and the rate of denial of inappropriate requests (phase 1, 0/12 [0%]; phase 2, 9/13 [69%]; p < 0.001). More than 40% of requests were marked "ACR-noncodable" because of a lack of a matching clinical condition or variant. CONCLUSION: Introduction of the ACR Appropriateness Criteria resulted in an increase in the rate of performance of appropriate MRI examinations and a decrease in the rate of performance of inappropriate MRI examinations. ACR Appropriateness Criteria were applicable to approximately 50% of MRI requests.

Facial nerve palsy after acute exposure to dichloromethane.

BACKGROUND: Dichloromethane poisoning affects predominantly the central nervous and the cardiovascular systems, and results from both carboxyhemoglobin formation and direct solvent-related narcosis. Exposure is frequently occupational and related to paint-stripping. Several reports have described severe adverse effects as well as fatalities. Conflicting reports regarding peripheral nerve toxicity have been found with no reports of clinical acute toxicity heretofore. METHODS: We present a case report of a patient who developed a facial nerve palsy after acute occupational exposure to Dichloromethane. The patient was part of a paint removing crew who have worked without proper protecting measures and were thus exposed to high levels of Dichoromethane. RESULTS: The patient was involved in paint stripping with Dichloromethane, and developed facial nerve palsy. Other known causes of facial palsy were excluded, and although idiopathic palsy cannot be ruled out, there were no corroborating findings. Carboxyhemoglobin levels taken after a significant delay were normal. CONCLUSION: This is the first article that describes a case of Facial Nerve Palsy related to acute dichloromethane exposure, indicating a possible peripheral neurotoxic effect of this solvent.

The prevalence of obesity and associated morbidity among 17-year-old Israeli conscripts.

BACKGROUND: There has been a significant increase in the prevalence of obesity among children and adolescents over the last few decades. Obesity is associated with significant psychosocial and physical morbidity. OBJECTIVE: The aim of this study was to define the prevalence of obesity and associated morbidity, including type 2 diabetes and hypertension, among 17-year-old adolescents. A comparison between the morbidity patterns of females and males was also performed. DESIGN: All 17-year-old Israeli nationals are obliged by law to present at the Israel Defence Forces recruiting office for a medical examination, with the exception of orthodox religious and Arabic adolescents. Height and weight are measured and classified, and a trained specialist evaluates those with suspected associated diseases. The level of education is also recorded. RESULTS: Our survey included 76,732 adolescents, 32,402(42.2%) females and 44,330(57.8%) males. The prevalence of obesity and morbid obesity among 17-year-old Israeli conscripts was 4.1% in males and 3.3% in females. The prevalence of borderline overweight was 12.4% in males and 11.4% in females. The prevalence of hypertension and type 2 diabetes was significantly higher among conscripts with BMI>30 kg/m2 in both genders. There was also a significantly higher prevalence of hypertension and type 2 diabetes in males compared with females(P<0.001, 0.015). A significantly higher prevalence of conscripts without high-school education(<10 years of education) was found among females with BMI>30 kg/m2. There was no significant difference among the male conscripts. CONCLUSIONS: This study found a relatively low prevalence of obesity among 17-year-old Israeli conscripts, but an alarmingly high prevalence of borderline overweight. Obesity was correlated with a higher prevalence of hypertension and type 2 diabetes, and a lower level of education. There was a significant difference between genders in the prevalence of hypertension and type 2 diabetes, and this should be further investigated. These data call for the creation of new education programmes on the prevention of overweight among children and adolescents.

Gallbladder mucin plays a role in gallstone formation.

Mucin is a high-molecular-weight glycoprotein that is synthesized, stored, and secreted by epithelial mucosal cells, especially goblet cells. Mucin proteins are derived from many different genes, termed MUC genes. Several lines of evidence point to a biological role for mucin in cholesterol gallstone formation. Mucin serves as a pronucleating agent in experimental and human gallstone disease, and the hydrophobic binding sites in the polypeptide core of mucin may provide a favorable environment for nucleation of cholesterol monohydrate from supersaturated bile. Mucin hypersecretion is prominent in many animal models of gallstone formation, thus contributing by its pronucleating quality to gallstone formation. According to some research, mucin hypersecretion may also contribute to the formation of brown pigment stones. This may be explained in part by the findings that lipopolysaccharides derived from certain bacteria are effective stimulants of mucin secretion. Aspirin and nonsteroidal anti-inflammatory drugs inhibit gallbladder mucin secretion and prevent gallstone formation in animal models. Expanding our knowledge on mucin research may improve our understanding of the natural history of gallstone formation and enable the development of new treatment strategies.

