Shlomo Moshe

Functional evaluation in patients with chronic obstructive pulmonary disease : pulmonary function test versus cardiopulmonary exercise test

The pulmonary function test (PFT) alone may be inadequate for predicting work-related exercise capacity in patients who file workers’ compensation claims for respiratory limitation and compensation. Two hundred sixteen ambulatory patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 second = 54.1 ± 16.8% predicted) were administered the PFT and cardiopulmonary exercise test, and the results were analyzed by categorical statistical comparison, based on standard medical impairment classifications. Sixty-five patients (30.1%) were similarly classified by the two methods. Of the remaining patients, 132 (61.1%) were found to be less impaired according to the cardiopulmonary exercise test than according to the PFT, and 19 (8.8%) were more impaired according to the PFT. The results favor the use of the cardiopulmonary exercise test for the routine evaluation of respiratory impairment in patients with chronic obstructive pulmonary disease, particularly for patients with mild or moderate impairment revealed by the PFT. The large discrepancy between the two procedures emphasizes the need for a novel approach.

Neuropathy in an Artist Exposed to Organic Solvents in Paints: A Case Study

Abstract A 61-year-old artist in Israel had been painting for 30 years in his home studio. He had been healthy until he reached the age of 59.5 years, at which time he began complaining of weakness and paresthesia in both hands and legs. He also complained that he had difficulty concentrating, and his memory was impaired. His work was unusual in that he painted large posters (i.e., 2 × 3 m) with different mixtures of organic solvents, including toluene, xylene, benzene, methyl ethyl ketone, toluene diisocyanate, acetone, and thinner. He did not use any protective gloves and did not wear a mask. He was evaluated with several methods and was diagnosed as having peripheral and central neuropathy, including ototoxic hearing loss as a result of long exposures to organic solvents. The authors were unable to find any similar case report in the literature.

Occupational airborne contact dermatitis to simvastatin, carvedilol, and zolpidem

Simvastatin is a 3-hydroxy-2 methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, commonly used as a lipid-lowering agent. Carvedilol is a nonselective beta-adrenergic blocking agent with alpha 1-adrenergic blocking activity and no intrinsic sympathomimetic activity. It is usually prescribed as an antihypertensive agent. Zolpidem is an imidazopyridine sedative–hypnotic structurally unrelated to the barbiturates and benzodiazepines, used for treatment of insomnia. We present a case of an airborne contact dermatitis to these three drugs in the setting of a pharmaceutical industry.

Management of Chronic Exertional Compartment Syndrome and Fascial Hernias in the Anterior Lower Leg With the Forefoot Rise Test and Limited Fasciotomy

Background: Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier wants to continue training, there is no proven effective nonoperative treatment, and fasciotomy of 1 or more of the lower leg muscle compartments is usually recommended. Our clinical protocol differs from most reported ones in the use of the forefoot rise test to increase pressure and provoke pain and our recommending minimal surgery of the anterior compartment only. We present results of surgery based on our clinical management flowchart. Methods: Patients who had surgery during a 12-year period were reviewed by telephone interview or office examination. Pain was graded from 0 (none) to 4 (unbearable). Preoperative resting and exercise anterior compartment pressures were evaluated in most subjects before and immediately following a repeated weight-bearing forefoot rise test. Surgery was under local anesthesia, limited to the anterior compartment only and percutaneous (excepting muscle hernias). There were 36 patients, mean age 24 years. Results: Of 16 patients who were originally operated unilaterally, 5 patients were later operated on the other side. Mean presurgery resting pressure was 56 mm Hg (40-80 mm Hg) rising to 87 mm Hg (55-150 mm Hg) with exercise. Mean exercise pain score dropped from 2.9 presurgery to 1.3 postsurgery (n = 35, P < .0001). Complications included superficial peroneal nerve injury (3 legs in 3 patients, 1 requiring reoperation). Conclusion: When we used our clinical management flowchart based on the forefoot rise test, percutaneous fasciotomy of the anterior compartment alone provided good clinical results. Care must be taken to prevent injury to the superficial peroneal nerve in the distal lower leg. Level of Evidence: Level IV, retrospective case series.

