Hepatitis C Virus Elimination Program among Prison Inmates, Israel.

The Israeli Prison Services implemented a hepatitis C virus (HCV) elimination program in 2020. Inmates considered high risk for HCV were offered serology; HCV-seropositive participants were offered HCV RNA testing. Among participants, 7.0% had detectable HCV RNA and were offered antiviral drug therapy. This program reduced HCV burden among incarcerated persons.

Health promotion programs in prison: attendance and role in promoting physical activity and subjective health status.

Introduction: Maintaining an inmate's health can serve as a challenge due to unhealthy background, risky behavior, and long imprisonment. This study aimed to analyze the prevalence of participation in health promotion activities among Israeli inmates and its association with their physical activity levels and subjective health status. Methods: A cross-sectional study was designed to examine 522 inmates (429 males, 93 females). The data were collected by trained face-to-face interviewers and self-report questionnaires. Results: Most of the participants (82.37%) did not meet the recommended physical activity level. Half of the participants reported that their physical activity levels decreased since they were in prison compared with 29.50% who reported that their physical activity levels increased. Physical activity and subjective health status were significantly higher among younger male inmates. Furthermore, participation in health-promoting activities was associated with higher levels of physical activity and subjective health status. Discussion: Health promotion activities may play an important role in addressing the challenges of maintaining inmate health. Implications of the findings are further discussed.

Assessment of Nutritional Status and Health Perception among Male Inmates in Israeli Prisons.

The nutritional and health perceptions of inmates are crucial to their overall well-being. However, limited research has been conducted on this topic. This study aimed to assess the nutritional and health perception state of male inmates in eleven prisons in Israel. A cross-sectional study was conducted between February and September 2019 with 176 voluntary participants. Structured questionnaires were used to collect data on socio-demographic characteristics, healthy habits, subjective health status, and prison situation variables. The study found that the prevalence of overweight (40%) and obesity (18.1%) among 18-34-year-old inmates was significantly higher than in the reference Israeli population. Short detention periods (up to one year) predicted less weight gain, while older age predicted poorer health status. Better emotional status significantly predicted better subjective health status among male inmates. There is a need for nutrition interventions to improve the health of inmates. The significant weight gain during incarceration and the associated lower health index and stress highlights the importance of increasing knowledge and promoting a healthier lifestyle in incarceration as early as possible and continuing over time.

The effect of direct-acting antiviral regimens and telemedicine on the treatment of inmates with hepatitis C virus infection in Israeli prisons.

BACKGROUND: Direct-acting antiviral (DAA) regimens and telemedicine services are both options for treating hepatitis C virus (HCV) within the prison setting. We aimed to compare factors associated with HCV treatment success over the past decade in Israeli prisons, specifically the influence of DAAs and telemedicine. METHODS: We retrospectively reviewed the medical records of inmates with HCV infection in Israeli prisons from 2010 through 2020. Demographic, clinical, and laboratory data were recorded, including treatment regimens and success rates. RESULTS: A total of 273 inmates were treated; mean age 45 ± 9.36 years; 98.2% males; 63.9% with a history of drug abuse. Advanced fibrosis was documented in 42.9%. The most common genotypes were 1 (46%) followed by 3 (40.7%). Interferon-based regimens were given to 68 inmates between 2010 and 2017. DAA agents were introduced in 2016, with pan-genotype regimens being exclusively used since 2019. Telemedicine services were used in 140 patients (51.3%), starting in February 2019. The sustained viral response (SVR) rate with interferon-based therapy was 78.8% and 98.8% with DAA treatment, giving an overall SVR of 93.2%. This difference between regimens proved to be the only statistically significant predictor of treatment success. The number of prisoners being treated with DAAs increased exponentially after telemedicine was introduced. Comparable SVR rates were achieved with either in-person or telemedicine consultation. CONCLUSION: Screening of this high-risk population and using telemedicine for treatment may be an effective strategy for the elimination of HCV from the prison population.

Use of vaccination in a large outbreak of primary varicella in a detention setting for African immigrants.

