Strict vegan, low-calorie diet administered by caregiving daughter to elderly mother--is this elder abuse?

We present a case in which a 40 year old woman, who was the primary care-giver of her 78 year-old mother, provided a strict vegan diet which caused the mother severe malnutrition. The mother was hospitalized with severe functional deterioration and, while eating a proper diet during hospitalization, gained weight and her condition improved. The case was reported to the Welfare Officer and the mother was released under the supervision of the Welfare Officer. Cases of severe malnutrition and even death of infants who were fed a strict vegan diet have been reported. This case raises some ethical and legal issues. Should a guardian or a caregiver be allowed to make decisions regarding the way of life and medical treatment of the person in his/her charge which are likely to endanger that person's health and when is it appropriate for society to intervene in individual freedom? The paper includes a review of some reported cases of child and elder abuse or neglect which illustrate these issues.

Survey of Israeli Air Force line commander support for fatigue prevention initiatives.

BACKGROUND: Sustained and continuous high intensity military operations have increased in scope in recent years. These mandate ever more sophisticated efforts to prevent and ameliorate aviator fatigue. Successful implementation of new fatigue countermeasures requires thorough pretesting among experienced aviator opinion leaders: base and squadron commanders. METHODS: An anonymous and voluntary survey questionnaire containing background material and Likert-scale questions regarding 14 primary through tertiary fatigue prevention initiatives current in the aeromedical literature or unique to the IAF was distributed to all base and flight squadron commanders in the IAF. RESULTS: Of the commanders, 38% returned fully completed questionnaires. The most popular primary prevention initiatives (garnering 87% support) dealt with reservist aviators: 1.) requiring reserve pilots to arrive at the squadron at least 3 h before night flights to facilitate napping time, and 2.) improving scheduling coordination of those reservists employed as civilian aircrew. The chief (88% support) secondary prevention countermeasure endorsed was to utilize stimulant drugs such as caffeine or amphetamines to sustain the alertness of fatigued aviators. Leading the list of tertiary prevention initiatives (75% support) was the suggestion that squadrons debrief the incidence of aviator fatigue, as well as their success in the area of time-management when debriefing high tempo exercises and operational missions. CONCLUSIONS: Commanders differentially supported a wide range of fatigue countermeasures. Use of stimulant drugs achieved the broadest support. Instituting specific measures to facilitate alertness in reservist aviators was also a priority. Surveying the degree of commander support for new fatigue prevention initiatives provides the basis for prioritization of scarce resources, should improve line cooperation, and provides important experience-proven feedback for researchers and policy-makers.

An algorithm for pulmonary screening of military pilots in Israel.

BACKGROUND: Medical screening is used routinely to qualify and classify candidates for pilot training. The respiratory system assumes even greater importance owing to the increased stress of flying high-performance aircraft in a hostile environment characterized by high altitude, varying acceleration ("G" forces), and the possibility of rapid decompression. Any respiratory dysfunction may threaten the pilot's health, flight safety, and completion of the mission. Only those candidates with the highest psychophysical score are accepted to undergo special aeromedical screening. Physical suitability is an important factor in the selection and classification of candidates for flight training programs, and pulmonary function testing is central within this screening protocol. METHODS: We developed a respiratory algorithm for this unique screening process. The algorithm represents a practical and efficient approach for large-scale screening of healthy candidates for flight training. The algorithm deals with the major pulmonary health problems encountered in a previously screened healthy population aged 17 to 25 years. If by anamnesis, physical examination results, or baseline spirometry findings there is reason to suspect a respiratory problem that could emerge to endanger the pilot's life, a specially designed evaluation is performed according to the algorithm. We explain, step by step, the basis for each suggested test in order to reach a decision (operational specifications). The pulmonary function studies we recommend are reasonably priced and can be easily and reliably performed by regular medical staff technicians. The major justification for performing pulmonary function studies in a healthy population that has already gone through a preliminary medical screening and has been found fit is to identify occult or latent abnormalities. These abnormalities may have no or minimal clinical expression under ordinary circumstances but, under the stress of flight during the ensuing 5 to 10 years, may produce serious limitation in function. RESULTS: Two cases, seen in the Air Force Medical Center, are presented to illustrate how the algorithm is implemented. The algorithm has been in use for more than 5 years, and has been applied to the screening of several thousand candidates. Follow-up of the accepted candidates has not revealed any significant defects in the decision-making process. CONCLUSION: Use of the algorithm is highly cost-effective since it allows for nonspecialist physicians to carry out pulmonary screening and involves the pulmonary specialist only infrequently, ie, when a particularly complicated and/or borderline case is encountered. It is our contention that a similar algorithm would be useful in many other settings where large-scale screening is required.