Does exercise cause asthma

BACKGROUND The Israel Defence Forces needed to define the correlation between physical activity and asthma. AIM To determine whether combat unit (CU) soldiers are more susceptible to exercise-induced asthma (EIA) than other military units. METHODS A follow-up study of recruits with normal clinical and pulmonary function tests over a period of 30 months after having been assigned to CU, maintenance units (MU) or clerical tasks (CT). The participants chosen had already been subjected to additional tests 6 weeks after induction to eliminate any cases of active asthma. RESULTS Out of 799 subjects, 125 developed asthma during the follow-up. Twenty-one per cent of those in the CU developed asthma against 15% in the MU and 5% in the CT. The relative risks for newly diagnosed asthma were 3.7 for CU/CT (P < 0.001), 2.7 for MU/CT (P < 0.001) and 1.4 for CU/MU (P < 0.05). EIA was observed as the only manifestation of asthma in 32% of the soldiers posted in CU compared to 13 and 11% in MU and CT, respectively. CONCLUSION The increased risk of EIA in CU compared to MU and CT may indicate that any one or all the factors associated with CU service conditions could contribute to this increased risk of uncovering the mild cases of asthma, especially EIA, that had been overlooked up to the time of induction into the army.

Predictors of return to work with upper limb disorders

BACKGROUND Return to work (RTW) is a key goal in the proper management of upper limb disorders (ULDs). ULDs stem from diverse medical aetiologies and numerous variables can affect RTW. The abundance of factors, their complex interactions and the diversity of human behaviour make it difficult to pinpoint those at risk of not returning to work (NRTW) and to intervene effectively. AIMS To weigh various clinical, functional and occupational parameters that influence RTW in ULD sufferers and to identify significant predictors. METHODS A retrospective analysis of workers with ULD referred to an occupational health clinic and further examined by an occupational therapist. Functional assessment included objective and subject ive [Disability of the Arm, Shoulder and Hand (DASH) score] parameters. Quantification of work requirements was based on definitions from the Dictionary of Occupational Titles web site. RTW status was confirmed by a follow-up telephone questionnaire. RESULTS Among the 52 subjects, the RTW rate was 42%. The DASH score for the RTW group was 27 compared with 56 in the NRTW group (P < 0.001). In multivariate analyses, only the DASH score was found to be a significant independent predictor of RTW (P < 0.05). CONCLUSIONS Physicians and rehabilitation staff should regard a high DASH score as a warning sign when assessing RTW prospects in ULD cases. It may be advisable to focus on workers with a large discrepancy between high DASH scores and low objective disability and to concentrate efforts appropriately.

Value of Preemployment Medical Assessments for White-Collar Workers

Employee absenteeism as a result of illness, as well as the need to enhance worker efficiency, are areas of increasing concern to employers. Given that preemployment medical assessments are expensive, the authors believe it is prudent to evaluate the cost-effectiveness of such procedures. Medical literature was reviewed, and relevant studies on preemployment assessments were analyzed in terms of yield and methodology. The authors found no clear guidelines for preemployment medical evaluations for white-collar applicants, who typically work in low-risk environments; however, they did conclude that laboratory testing and imaging methods are likely overused. Clear criteria should exist for medical assessment of job applicants, with an emphasis on cost-effectiveness. On the basis of recommendations contained in the literature, the authors suggest use of a self-administered questionnaire, with evaluation by an occupational health staff member when necessary, as the method(s) of choice for preemployment assessment of white-collar workers.

