Michael Wiener

Treatment of overuse patellofemoral pain : prospective randomized controlled clinical trial in a military setting

The efficacy of treatment of overuse patellofemoral pain with an elastic knee sleeve with a silicone patellar ring was compared with a simple elastic sleeve and with no treatment in a prospective study of 395 army recruits. During 14 weeks of basic training, 84 knees were diagnosed as having overuse patellofemoral pain. Recruits treated with a simple elastic knee sleeve had a statistically significant better comfort score and more had their pain resolved by the end of training than those treated with elastic knee sleeves with a silicone patellar ring. The mean pain score at the end of training decreased more among recruits who were treated with a simple elastic knee sleeve than among recruits who received no treatment, but this difference was not significant. Among the treatment options tried, the simple elastic knee sleeve was no more effective than no treatment at all, but it was more effective than the more elaborate patellar brace.

First recorded outbreaks of meningococcal disease in the Israel Defence Force: three clusters due to serogroup C and the emergence of resistance to rifampicin.

SummaryOutbreaks of meningococcal disease were observed for the first time in the Israel Defence Force (I. D. F.) in 1992 and 1993, while in previous years, cases appeared in sporadic fashion. Two episodes in the winter of 1992 involving three and two individuals, respectively, were caused byNeisseria meningitidis group C, which was notypable and nonsubtypable (C:NT:-). Three cases in one event in early 1993 were due to group C:NT:P1.2, the two secondary cases being caused by strains completely resistant to rifampicin. While these outbreaks were small, they should be seen against a background of the emergence of relatively virulent clones of serogroup C which have caused significant outbreaks in several countries. This and the drug resistance problem will require medical decision-makers to review strategies for the prevention of meningococcal disease, taking into account alternative agents for chemoprophylaxis as well as a possible role for vaccination.ZusammenfassungIn den Jahren 1992 und 1993 wurden erstmals im israelischen Militär Ausbrüche von Meningokokkenerkrankungen beobachtet, vorher waren nur sporadische Fälle aufgetreten. Bei zwei Episoden im Winter 1992 waren drei beziehungsweise zwei Personen betroffen. Der Erreger warNeisseria meningitidis Gruppe C; die Isolate waren nicht typisierbar oder subtypisierbar (C : NT :-). Drei Fälle, die Anfang 1993 auftraten, wurden durch Gruppe C : NT : P1.2 verursacht; die beiden sekundären Fälle wurden durch Stämme ausgelöst, die gegen Rifampicin vollständig resistent waren. Wenn diese Ausbrüche auch klein waren, sollte bedacht werden, daß in verschiedenen Ländern relativ virulente Stämme von Serogruppe C auftraten, die umfangreiche Epidemien ausgelöst haben. Aus diesem Grund und wegen des Problems der Antibiotikaresistenz sollten Fachgremien die Strategien für die Prävention der Meningokokkeninfektion neu überdenken und alternative Substanzen für die Chemoprophylaxe einbeziehen sowie die Bedeutung der Impfung berücksichtigen.Outbreaks of meningococcal disease were observed for the first time in the Israel Defence Force (I. D. F.) in 1992 and 1993, while in previous years, cases appeared in sporadic fashion. Two episodes in the winter of 1992 involving three and two individuals, respectively, were caused byNeisseria meningitidis group C, which was notypable and nonsubtypable (C:NT:-). Three cases in one event in early 1993 were due to group C:NT:P1.2, the two secondary cases being caused by strains completely resistant to rifampicin. While these outbreaks were small, they should be seen against a background of the emergence of relatively virulent clones of serogroup C which have caused significant outbreaks in several countries. This and the drug resistance problem will require medical decision-makers to review strategies for the prevention of meningococcal disease, taking into account alternative agents for chemoprophylaxis as well as a possible role for vaccination. In den Jahren 1992 und 1993 wurden erstmals im israelischen Militär Ausbrüche von Meningokokkenerkrankungen beobachtet, vorher waren nur sporadische Fälle aufgetreten. Bei zwei Episoden im Winter 1992 waren drei beziehungsweise zwei Personen betroffen. Der Erreger warNeisseria meningitidis Gruppe C; die Isolate waren nicht typisierbar oder subtypisierbar (C : NT :-). Drei Fälle, die Anfang 1993 auftraten, wurden durch Gruppe C : NT : P1.2 verursacht; die beiden sekundären Fälle wurden durch Stämme ausgelöst, die gegen Rifampicin vollständig resistent waren. Wenn diese Ausbrüche auch klein waren, sollte bedacht werden, daß in verschiedenen Ländern relativ virulente Stämme von Serogruppe C auftraten, die umfangreiche Epidemien ausgelöst haben. Aus diesem Grund und wegen des Problems der Antibiotikaresistenz sollten Fachgremien die Strategien für die Prävention der Meningokokkeninfektion neu überdenken und alternative Substanzen für die Chemoprophylaxe einbeziehen sowie die Bedeutung der Impfung berücksichtigen.