BACKGROUND: Primary varicella (PV) presents a public health risk for adults in closed residential settings, especially for immigrants from tropical areas where infection during childhood is less likely. METHODS: In this study, an outbreak of PV at a detention facility for illegal immigrants from Eritrea and Sudan in southern Israel is described. Basic demographic information and clinical course for all cases were obtained. RESULTS: One hundred and nine cases of PV, all in young adult men aged 18-40 years, were diagnosed over a 7-month period (June to December 2012). Diagnosed patients were placed in quarantine until the resolution of illness without other public health measures being implemented. The Israeli Ministry of Health was notified of the outbreak in early December and recommended two doses of varicella vaccine for all susceptible detainees and staff. Within 2 weeks of completion of the first dose of vaccine, there was only one additional case in a detainee immunized 13 days prior to diagnosis. The effectiveness of vaccination in halting the outbreak was immediate, despite the fact that 15.6% of detainees refused to be immunized. CONCLUSIONS: The possible roles of vaccination or natural infection in achieving herd immunity and thereby ending the outbreak in this population are discussed. We recommend considering early vaccination for all when an outbreak or a series of connected cases is detected in a closed-residential setting such as the detention facility described here.

Role of air-medical evacuation in mass-casualty incidents--a train collision experience.

BACKGROUND: On 21 June 2005, a passenger train collided with a truck near Revadim, Israel. The collision resulted in a multiple-scene mass-casualty incident in an area characterized by difficult access and a relatively long distance from trauma centers. A major disaster response was initiated by civilian and military medical forces including the Israeli Air Force (IAF) Search and Rescue teams. The air-medical evacuation from the accident site to the trauma centers, the activities of the airborne medical teams, and the lessons learned from this event are described in this report. METHODS: A retrospective analysis of data gathered from relevant elements that participated in management, treatment, and evacuation from the accident site was conducted. RESULTS: The accident resulted in 289 injured passengers and seven of the injured were killed. Six helicopters (performing nine sorties) participated. Helicopters evacuated trauma victims and aided in transporting air-medical teams to the site of the collision. Overall, 35 trauma victims (10 urgent) were evacuated by air to trauma centers. The length of time between the first helicopter landing and completion of the air evacuation was 83 minutes. The air-medical evacuation operation was controlled by the commander of the IAF Search and Rescue. Different crew compositions were set in real time. CONCLUSIONS: Air-medical evacuation during this unique event enabled prompt transportation of casualties from the scene to trauma centers and provided reasonable distribution of patients between various centers in the region. This operation highlighted the necessity for flexibility in medical decision-making and the need for nonconventional solutions regarding crew compositions during management of an airborne evacuation in similar settings. Air-medical evacuation should be considered as a part of responses to mass-casualty incidents, especially when the site is remote or characterized by accessibility difficulties.

Interventricular septum thickness predicts future systolic hypertension in young healthy pilots.

Left ventricular hypertrophy (LVH) has been associated with hypertension, although debate exists as to whether LVH is caused by elevated blood pressure (BP) or is a risk factor for its development. The present study evaluates the association between left ventricular structure and the development of hypertension in a young healthy population. We followed young healthy Israeli Air Force aviators from initial echocardiography at the start of their military service to a mean of 7.5+/-3.0 years. Data collection included annual BP measurements, height, weight, smoking habits, and lipid profile. We monitored 500 Air Force men with a mean age of 20.5+/-3.3 (range, 17-40) years and baseline BP of 125+/-13/74+/-8 mmHg. Systolic BP during follow-up was associated with baseline systolic BP, interventricular septum (IVS) thickness, and ejection fraction, whereas diastolic BP was associated only with baseline diastolic BP and body mass index. The probability that the systolic BP during follow-up would be higher than the median was twice that in those with an IVS thickness greater than the median. In conclusion, IVS thickening was associated with long-term elevation of systolic BP. Therefore, it seems that IVS thickening is not merely a result of long-term BP elevation, but may predict the development of systolic hypertension.

Physical examination and ECG screening in relation to echocardiography findings in young healthy adults.