The sleeping aviator--aeromedical disposition of Kleine-Levin syndrome.

We present the case of an aviator with Kleine Levin syndrome (KLS). History, physical examination, and special studies presented confirm the diagnosis of this syndrome. Our patient presented as an atypical case of KLS with respect to the presenting symptoms and to frequency of the episodes (6 years apart). He exhibited only intense somnolence, easy arousability, photophobia, hyperacousis, and a voracious appetite. Following a complete medical work up we recommended that an applicant with such a classical case of KLS be disqualified as a crewmember; however, in cases such as that presented above a limited waiver may be considered. The aeromedical significance of this case is to reinforce the importance of screening candidates and seeking precise diagnosis of a past illness or hospitalization.

[Primary quality control in Israel Air Force clinics].

The practice of primary medicine within a military framework differs from that in the civilian environment in: accessibility, its consumers, obligations of the providers, involvement of the funder (the commanders), and ability to define and enforce professional guide lines. These differences influence the scope of medical service, as well as affect the methods and results of quality control. A system of quality control evaluation and feedback of military primary care in 16 Israel Air Force clinics was carried out by a team of experienced physicians using peer group review and according to a specially prepared protocol. Emphasis was placed on medical record assessment using obligatory markers of adequate medical evaluation and treatment. Identification of the population at risk, further medical training, and medical administration with a direct effect on the quality of medical treatment were also evaluated. 2 quality control surveys with feedback were carried out 6 months apart. The overall mean score was 81.66 +/- 7.16% at the first evaluation, increasing to 88.60 +/- 7.46% at the second (p < 0.01). The greatest improvements were in follow-up of population at risk (increasing from 68.4% to 86.4%, p < 0.025), training of medical teams, (from 75.7% to 87.5%, p < 0.05) and patient case management (from 79.4% to 85.1%, N.S.). Categories in which there was no improvement were medical records, recovery of old medical files and patient education. The categories in which there was improvement had a common denominator: "recognition of importance" and "provision of patterns" by headquarters. The quality control system was designed for routine use, and not as a research project.(ABSTRACT TRUNCATED AT 250 WORDS)

Postural control in pilots and candidates for flight training.

Postural control may reflect the pilot's ability to deal successfully with the stresses of spatial orientation. In this study, we hypothesized that fighter pilots would have better performance on the "tetra-axiametric posture test" than would helicopter pilots (less rigorously selected) and candidates for flight training. We tested 28 fighter pilots, 23 helicopter pilots and 43 candidates by tetra-axiametric posturography. Fighter pilots were found on the level position to have significantly more compensatory anterior-posterior sway (moving anterior-posterior rather than laterally, p = 0.02) and required less movements to maintain balance (p = 0.02) than did candidates. Helicopter pilots had intermediate values. In stressed positions, fighter pilots demonstrated relatively more slow movements (p = 0.018) than did the candidates, which may be related to increased labyrinth control. In the stressed positions, helicopter pilots had postural profiles similar to the candidates. We conclude that there are significant differences in postural control as tested by tetraaxiametric posturography between fighter pilots, helicopter pilots, and candidates for flight training. This could be due to either innate ability, which could be used in the selection process, or to training. A prospective study is planned in order to determine if posturography can predict a candidate's ability to complete flight training.

Metabolic effects of nicotine on human adipose tissue in organ culture.