Long-term persistence of anti-diphtheria toxin antibodies among adults in Israel. Implications for vaccine policy.

Vaccination against diphtheria has essentially led to the disappearance of the disease in Israel. However, in other countries with high immunization coverage, isolated cases and small outbreaks have occurred in adults. Immunity following vaccination or natural exposure to toxigenic strains ofC. diphtheriae is conferred by serum antibodies to diphtheria toxin. Since booster doses of diphtheria toxoid are recommended every ten years in adults, this raises the question of persistence of protective levels Of anti-diphtheria toxin antibodies. In this study we assessed a possible age-related decline in anti-diphtheria toxin antibodies among adults in Israel. The study population comprised random samples in three age groups: 263 male recruits aged 18–19 years, 116 male reserve soldiers aged 25–35 years and 153 aged 41–51 years. Anti-diphtheria toxin antibody levels were measured by means of ELISA. Results indicate that 64.3% (95% CI=58.5–70.1%) of those aged 18–19 had anti-diphtheria toxin levels in excess of 0.1 IU ml−1, whereas the corresponding figures for ages 25–35 and 41–51 were 32.8% (95% CI=24.2–41.3%) and 15% (95% CI=9.4–20.7%). However, even in the oldest age group, 95.4% (95% CI=90.8–98.1%) had antibodies above the presumed protective level of 0.01 IU ml−1. Although these results indicate a significant age-related decline in anti-diphtheria toxin antibodies in vaccinated subjects, most had apparently protective levels. The absence of cases suggests that vaccine-induced immunity is long-lasting. However the immune status of the population should be carefully monitored.

Creatine kinase activity decrease with short-term freezing.

Freezing of serum samples at -30 degrees C without protective agents is the simplest and least expensive method of storage in serum banks. We investigated the stability of creatine kinase (CK) in human sera after freezer storage under such conditions for 24 h (n = 30) or for 2 or 4 weeks (n = 99). CK activity was measured in fresh sera and compared to matched thawed sera after freezer storage at the designated time intervals. The enzymes median activity decreased significantly after 24 h, 2 weeks, and 4 weeks of freezer storage by 2.6, 5.9, and 8.3%, respectively (p < 0.0001, r = 0.99). Sex or high CK initial values had no significant effect on these results. We conclude that freezer storage of serum at -30 degrees C, even for short periods, causes a steady and significant decline in CK activity. These results should be taken into consideration when analyzing CK activity in frozen sera for research or clinical purposes.

Immunity to measles in young adults in Israel.

SummaryThe likelihood of an epidemic of measles in 1990–92 in Israel prompted us to study the immune status against measles in a random sample of 454 recruits aged 18–19 years in order to obtain data that might be used in determining vaccination policy. This cohort had received one dose of measles vaccine at 12 months of age. The measles immunity status was studied by determination of antibody values that were measured by means of an enzyme-linked immunosorbent (ELISA) IgG antibody test. Of the recruits, 84.6% were found to have positive sera for anti-measles IgG antibodies, while 13.7% had negative sera. Eight (1.7%) subjects had borderline results. The results of this study indicate the need to administer a second dose of measles vaccine at an older age in addition to the MMR (measles, mumps, rubella) vaccine that is now given in Israel at 12 months of age. This step will help achieve the World Health Organizations target of complete eradication of measles.ZusammenfassungDie Möglichkeit einer Masernepidemie in Israel in den Jahren 1990–92 veranlaßte eine Stichprobenuntersuchung, wobei 454 18- bis 19jährige Rekruten auf ihren Masernimmunstatus untersucht wurden. Die Daten sind für die weiteren Impfstrategien von grundlegender Bedeutung. Die untersuchte Gruppe hatte im Alter von 12 Monaten eine Dosis Masernimpfstoff erhalten. Der Masernimmunstatus wurde durch IgG-Antikörper mittels ELISA bestimmt. Bei 84,6% der Seren fanden sich positive, bei 13,7% negative und bei acht Fällen (1,7%) grenzwertige Testergebnisse. Aus diesen Ergebnissen ist abzuleiten, daß zusätzlich zu der nun in Israel eingesetzten MMR-Vakzine (Masern, Mumps, Röteln), die im Alter von 12 Monaten appliziert wird, eine Auffrischimpfung gegen Masern zu einem späteren Zeitpunkt erforderlich ist. Das Ziel der WHO, die Masern vollständig auszurotten, dürfte damit erreichbarer werden.