BACKGROUND AND AIMS: Cardiovascular screening in young adults is an important tool in many occupational settings. Our aim was to test whether screening physical examination and ECG influence the rate of abnormal echocardiogarphic findings in young healthy subjects. METHODS: Consecutive echocardiography results of 18- to 20-year-old flight candidates were analyzed retrospectively. Echocardiographies were performed as part of a screening protocol, which includes ECG, physical examination and referral for echocardiography for any positive finding. A second stage includes universal echocardiography for all candidates. RESULTS: 1,066 subjects were evaluated; 489 subjects underwent echocardiography following referral because of abnormal auscultatory or ECG findings. Findings (mostly mild valvular insufficiencies) were demonstrated in 12.7%, with only 0.6% of subjects disqualified. In subjects who underwent universal echocardiography (n = 577), findings (mostly mild valvular insufficiencies) were detected in 18%, with only 0.5% of subjects disqualified. CONCLUSIONS: The rate of significant echocardiography findings is extremely low in this young and healthy population. The presence of abnormal findings on either physical examination or ECG screening was not demonstrated to alter the rate of abnormal echocardiographic findings. We suggest that the low yield of screening should be weighed against the cost of an unidentified congenital cardiac lesion in the specific setting.

Postmortem computed tomography in victims of military air mishaps: radiological-pathological correlation of CT findings.

A thorough medical inquiry is included in every aviation mishap investigation. While the gold standard of this investigation is a forensic pathology examination, numerous reports stress the important role of computed tomography in the postmortem evaluation of trauma victims. To characterize the findings identified by postmortem CT and compare its performance to conventional autopsy in victims of military aviation mishaps, we analyzed seven postmortem CT examinations. Musculoskeletal injuries accounted for 57.8% of the traumatic findings identified by postmortem CT. The most frequent findings were fractures of the rib (47%), skull (9.6%) and facial bones (8.6%). Abnormally located air accounted for 24% of findings, for which CT was superior (3.5% detected by autopsy, 100% by postmortem CT, P < 0.001). The performance of autopsy in detecting injuries was superior (autopsy detected 85.8% of all injuries, postmortem CT detected 53.9%, P < 0.001), especially in the detection of superficial lesions (100% detected by autopsy, 10.5% by postmortem CT, P < 0.001) and solid organ injuries (100% by autopsy, 18.5% by postmortem CT, P < 0.001). Performance in the detection of musculoskeletal injuries was similar (91.3% for autopsy, 90.3% for postmortem CT, P = not significant). Postmortem CT and autopsy have distinct performance profiles, and although the first cannot replace the latter it is a useful complementary examination.

Patients' views on optimal visit length in primary care.

Visit length (VL) has been decreasing over the last decades. Patients and physicians alike hold that this may have adverse affects on quality of care and patient-doctor rapport. Our aim was to study the optimal VL as viewed by the patients as well as possible related factors such as demographicparameters and patient satisfaction. By using surveys, we determined that patient satisfaction was highly correlated with VL and satisfaction from VL. Optimal VL as viewed by the patients was 15.4 minutes on average with considerable variation. Longer expected VL was associated with longer visits. Patient satisfaction from the visit was significantly decreased when expressed optimal VL exceeded the estimated duration of the visit. The surveys demonstrated that in young adults, satisfaction is highly correlated with VL. When asked, patients expect attainable VLs, which are on average only somewhat longer then the scheduled duration. We believe that patients should take part in decisions regarding visit scheduling. We suggest that individualization may contribute to the cost-effectiveness of physicians' time.

In-flight barodontalgia: analysis of 29 cases in military aircrew.

OBJECTIVE: The purpose of this study was to assess the current in-flight incidence of barodontalgia, defined as dental pain caused by a change in barometric pressure in an otherwise asymptomatic tooth, and to identify the associated dental pathologies and etiologic factors. METHODS: A total of 450 questionnaires were e-mailed to permanent fighter, helicopter, and transport aircrews of the Israeli Air Force. They were asked to report whether they had ever suffered from a toothache during flight. If a positive answer was reported, the subject was interviewed and his dental file was reviewed to obtain details about the incidence. RESULTS: There were 331 (73.6%) aircrew members who responded. Of those, 27 (8.2%) reported at least 1 case of barodontalgia; their mean age +/- SD was 29.7 +/- 7.3 yr and the occurrence by aircraft platform were 9.0% of fighter, 8.0% of helicopter, and 7.0% of transport respondents. Many of the cases originated from vital and/or inflamed pulp (40.7%), whereas the other cases were due to pulp necrosis or peri-apical periodontitis (18.5%) and barosinusitis (18.5%). None of the patients reported premature mission termination due to dental pain. The incidence of barodontalgia was estimated as 1 case per 100 flight-years. CONCLUSIONS: Even with modern dental care, military aircrews from all the flight platforms may occasionally experience barodontalgia. Flight surgeons and dentists should be aware of this phenomenon and use preventive measures to minimize its incidence and severity.