Overexpression of 15-lipoxygenase in the vascular endothelium is associated with increased thymic apoptosis in LDL receptor-deficient mice.

BACKGROUND: 15-Lipoxygenase (15-LO) is a nonheme iron-containing enzyme that catalyzes the peroxidation of fatty acids. Herein, we studied the effect of 15-LO overexpression in the vascular endothelium on thymocyte apoptosis by evaluating thymuses from low-density lipoprotein receptor-deficient (LDL-RD) mice and LDL-RD/15-LO mice. Thymuses were evaluated by immunohistochemistry and by TUNEL whereas in vitro studies were carried out by employing freshly isolated thymocytes from the respective mice and evaluation of apoptosis by propidium iodide and annexin V cytometry. METHODS AND RESULTS: The apoptotic index in LDL-RD/15-LO mice was significantly higher than in the LDL-RD mice. In the thymic medulla the difference was smaller, although still significant. Freshly isolated thymus cells from LDL-RD/15-LO mice exhibited a higher rate of spontaneous cell death than controls. Incubation of thymus cells in the presence of the cell-permeable caspase-3 inhibitor DEVD-CMK resulted in a decrease in the frequency of apoptotic cells in LDL-RD/15-LO thymocytes, whereas no effect was evident in control thymocytes. The antioxidant N-acetylcysteine causes the increase in apoptosis in both groups. CONCLUSION: LDL-RD/15-LO mice exhibit increased thymocyte apoptosis both in vivo and in vitro. These findings may suggest a role for 15-LO in the natural selection of thymocytes.

The effect of acarbose on insulin resistance in obese hypertensive subjects with normal glucose tolerance: a randomized controlled study.

AIM: Acarbose, a glucose oxidase inhibitor, delays the absorption of glucose thus reducing post-prandial blood glucose level, haemoglobin A1c (HbA1c) and insulin resistance in patients with diabetes mellitus and in subjects with impaired glucose tolerance. The effect of acarbose in subjects with normal glucose tolerance (NGT) has hitherto not been examined. The aim of the present study was to examine the effect of acarbose in obese hypertensive subjects with NGT. METHODS: A double-blinded, parallel group study was performed on 56 male subjects with hypertension, body mass index (BMI) 27-35 kg/m2, fasting blood glucose < or =6 mmol/l and a normal oral glucose tolerance test. Blood pressure, HbA1c, lipid profile and insulin resistance [homeostasis model assessment (HOMA) index] were determined initially and following 24 weeks of acarbose, 150 mg/day or placebo. The primary end point was the change in insulin resistance. Anti-hypertensive treatment and diet were kept constant during the study. RESULTS: Insulin resistance decreased in acarbose users but not on placebo. HOMA index declined from 5.36 +/- 1.7 to 4.10 +/- 1.6 (p=0.001) on acarbose, the corresponding values on placebo were 5.44 +/- 1.9 and 5.53 +/- 1.7. A decrease in serum triglyceride values (2.16 +/- 0.16 mmol/l to 1.76 +/- 0.15 mmol/l, p=0.02) took place on acarbose with no change on placebo. There was no change in BMI, low-density lipoprotein or high-density lipoprotein values in either group. Blood pressure declined equally in both the groups, probably due to better patient compliance. CONCLUSIONS: Acarbose may reduce insulin resistance and triglycerides also in obese hypertensive subjects with normal glucose tolerance.

Seizures as a presenting symptom of phaeochromocytoma in a young soldier.

