Quality of life at the Dead Sea region: the lower the better? An observational study.

BACKGROUND: The Dead Sea region, the lowest in the world at 410 meters below sea level, is considered a potent climatotherapy center for the treatment of different chronic diseases. OBJECTIVE: To assess the prevalence of chronic diseases and the quality of life of residents of the Dead Sea region compared with residents of the Ramat Negev region, which has a similar climate, but is situated 600 meters above sea level. METHODS: An observational study based on a self-administered questionnaire. Data were collected from kibbutz (communal settlement) members in both regions. Residents of the Dead Sea were the study group and of Ramat Negev were the control group. We compared demographic characteristics, the prevalence of different chronic diseases and health-related quality of life (HRQOL) using the SF-36 questionnaire. RESULTS: There was a higher prevalence of skin nevi and non-inflammatory rheumatic diseases (NIRD) among Dead Sea residents, but they had significantly higher HRQOL mean scores in general health (68.7 ± 21 vs. 64.4 ± 22, p = 0.023) and vitality (64.7 ± 17.9 vs. 59.6 ± 17.3, p = 0.001), as well as significantly higher summary scores: physical component score (80.7 ± 18.2 vs. 78 ± 18.6, p = 0.042), and mental component score (79 ± 16.4 vs. 77.2 ± 15, p = 0.02). These results did not change after adjusting for social-demographic characteristics, health-related habits, and chronic diseases. CONCLUSIONS: No significant difference between the groups was found in the prevalence of most chronic diseases, except for higher rates of skin nevi and NIRD among Dead Sea residents. HRQOL was significantly higher among Dead Sea residents, both healthy or with chronic disease.

Increased vitamin D serum levels correlate with clinical improvement of rheumatic diseases after Dead Sea climatotherapy.

BACKGROUND: Ultraviolet B (UVB) rays are required by the skin for the production of vitamin D. The intensity of UVB at the Dead Sea area is the lowest in the world. Low vitamin D levels are often associated with musculoskeletal symptoms. OBJECTIVES: To assess the effectiveness of climatotherapy at the Dead Sea on the production of vitamin D in Norwegian patients suffering from various rheumatic diseases and to investigate possible associations between increased vitamin D serum levels, musculoskeletal symptoms and disease severity. METHODS: Sixty Norwegian patients who came to the Dead Sea area for 21 days of medical rehabilitation were divided into three groups according to their diagnosis: chronic pain syndromes, i.e., low back pain or fibromyalgia (Group 1, n=33); rheumatoid arthritis (Group 2, n=16); and osteoarthritis (Group 3, n=11). Serum 25-hydroxyvitamin D (25-OH-D) levels were determined at arrival and prior to departure. The treatment protocol included daily sun exposure (climatotherapy), bathing in the Dead Sea and mineral spring water (balneotherapy), mud applications and fitness classes. RESULTS: 25-OH-D serum levels increased significantly from 71.3 +/- 26.6 nM at arrival to 89.3 +/- 23.2 nM prior to departure (P < 0.001). Adjusted for the initial levels of pain (assessed by a visual analog scale) and disease severity, a direct correlation was observed between increased 25-OH-D serum levels and pain reduction (P = 0.012) and reduction of disease severity (P = 0.02). CONCLUSIONS: Climatotherapy at the Dead Sea induces significant changes in vitamin D. Increased 25-OH-D serum levels are associated with reduced musculoskeletal pain and disease severity.

[The influence of single immersion in Dead Sea water on glucose, insulin, cortisol and C-peptide levels in type 2 diabetes mellitus patients].