Evaluation of magnetic resonance imaging regulatory methods in the Israeli Air Force.

BACKGROUND: The use of magnetic resonance (MR) imaging (MRI) among many medical professions is growing. Many health care systems have formed control mechanisms to ensure proper utilization of MRI. This western world trend is also valid in the Israeli Air Force (IAF). At the time of the study, two methods existed for consideration of MR requests in the IAF: (1) consideration by a primary reviewer, no clinical guidelines (applied to all MR examination requests, knee MR excluded). (2) Consideration by a primary reviewer according to basic clinical guidelines established by the Israeli Defense Forces medical section and by communication with an orthopedic specialist (applied to knee MR requests). Both methods did not include consultation with established criteria (such as American College of Radiology (ACR) appropriateness criteria). OBJECTIVE: To evaluate the appropriateness of the current regulatory methods of MRI utilization in the IAF by comparing approval/rejection decisions to established ACR criteria. METHODS: The study is a retrospective analysis of written records of air force personnel, for whom MRI was requested by a specialist. We gathered information regarding the clinical problem and the final decision concerning approval or rejection of the MRI request. We then consulted with the ACR appropriateness criteria. In case a matching ACR clinical variant was found, an appropriateness value was assigned to the request. Otherwise, the request was noted as "ACR irrelevant". We predetermined to label all studies with an ACR value of 1 to 3 as inappropriate, 4 to 6 as "gray zone," and 7 to 9 as appropriate. We then compared the ACR-based decision to the original outcome of the request. RESULTS: The overall approval rate for MRI requests evaluated by a primary reviewer only was 96%. The overall approval rate for MRI requests evaluated by a primary reviewer, basic clinical guidelines, and specialist consultation was 51%. Among the four most prevalent MR requests types (brain, knee, spine, and shoulder), requests in the 7 to 9 scale (appropriate requests) accounted for 52%. Regarding appropriate requests, there was a 100% approval rate by a primary reviewer only compared with 17% for requests considered by a primary reviewer, basic guidelines, and specialist consultation (83% of appropriate requests were rejected by this method). Requests in the 1 to 3 scale (inappropriate requests) accounted for 3% of all requests. In this group, there was a 100% approval rate by both methods of consideration. Requests in the 4 to 6 scale (gray zone requests) also accounted for 3% of the total and requests which could not be assigned an ACR appropriateness value (ACR-irrelevant requests) accounted for 42% of total requests. The rate of approval of these requests by a primary reviewer only and by a primary reviewer, guidelines, and consultant was 97% and 83%, respectively. CONCLUSIONS: Both MR approval mechanisms that were applied in the IAF have not shown a strong correlation with ACR appropriateness criteria, with significant rates of both overuse and underuse of MRI. The high rate of requests that could not be assigned an ACR appropriateness value may indicate a need to broaden the appropriateness criteria coverage of clinical conditions and variants.

Effect of a computerized online grading system on patient satisfaction in a military primary health care setting.

Patient satisfaction is gaining recognition as an important determinant of the quality of medical care. We conducted an analysis to evaluate the effect of a computerized online system that comparatively displays grades of patient satisfaction among primary care military infirmaries. Fifteen Israel Air Force primary care infirmaries served as the intervention group, and 130 Israel Defense Force infirmaries were the control group. Baseline patient satisfaction was surveyed in all infirmaries. In the intervention group only, infirmaries were resurveyed at 3-month intervals during a 1-year period. Satisfaction scores were continuously displayed on an intranet site in a comparative graphical manner by using the computerized system, available only to the intervention group. At the endpoint, patient satisfaction improved in both groups. However, the magnitude of improvement in the intervention group was significantly greater, in comparison with the control group. The most pronounced improvement was noted in availability of service (intervention group, 57.9% at baseline vs. 66.0% at endpoint, p < 0.001; control group, 67.5% vs. 69.6%, p < 0.025). We conclude that the use of this computerized system in conjunction with promotional efforts resulted in significant improvements in patient satisfaction.