Allergic contact dermatitis among maintenance and clerical workers in a military population

Contact dermatitis is one of the leading causes of occupational morbidity and absenteeism and has become an intolerable cause of missed workdays and health problems in the Israeli military. The aim of this study was to determine the rate of contact dermatitis in maintenance and clerical workers, the common allergens causing it, and the background of atopy in the subjects in order to design preventive measures. Medical records of all recruits to the Israel Defense Forces from 2000 to 2003 were reviewed for contact dermatitis. The 102 cases found were further assessed for job assignment, atopic background, and allergens. Of the 102 cases, 60 had irritant contact dermatitis and 42 had allergic contact dermatitis, of which 33 (78.6%) were maintenance workers, mainly mechanics. 13 soldiers in the maintenance job category (39%) and 2 soldiers in the clerical group (22.2%) had atopic background. There were 55 positive reactions in patch tests, 25 of them to oil and cooling fluids, with 14.5% attributed to methylchloroisothiazolinone/methylisothiazolinone) (Kathon CG). Atopy was found to be a risk factor for allergic contact dermatitis in our study and should be screened for in job assignment procedures in the military. Oil and greases contain significant allergens, especially their preservatives.

Atopy as a risk factor for the development of asthma in young recruits.

Abstract Objective: Asthma is one of the most common chronic diseases globally. Atopy, and especially allergic rhinitis (AR), was found as an important risk factor for asthma. The purpose of this study was to examine the association between different atopic parameters and military professions to the incidence of asthma. Methods: In a retrospective study, we included 128 591 Israel Defense Forces soldiers drafted between the mid-nineties to the early-2000s. We examined the incidence rates of asthma in relation to atopic background and to military profession. Results: The relative risk (RR) for the development of asthma in persons with a history of AR and the RR for asthma in atopics vs. nonatopics was 1.86 (95% CI: 1.57–2.21) and 1.73 (95% CI: 1.47–2.04), respectively. The RR for the development of asthma in persons with a history of AR was higher in Combat Units (CU) and Administrative and Driving units (ADU) (RR = 2.80; 95% CI: 2.09–3.76 and RR = 1.58; 95% CI: 1.19–2.12, respectively) than in Maintenance Units (MU) (RR = 1.27; 95% CI: 0.93–1.74). When comparing the risk for asthma amongst persons with AR, we found it lower in MU compared to ADU (RR = 0.65; 95% CI: 0.43–0.97). In atopics vs. non-atopics, the risk for asthma was higher in ADU as compared to other occupations. Conclusions: Atopy, particularly AR, is a risk factor for the development of new-onset asthma in young adults. Atopy has the highest significant effect in CU where the physical demands are higher.

The case for orthopaedic medicine in Israel

BackgroundMusculoskeletal complaints are probably the most frequent reasons for visiting a doctor. They comprise more than a quarter of the complaints to primary practitioners and are also the most common reason for referral to secondary or tertiary medicine. The clinicians most frequently consulted on musculoskeletal problems, and probably perceived to know most on the topic are orthopaedic surgeons. But in Israel, there is significant ambivalence with various aspects of the consultations provided by orthopaedic surgeons, both among the public and among various groups of clinicians, particularly family practitioners and physiotherapists.MethodsIn order to understand this problem we integrate new data we have collected with previously published data. New data include the rates of visits to orthopaedic surgeons per annum in one of Israel’s large non-profit HMO’s, and the domains of the visits to an orthopaedic surgeon.ResultsOrthopaedic surgeons are the third most frequently contracted secondary specialists in one of the Israeli HMO’s. Between 2009 and 2012 there was a 1.7% increase in visits to orthopaedists per annum (P < 0.0001, after correction for population growth). Almost 80% of the domains of the problems presented to an orthopaedic surgeon were in fields orthopaedic surgeons have limited formal training.DiscussionWhile orthopaedic surgeons are clearly the authority on surgical problems of the musculoskeletal system, most musculoskeletal problems are not surgical, and the orthopaedic surgeon often lacks training in these areas which might be termed orthopaedic medicine. Furthermore, in Israel and in many other developed countries there is no accessible medical specialty that studies these problems, trains medical students in the subject and focuses on treating these problems. The neglect of this area which can be called the “Orthopaedic Medicine Lacuna” is responsible for inadequate treatment of non-surgical problems of the musculoskeletal system with immense financial implications. We present a preliminary probe into possible solutions which could be relevant to many developed countries.