BACKGROUND: Bathing in sweet or mineral water can induce significant physiological changes in several body systems including the endocrine system. To date, there have only been a small number of reports that balneology can reduce blood sugar Levels in patients with type 2 diabetes mellitus (DM]. OBJECTIVE: To compare the effects of a single immersion in sweet or mineral water on blood glucose, insulin, cortisol and c-peptide levels in patients with type 2 DM. METHODS: Fourteen patients with type 2 DM and six healthy volunteers were immersed in water twice, with an interval of two weeks in between immersions. The first immersion was in Dead Sea water and the second in sweet water. In both cases the water was warmed to a temperature of 35 degrees C and the bath continued for 20 minutes. Three blood samples were taken from each of the participants at every immersion. The first sample was taken just prior to the start of immersion, the second sample was taken directly at the end of immersion, and the third sample, one hour later. In each sample the blood was tested for glucose, insulin, cortisol, and c-peptide Levels. RESULTS: A significant reduction was seen in blood glucose levels among DM patients who were immersed in Dead Sea water. The glucose levels dropped from a base Line level of 163 +/- 32.4 mg/dl prior to immersion, to 151 +/- 28.8 at the end of the immersion, and to 141 +/- 34.6 an hour later. All the differences were statistically significant: baseline to end of immersion (P = 0.006), end of immersion to one hour later (P = 0.024), and baseline to one hour after immersion (P=0.005). The difference in blood glucose was much Less following immersion in sweet water and did not reach statistical significance except between the end of immersion and one hour later. No significant differences were found for insulin, cortisol, and c-peptide levels between DM patients and healthy volunteers following immersion. CONCLUSION: One-time immersion in Dead Sea water reduces blood glucose levels in type 2 DM patients compared to healthy volunteers.

[The Dead Sea--a unique resort for patients suffering from joint diseases].

The Dead Sea area is an excellent and unique resort for patients suffering from a wide range of inflammatory and non-inflammatory joint diseases. Factors contributing to the beneficial effect are the high concentration of salts and minerals in the Dead Sea water and in the water from springs in the area, medical mud, and the unique climatic conditions including high barometric pressure, relative low humidity and high temperatures. This review describes the various balneotherapy modalities and the existing body of research describing their utility. Balneotherapy significantly improves most patients' conditions and in some cases leads to complete remission of several months duration. Although of importance, balneotherapy is not curative. An important advantage of balneotherapy is the lack of serious adverse effects, and, in contrast to some physicians' beliefs, the scarcity of contraindications for therapy at the Dead Sea area.

Intermittent balneotherapy at the Dead Sea area for patients with knee osteoarthritis.

BACKGROUND: Balneotherapy, traditionally administered during a continuous stay at the Dead Sea area, has been shown to be effective for patients suffering from knee osteoarthritis. OBJECTIVES: To evaluate the effectiveness of an intermittent regimen of balneotherapy at the Dead Sea for patients with knee osteoarthritis. METHODS: Forty-four patients with knee osteoarthritis were included in a prospective randomized single-blind controlled study. The patients were divided into two groups: a treatment group (n=24), which were treated twice weekly for 6 consecutive weeks in a sulfur pool heated to 35-36 degrees C, and a control group (n=20) treated in a Jacuzzi filled with tap water heated to 35-36 degrees C. Participants were assessed by the Lequesne index of osteoarthritis severity, the WOMAC index, the SF-36 quality of health questionnaire, VAS scales for pain (completed by patients and physicians), and physical examination. RESULTS: A statistically significant improvement, lasting up to 6 months, was observed in the treatment group for most of the clinical parameters. In the control group the only improvements were in the SF-36 bodily pain scale at 6 months, the Lequesne index at 1 month and the WOMAC pain score at the end of the treatment period. Although the patients in the control group had milder disease, the difference between the two groups was not statistically significant. CONCLUSIONS: Intermittent balneotherapy appears to be effective for patients with knee osteoarthritis.

Pulmonary functions testing in patients with rheumatoid arthritis.

BACKGROUND: A high incidence of abnormal pulmonary function tests has been reported in cross-sectional studies among patients with rheumatoid arthritis. Few patients have been enrolled in longitudinal studies. OBJECTIVES: To perform PFT in rheumatoid arthritic patients without pulmonary involvement and to identify variables related to changes in PFT over 5 years of follow-up. METHODS: Consecutive RA patients underwent PFT according to recommendations of the American Thoracic Society. All surviving patients were advised to repeat the examination 5 years later. RESULTS: PFT was performed in 82 patients (21 men, 61 women). Their mean age was 55.7 (15.9) years and the mean RA duration was 11.1 (10) years. Five years later 15 patients (18.3%) had died. Among the 67 surviving patients, 38 (56.7%) agreed to participate in a follow-up study. The initial PFT revealed normal PFT in only 30 patients (36.6%); an obstructive ventilatory defect in 2 (2.4%), a small airway defect in 12 (17%), a restrictive ventilatory defect in 21 (25.6%), and reduced DLco in 17 (20.7%). Among the 38 patients participating in the 5 year follow-up study, 8 developed respiratory symptoms, one patient had a new obstructive ventilatory defect, one patient developed a restrictive ventilatory defect, and 5 patients had a newly developed small airway defect. The DLco had improved in 7 of the 8 patients who initially had reduced DLco, reaching normal values in 5 patients. Over the study period a new reduction in DLco was observed in 7 patients. Linear regression analyses failed to identify any patient or disease-specific characteristics that could predict a worsening in PFT. The absolute yearly decline in forced expiratory volume in 1 sec among our RA patients was 47 ml/year, a decline similar to that seen among current smokers. CONCLUSIONS: Serial PFT among patients with RA is indicated and allows for earlier identification of various ventilatory defects. Small airways disturbance was a common finding in our RA patients.