Fragments of human adipose tissue were maintained in culture for 1 week in a medium containing 1 mU/ml insulin and 100 ng/ml dexamethasone. Under these conditions lipoprotein lipase activity was present in human adipose tissue fragments which converted [14C]glucose to 14CO2 and [14C]triglyceride. Both metabolic parameters studied were affected by human tumor necrosis factor and brefeldin A. When fragments of human adipose tissue after 1 week in culture were incubated with nicotine tartrate for 20 h, a slight but significant increase in lipoprotein lipase activity was observed, and an increased conversion of [14C]glucose to 14CO2 and [14C]triglyceride occurred. Nicotine was taken up by human adipose tissue, but no conversion to cotinine was observed. Our data demonstrate a direct effect of nicotine on human adipose tissue metabolism. Furthermore, it is suggested that weight loss in smokers is a multifactorial phenomenon, and one of the important factors to be considered is the direct effect of nicotine within the tissue.

Heat stress and helicopter pilot errors.

Helicopter pilots are subjected to degrees of heat stress that under laboratory conditions result in decreased performance. However, the effect of heat stress on the frequency of helicopter pilot errors is uncertain. The purpose of this study is to determine whether there is an association between ambient heat stress and pilot error. The records of 500 helicopter accidents and incidents due to pilot error during the months May through October were selected at random. On the day of the event, ambient dry bulb and wet bulb temperatures were recorded and compared to temperature and humidity readings on 1000 days chosen at random over the same time period, after eliminating days where events occurred. There was a significant difference between the dry temperature distributions of the days with pilot error compared with the control group (chi 2 = 47.54, P < .0001). A dose-response relationship was found, with a significantly lower risk when ambient dry bulb temperatures were 25 to 29 degrees C (odds ratio, 0.6; 95% confidence interval, 0.5 to 0.8, P < .0001), an increased risk of 1.6 (1.3 to 2.0, P < .0001) at 30 to 34 degrees C, and the highest risk at 35 degrees C or more (6.2, 95% confidence interval, 2.1 to 21.8, P < .0002). There is a dose-response relationship between ambient heat stress and pilot error in Israel military helicopter pilots. This is the first study outside the laboratory showing a connection between heat stress and accidents due to human error. Further studies are required to substantiate our findings and to determine whether extrapolation to other settings is warranted.

Coagulation activation following estrogen administration to postmenopausal women.

We investigated coagulation system activation following estrogen treatment in 29 healthy postmenopausal women. Study participants received conjugated estrogens at 0.625 and 1.25 mg per day, and placebo for 3-month periods in a randomized crossover protocol. Blood samples were obtained on two consecutive days at the end of each treatment period for immunoassays of F1+2 and fibrinopeptide A (FPA), markers of factor Xa action on prothrombin and thrombin action on fibrinogen in vivo, respectively. Treatment with estrogens at a dose of 0.625 or 1.25 mg resulted in significant increases in mean F1+2 levels of 40 and 98%, respectively, and in mean FPA levels of 37 and 71%, respectively. The measurements of F1+2 were significantly higher in women receiving 1.25 mg of estrogen than 0.625 mg. We also observed significant declines in the levels of antithrombin III and total protein S antigen. Immunologic levels of protein C increased modestly at only the 1.25 mg estrogen dose level. These data indicate that low doses of oral estrogens (< or = 1.25 mg per day) frequently increase the amount of thrombin generated in vivo. Our observations may help to explain the increased thrombotic risk that has been observed with higher doses of this medication (> or = 2.5 mg).

Predicting increases in skin temperature using heat stress indices and relative humidity in helicopter pilots.

We used measurements of heat stress in the cockpit of Bell 206 and 212 helicopters manned by a crew of two to predict changes in the skin temperatures of 50 pilots over a 1-h ground standby period. Cockpit wet bulb globe temperatures increased from 28.1 +/- 5.6 degrees C to 32.9 +/- 3.9 degrees C over the 1-h ground standby period. Skin temperatures increased from 34.7 +/- 1.1 to 35.4 +/- 1.1 degrees C, while heart rate increased from 79.4 +/- 9.6 to 82.6 +/- 9.8 bpm. Cockpit wet bulb temperatures explained 26.9% of the variance of the increase in skin temperature (P = 0.0002). Wet bulb globe temperatures, discomfort index and dry bulb temperatures did not improve the predictive value of wet bulb temperatures alone. Relative humidity was not significantly associated with the increase in skin temperature. We conclude that wet bulb temperatures predict changes in skin temperature as well as other heat stress indices. Furthermore, despite high cockpit temperatures, pilots experienced only minimal strain during the 1-h ground standby period. Extrapolation of our results to the effects on body temperature of higher degrees of heat stress and physical activity is unwarranted and deserves further study.