Trauma anesthesia for disasters. Anything, anytime, anywhere.

Field anesthesia can be practiced safely and effectively but requires special training to acquire familiarity with the techniques. Because field anesthesia may be required even in sophisticated countries for entrapment situations, skill should be maintained by practicing the appropriate techniques on a regular basis. Field anesthetic techniques are not second rate methods; they are just different. Although improvisation in the disaster situation has merit, it is not the place for experimenting with new and untried techniques.

Safety and immunogenicity of the oral E. coli K12-S. flexneri 2a vaccine (EcSf2a-2) among Israeli soldiers

A double-blind placebo-controlled study was carried out on the safety and immunogenicity of the oral Shigella flexneri (EcSf2a-2) vaccine among Israeli soldiers. Sixty volunteers received the vaccine and 59 received placebo. Fifty-three were given the full vaccine regimen (four doses). Doses ranged between 4.1 x 10(8) and 1.1 x 10(9) c.f.u. Visits to the unit clinic for mild gastrointestinal symptoms were common after the first dose in vaccinees (13%) as compared with placebo recipients (5%), but the difference was not significant, p = 0.12. Similarly, there was no difference between the groups for either gastrointestinal or non-gastrointestinal complaints reported by questionnaire. The vaccine strain was excreted by 69% and 67% of the vaccinees one day after receiving the second and the fourth doses, respectively. As judged by antibiotic susceptibility, phage typing and restriction fragment length polymorphism (RFLP), the vaccine strain emerged as genetically stable after replication in human gut and shedding. There was neither bacteriological nor serological evidence of transmission of the vaccine from vaccinees to placebo recipients. Eighteen of 26 (69.2%) and 11 of 30 (36.7%) vaccinees had significant IgA secreting cell responses 7 and 21 days after the first dose, respectively. Significant IgA or IgG serum antibody response to S. flexneri 2a LPS was detected in 30% of the vaccinees. These results support further evaluation of EcSf2a-2 vaccine protective efficacy in field studies.

Clinical Trials of Shigella Vaccines in Israel

Shigellosis or bacillary dysentery is caused by organisms belonging to genus Shigella, divided into four species (S. dysenteriae, S. boydii, S.flexneri and S. sonnei). With the exception of S. sonnei which has a single serotype, each species is divided into several serotypes according to the O-polysaccharide antigen of the cell wall (S. dysenteriae has 12 serotypes, S. flexneri has 6 serotypes, and S. boydii has 18 serotypes). Shigella spp. are invasive organisms that penetrate into the enterocytes of the colon epithelium, escape very quickly from the phagocytic vacuole and multiplicate intracellularly. Although non-motile, shigellae can move on an actin skeleton and spread to adjacent cells. The inflammatory process is usually limited to the lamina propria and does not involve the spread of Shigella deeper, into the submucosa. Pathogenesis in Shigella spp. is associated with a constellation of genes encoded on both the chromosome and a large 140 MDa virulence plasmid. These genes can be divided into two groups: regulatory genes and structural genes. The 140 MDa plasmid encodes for all the genes essential for invasion of Shigella into the epithelium of the colon. Regulatory genes are located on the virulence plasmid or on the chromosome.

The remuneration of dentists in a special project of the Israeli Defence Forces

The behavior of health care professionals is known to be influenced, in part, by their method of remuneration and the financial incentives they face. Describes how the Medical Corps of the Israel Defence Forces (IDF) went about choosing a reimbursement method to increase incentives for dentists and decrease waiting time for the public. Based on q questionnaire sent to all 23 dentists working in a unique IDF civilian dental clinic, and on other information which was available on the productivity and income of these dentists, a new method of remuneration was suggested and accepted, by which a combined method of fee-for-service and salary will be introduced. The base hourly pay and per crown fee were set on levels which provide for a larger compensation range and increase the incentive for improved productivity levels. This suggested method will be investigated further and re-evaluated one year after its implementation.

The Employment of Civilian Dentists in the Israel Defence Forces: A Public‐Private Mix Case Study

Documents how the Dental Service of the Israel Defence Forces (IDF) successfully implemented private sector approaches to reimbursement and staffing in a special project designed to improve prosthodontic care for career military personnel. The innovative public‐private synthesis enabled the IDF to relieve bottlenecks and increase productivity while securing high levels of employee and patient satisfaction. The success of the innovation can be attributed, in part, to specific measures taken to adapt private sector practices to the culture and norms of the public sector and to integrate the new program into the broader organizational framework of the IDF Medical Corps. The recruitment of managers appropriate to the various stages of the organizational change cycle also played an important role in the project′s success. The study is based on in‐depth interviews of senior managers within the IDF medical corps, interviews of the managers directly involved in implementing the change, IDF budget reports and prod...