Atherosclerotic cardiovascular disease in systemic lupus erythematosus: the Beer Sheva experience.

Atherosclerotic disease is common in systemic lupus erythematosus and is the result of multiple pathogenic mechanisms that include traditional risk factors as well as SLE-related factors. Endothelial dysfunction and arterial stiffness contribute significantly to the atherogenic process. Dobutamine stress echocardiogram has not been shown to detect subclinical coronary artery disease; however, the high percentage of left ventricular outflow gradient requires further evaluation and follows-up studies.

A rare case of enterobacter endocarditis superimposed on a mitral valve rheumatoid nodule.

We present the case of a 56-year-old man with longstanding seropositive active erosive and deforming rheumatoid arthritis with no peripheral rheumatoid nodules; he immigrated from the former Soviet Union (where he did not receive any disease-modifying antirheumatic drugs) to Israel in 1995. In February 2005, he had a buccogingival mucosal abscess on his lower lip, which was treated by surgical drainage, followed by prolonged antibiotic therapy. One and a half years later, he had 2 episodes of transient ischemic attacks characterized by speech difficulties and moderate weakness on his right side. Transesophageal echocardiogram revealed a mass on the anterior mitral valve leaflet. Repeated blood cultures were negative, and the patient was afebrile all the time. The patient underwent mitral valve replacement and the histologic findings of the mass were typical of both a rheumatoid nodule and bacterial endocarditis. The patient recovered fully after 6 weeks of antibiotic therapy. Emboli from a rheumatoid nodule should always be considered in patients with rheumatoid arthritis who present with transient ischemic attacks.

[The association between sports activity and knee osteoarthritis].

Osteoarthritis (OA) is the most common non-inflammatory joint disease. The hip and knee, the main weight-bearing joints, are most commonly affected. Previous trauma to the joints is strongly associated with OA. Participation in various sports activities, including fitness room activities, intensive running and cycling, is on the rise. These activities offer potential health benefits and have been advocated for the primary and secondary prevention of many diseases, including diabetes and coronary artery disease. However, it has been hypothesized that physical activity might increase cartilage degeneration and thus accelerate knee OA. In this article we review the literature with the purpose of evaluating the purported association between sports activity and knee OA. Previous research did not show a significant association between intense physical activity and knee OA in the general population. A strong association was found in cases of former joint injury and in acquired and congenital joint defects. Moderate physical activity is recommended for people already suffering from OA with the goal of increasing muscle-strength, reducing pain and preserving the range of movement in the affected joints. People who wish to participate in sports activities should be evaluated by their family physician. This evaluation should include assessment of risk factors for knee OA, particularly in patients with previous joint injury.

[Physical trauma and fibromyalgia--is there a true association?].

A total of 25-50% of fibromyalgia patients (FM) report the occurrence of physical trauma that preceded the onset of their symptoms by several weeks to several months. Yet, there is still no agreement among experts as to whether physical trauma can cause FM. The severity of the injury varies, but is usually milder than that seen in patients with post-traumatic stress syndrome. Road accidents, and, in particular, whiplash injuries, or accumulated injury inherent in some occupations have been described as causes of fibromyalgia. The only two prospective studies that assessed the incidence of fibromyalgia syndrome following accidents, such as whiplash injuries, were conducted by Israeli researchers and they reported opposite results. Possible mechanisms for the development of the syndrome following trauma have not been elucidated sufficiently to date. Stressful conditions are also known to contribute to the appearance of the syndrome. In most likelihood, there is no significant difference between idiopathic fibromyalgia and post traumatic fibromyalgia in terms of clinical course, symptom severity and prognosis, although some investigators have reported a worse prognosis in post-traumatic cases. In Israel, there is an increase in the number of suits filed against private insurance companies and the National Insurance system for post-traumatic fibromyalgia. According to the literature, it is probable that the number of cases that involve malingering or secondary gain is low. The ongoing controversy among medical experts as to whether there is an association between FS and physical trauma has made it very difficult, in the absence of guidelines and objective tools, for the legal and administrative systems to deal with this difficult issue.