The failure analysis of composite material flight helmets as an aid in aircraft accident investigation.

Understanding why a flying helmet fails to maintain its integrity during an accident can contribute to an understanding of the mechanism of injury and even of the accident itself. We performed a post-accident evaluation of failure modes in glass and aramid fibre-reinforced composite helmets. Optical and microscopic (SEM) techniques were employed to identify specific fracture mechanisms. They were correlated with the failure mode. Stress and energy levels were estimated from the damage extent. Damage could be resolved into distinct impact, flexure and compression components. Delamination was identified as a specific mode, dependent upon the matrix material and bonding between the layers. From the energy dissipated in specific fracture mechanisms we calculated the minimum total energy imparted to the helmet-head combination and the major injury vector (MIV) direction and magnitude. The level of protection provided by the helmet can also be estimated.

Primary Burkitt's lymphoma of the appendix.

Appendicitis is a very rare presenting symptom of abdominal Burkitt's lymphoma. Only four cases have previously been identified in the literature, all of them males. This is the first reported case of a female as well as the youngest and is representative of the therapeutic considerations in this unusual manifestation of the disease.

Factors associated with microhematuria in asymptomatic young men.

The prevalence of asymptomatic microhematuria (two to four or more erythrocytes per high-power field) in 1341 male Air Force personnel was 5.4%. The most powerful predictor of microhematuria (nearly 15-fold increased prevalence) was a history of recurrent microhematuria during the previous five years. Recurrent microscopic hematuria was present in 14.5% (8/55) of men with a history of urethritis, accounting for 26% (8/31) of the cases of recurrent microscopic hematuria. The prevalence of microhematuria was not affected by physical exercise, flight duty, or sexual intercourse during the 24 h preceding the urinalysis.

Low back pain in pilots.

A questionnaire on low back pain (LBP) was administered to 373 fighter pilots, 165 transport pilots, and 264 helicopter pilots. Helicopter pilots had more pain during flight than did fighter or transport pilots (34.5%, 12.9%, and 5.1%, respectively). A history of LBP temporally unassociated with flight was found in 26.5% of helicopter pilots, 31.5% of transport pilots and 25.2% of fighter pilots. We conclude that, despite the pain experienced by helicopter pilots in flight, they are not at increased risk for LBP unassociated with flight.

The significance of recurrent childhood respiratory disorders in flight training applicants.

A random sample of 1700 18-year-old applicants for flight training, who had been free from respiratory symptoms for 1 year or more, was screened for respiratory symptoms in the past. Those who denied such a history had a questionnaire sent to their parents for further verification. Altogether 70 subjects with a past history of "wheezing," "asthma," or "spastic bronchitis" were thus identified. Abnormalities in either FEV1/FVC, Vmax50 or Vmax75 were found in 40% of the subjects with a history of childhood "wheezing," "asthma," or "spastic bronchitis," but only in 8% of controls without such a history. A history of wheezing had no effect on the RV/TLC ratio. The age at which the last bout had occurred had no apparent effect on the degree of flow abnormalities. The most sensitive index for a flow abnormality was Vmax50, which was less than 74% of the predicted values in 2/(30%) of the 70 subjects tested. It is concluded that, in subjects with a history of "wheezing," "asthma," or "spastic bronchitis," flow abnormalities may persist even after prolonged remissions.

MRI and CT scan compared with microscopic histopathology in osteogenic sarcoma of the proximal tibia.

The authors report the case of a 15-year-old female who presented with a history of vague but constant pain about the medial aspect of her right knee. X-ray established the presence of an expanding lesion in the medial tibial plateau. Computerized axial tomography (CT) and magnetic resonance imaging (MRI) were used in the evaluation of the lesion. The authors compare the preoperative CT and MRI findings with the microscopic histopathology of the amputation specimen and note that the CT scan underestimated the extent of the microscopic tumor boundaries, whereas MRI showed altered activity beyond these boundaries.