New onset of seizures in young adults is frequently related to alcohol withdrawal, toxic exposure, central nervous system trauma and neoplasm. We describe a young soldier presenting to the emergency department with seizures and transient coma. On admission, he had hypertension, marked leukocytosis, hyper-glycaemia, acidosis, elevated creatinine and elevated creatine phosphokinase of muscle origin. A thorough work-up revealed elevated urinary catecholamines, and a left adrenal mass was found on MRI and MIBG scan. The patient underwent laparoscopic adrenalectomy and completely recovered. This is the first description of seizures as a presenting symptom of phaeochromocytoma.

Fibrosis regression induced by intravenous gammaglobulin treatment.

OBJECTIVES: To review case histories of patients in whom fibrosis played a significant role in the pathogenesis of their disease, and to determine whether intravenous gammaglobulin (IVIg) contributed to the regression of their fibrotic condition. METHODS: Eight patients with excess fibrotic reaction in the course of diverse diseases were analysed; a tendency that reverted with different IVIg treatment options. Myelofibrosis was predominant in three patients (a patient with a myeloproliferative syndrome, one with systemic lupus erythematosus, and one with Sjögren's syndrome). Three patients had scleroderma as their main feature, one patient had hepatitis C cirrhosis, and one had idiopathic thrombocytopenic purpura. RESULTS: Fibrotic excess was reduced in all the patients by IVIg treatment. In five patients the disease as a whole benefited from the infusion of immunoglobulins. CONCLUSION: IVIg may enhance resorption of fibrosis and promote healing in patients with fibrotic associated disorders.

Degenerative disease in lumbar spine of military parachuting instructors.

Parachuting, be it static line or skydiving, places enormous stresses on the human spine. It is, therefore, important to determine the prevalence and severity of degenerative changes in the lumbar spine of subjects who practice this sport activity. Seventy four parachuting instructors, mean age 33 years and with an average of 410 static line and skydiving jumps, were included in the study. Past radiographs were examined and compared to current anterolateral and lateral views of the lumbar spine, in order to determine the prevalence of degenerative changes and document possible progression. Doubtful radiographic changes in the lumbar spine were identified in 47.4 percent of the parachuting instructors, mild degeneration in 9.6 percent, moderate degenerative disease in 10.9 percent and severe radiographic changes in 5.5 percent. Schmorll nodes were found in 8.1 percent of the subjects. Traction spurs--osteophytes were identified in 6.8 percent. The degenerative changes correlated with age and the number of jumps. Spondylolysis of L5-S1 and L3-L4 segments were observed in 12.2 and 1.4 percent respectively. Progressive spondylolisthesis was found in 2 subjects. No correlation was found between the severity of radiographic changes and either the prevalence and the severity of low back pain. The present findings provide a rational for considering repeated sheer stress as an etiology of degenerative changes in the spinal cord, and as a possible contributing factor to the pathogenesis of spondylolysis. Further study has to be done comparing parachuting instructors to a non-parachuting group, or equivalent physically active individuals, in order to assess the effect of sport-background on the development of degenerative changes.

Streptococcal contamination of food: an unusual cause of epidemic pharyngitis.

The purpose of this article is to define the distinguishing characteristics of food-borne streptococcal pharyngitis by reviewing the literature. The main cause of this infection lies in poor handling and preservation of cold salads, usually those which contain eggs and are prepared some hours before serving. A shorter incubation period and a higher attack rate (51-90%) than in transmission by droplets was noted. The epidemics tend to occur in warm climates and in the hottest months of the year. Streptococcus pyogenes seems to originate from the pharynx or hand lesions of a food handler. In comparison to airborne transmission symptoms such as sore throat, pharyngeal erythema, and enlarged tonsils, submandibular lymphadenopathy are more frequent than coughing and coryza. Seven out of 17 reports revealed an M-untypeable serotype, which may possess virulent characteristics. Penicillin prophylaxis was shown to limit additional spread of the infection. There were no non-suppurative sequels, and suppurative sequels were very rare. We assume that the guidelines for the prevention of food poisoning would apply to food-borne streptococcal pharyngitis. Food handlers should be supervised to ensure they comply with strict rules of preparation and storage of food. Cold salads, especially those containing eggs, should not be left overnight before serving.