Influenza vaccination of patients with systemic lupus erythematosus: safety and immunogenecity issues.

The influenza vaccine is highly efficacious in the general population; however there have been concerns about the safety, and immunogenecity of the vaccine in patients with SLE. Several studies have suggested that the immune response of patients with SLE to influenza vaccine is significantly lower than the general population, mainly in patients with age > or =50 years and those treated with prednisone. The vaccine is safe for patients with SLE and it does not affect the clinical manifestations of SLE including renal features, disease activity, or the requirement for steroids or cytotoxic drugs. However, the vaccine may trigger the generation of autoantibodies which is usually short term and is not associated with clinical significance.

[Work related musculoskeletal disorders of the upper extremity].

Various musculoskeletal syndromes are considered to be work-related. The prevalence of a few of these syndromes is high. Repeated or continuous application of force over a prolonged period to the same muscle group, tendon, bursa or peripheral nerve, can cause cumulative damage. Non-physiological position of the upper limb during work time, can add further injury. The most frequent syndromes are tendonitis and tenosynovitis, nerve entrapment neuropathies and muscle injuries. Frank arthritis is relatively rare. Early diagnosis is usually associated with better prognosis and full recovery within few months.

[Pregnancy and rheumatoid arthritis--rheumatic, obstetric and gynecologic aspects].

Initial onset of rheumatoid arthritis (RA) during pregnancy is very rare. Significant improvement of symptoms and signs of RA occurs in most patients in the first trimester and persists throughout the pregnancy. The disease usually flares up a few months after delivery. Various hormonal changes which occur during pregnancy contribute to the observed amelioration. One of these changes is enhanced activity of T helper cells (Th2) and down-regulation of TH1 cells. As a result there is also decreased production of proinflammatory cytokines such as TNF-alpha and others. In addition, maternal-fetal disparity in the class II antigens HLA-DR and HLA-DQ correlates significantly with the amelioration of RA during pregnancy. Most of the disease-modifying anti-rheumatic drugs are contraindicated or non-recommended during pregnancy and lactation. There is insufficient data about the safety of the new biologic drugs such as anti-TNF-alpha during pregnancy, although a few recently published studies did not reveal any complications or unexpected side effects on the course of pregnancy and outcome of the newborn. The obstetric and gynecologic complications are rare and negligible.

Catastrophic thromboses and severe thrombocytopenia during heparin therapy in a patient with anti-phospholipid syndrome.

Catastrophic anti-phospholipid syndrome (CAPS) is a medical emergency characterized by thromboses of multiple small vessels of internal organs and the brain. Herein we present a patient with primary anti-phospholipid syndrome who developed CAPS manifested by hepatic, renal and splenic artery thromboses, as well as cerebral venous thrombosis. The course was further complicated by severe thrombocytopenia and haemolytic anemia. Two episodes of catastrophic thrombosis developed within 24-36 h after the initiation of heparin therapy, suggesting a role of heparin in triggering thromboses. The patient had no anti-platelet-factor-4 antibodies in repeated measurements, making clinical diagnosis of heparin-induced thrombocytopenia unlikely. The possible role of heparin in induction of thromboses and its therapeutic implication are detailed.

[Dead Sea and Tiberias as health resort areas for patients suffering from different types of arthritis].

In the last two decades balneotherapy and climatotherapy have been shown to be effective in cases of inflammatory arthritis such as rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis and non-inflammatory arthritis such as osteoarthritis and fibromyalgia. This review presents different modalities of balneotherapy, their mechanism of action, side-effects and major contraindications. The article also summarizes all the publications on clinical trials conducted in the Dead Sea and Tiberias.

Duplex study of the carotid and femoral arteries of patients with rheumatoid arthritis: a controlled study.

BACKGROUND: "Ultrasonic biopsy" (U-B) is a noninvasive screening technique to detect early atherosclerotic plaques and arterial wall changes. AIM: To identify atherosclerosis (AS) in the common carotid artery (CCA) and common femoral artery (CFA) of patients with rheumatoid arthritis (RA) and their matched controls. METHODS: Fifty-seven consecutive RA patients were enrolled in the study. Controls were matched by age, sex, ethnicity, and AS risk factors. All patients and controls underwent U-B study of the CCA and CFA. The U-B features were classified and scored as follows: Class A, normal (score 0); Class B, interface disruption (score 2); class C, intima-media (I-M) granulation (score 4); Class D, plaque without hemodynamic disturbance (score 6); Class E, stenotic plaque (score 8); and Class F, plaque with symptoms (score 10). Total score per patient was calculated. Classes A-B indicate an intact media or minimal interphase changes; classes D-F point to a significant medial involvement. Class C signifies a borderline lesion, with a potential for regression to normal, being unchanged, or progression to a plaque. RESULTS: Mean ages were 52.1 years for RA and 51.4 years for controls (P = 0.81). Eighty-six percent of the patients and 85% of controls were women. The mean disease duration of RA was 12.8 years. Frequencies of risk factors among the RA patients compared with controls were hypertension (28% versus 32%), smoking (37% versus 29%), dyslipidemia (23% versus 25%), diabetes mellitus (DM) (14% versus 14%), and family history of cardiovascular disease (CVD) (4% versus 7%). Forty-five percent of the RA patients had at least a single Classes D-F lesion (plaque) in 1 of the 4 vessels tested, compared with 40% in the control group (P = 0.19). The mean total U-B scores of the RA patients and controls were not significantly different (8.87 versus 9.49, P = 0.7). Univariate analyses have shown that the development of plaques in RA patients was associated with age >50 years, disease duration, hypertension, dyslipidemia, and smoking. Multivariate analysis found plaques to be strongly associated with age above 50 years and dyslipidemia. CONCLUSION: In unselected RA patients, besides classic AS risk factors, older age and longstanding disease may help predict the development of a severe morphological expression of AS.

Spa therapy for ankylosing spondylltis at the Dead Sea.

BACKGROUND: The efficacy of spa therapy in ankylosing spondylitis has not been investigated extensively. OBJECTIVE: To study the efficacy of balneotherapy and climatic therapy (climatotherapy) at the Dead Sea area in patients with ankylosing spondylitis. METHODS: In a single-blind randomized controlled study, 28 patients suffering from ankylosing spondylitis were allocated into two groups of 14 patients each. The first group (the combined treatment group) received balneotherapy (mud packs and sulfur pool) and exposure to the unique climatic conditions of the Dead Sea. The second group (the climatotherapy group) used the fresh water pool and experienced the same climatic conditions. The duration of treatment was 2 weeks and the follow-up period 3 months. RESULTS: For both patient groups a significant improvement was found in the outcome measures: Bath AS Disease Activity Index (P = 0.002), VisuarAnalog Scale for pain (P = 0.002) and VAS for spinal movement (P = 0.011). The variability was explained by the effect of time (within group effect) rather than the type of treatment (between group effect). Quality of life, assessed by the SF-36 questionnaire, was very low prior to the study, but improved in terms of pain amelioration in the combined treatment group. CONCLUSIONS: Climatotherapy at the Dead Sea area can improve the condition of patients suffering from long-standing ankylosing spondylitis.

Scientific evidence of the therapeutic effects of dead sea treatments: a systematic review.

OBJECTIVES: The Dead Sea, the deepest and most saline lake on earth, has been known from biblical times for its healing properties. The aim of this systematic review was to present critically the level of evidence for the claims of therapeutic effects of Dead Sea treatments in several rheumatologic diseases and psoriasis as well as to review these treatments' safety. METHODS: All articles cited in MEDLINE under the query, "Dead Sea," were reviewed. RESULTS: We found bona fide evidence that Dead Sea treatments are especially effective in psoriasis due to both the special characteristics of solar ultraviolet radiation in the Dead Sea and the Dead Sea water balneotherapy. Dead Sea mud and Dead Sea balneotherapy have been found to be beneficial in rheumatologic diseases, including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and knee osteoarthritis. In the safety analysis, we found no evidence for an increase in skin neoplasia, although skin actinic damage seems to be increased in patients treated in the Dead Sea. Dead Sea treatments do not lead to worsening of blood pressure. Substantial ingestion of Dead Sea water (generally in unusual near-drowning cases) is toxic and can result in cardiac rhythm disturbances because of electrolyte concentration abnormalities. Laboratory analysis of Dead Sea mud did not reveal mineral concentrations that could represent a health concern for their intended use. CONCLUSIONS: Dead Sea treatments are beneficial in several rheumatologic diseases and psoriasis and have a good safety profile.