Physician versus paramedic in the setting of ground forces operations: are they interchangeable?

BACKGROUND: The setting of military ground force operations can be demanding and requires a matched medical assistance plan. A major consideration is the type of medical caregiver that is assigned to the mission. We studied the similarities, differences, advantages, and disadvantages of physicians versus paramedics in this scenario. METHODS: We interviewed 20 ground force physicians, highly experienced in this setting. We summarized their responses and formulated quantitative decision-making tables regarding two sorts of missions: a long-duration mission, far from friendly definitive care, and a short-duration mission, close to friendly hospitals. RESULTS: The major areas in which physicians and paramedics differ, pertinent to a ground force operation are: formal education, on-job training, knowledge base, ability to treat a wide variety of medical conditions, ability to perform manual lifesaving procedures, social and moral impact, availability, physical fitness, combat skills, and cost. Of a maximum score of 100 points, for a long-term mission a physician scores 77.7 points while a paramedic scores 63.6 points. The scores for a short-term mission are 72.7 and 67.9, respectively. DISCUSSION: Physicians and paramedics are distinct groups of medical caregivers and this is also true for the setting of ground force operations. They are not interchangeable. Our data show that a physician has a relative advantage over a paramedic, especially in long-term missions, far from friendly facilities. CONCLUSION: A physician is the first choice for all kinds of military ground force missions while a paramedic can be a reasonable substitute for missions of short duration, close to definitive care.

Bruxism in military pilots and non-pilots: tooth wear and psychological stress.

BACKGROUND: Bruxism is the diurnal or nocturnal para-functional habit of clenching or grinding the teeth and affects 5-10% of the general western population. Bruxism can cause pain and irreversible damage to the teeth, periodontium, masticatory muscles, and temporo-mandibular joint. Variables such as general stress, work-related stress, and personality traits have been increasingly considered as initiating, predisposing, and perpetuating factors for bruxism. We sought to evaluate the potential of work-related stress and personality factors to induce bruxism among military pilots and non-pilot officers. METHODS: Subjects were 57 healthy male Israel Air Force officers (mean age 25.8+/-4.3 yr). Of these, 17 were jet-pilots, 18 helicopter-pilots, and 22 non-pilot officers. Tooth-wear was classified according to a six-point scale. In addition, the subjects responded to a battery of psychological questionnaires for self-assessment of stress at the workplace and their coping behavior. RESULTS: Bruxism of clinical importance (i.e., with dentin exposure) was found in 69% of the aircrew members but only 27% of the non-pilot group. No difference was found between groups regarding stress levels. DISCUSSION: Military aircrews may be relatively vulnerable to deleterious bruxism as well as other signs of chronic stress. Among bruxers, pilots tended to show coping strategies that were significantly more emotional and less task-oriented than non-pilots, whereas non-bruxers showed no significant differences in coping behavior. This study suggest that integrating dental and psychological preventive intervention may be helpful.

Effect of G-force on bicuspid aortic valve in aviators.

BACKGROUND AND AIMS: Bicuspid aortic valve (BAV) is a common congenital cardiac malformation. The major complications are aortic stenosis (AS), aortic regurgitation (AR), infectious endocarditis and aortic dissection. This paper aims to assess the hemodynamic importance of incidentally-found BAV in military aviators and evaluate the effect of high G-force on disease progression. METHODS: Aviators with BAV were detected by reviewing all cardiac assessment records between 1987 and 2005. All aviators underwent annual flight surgeon examination. Echocardiography was performed as recommended by our cardiologists and flight surgeons. RESULTS: Eight newly diagnosed cases of BAV were found. All of the aviators continued active aviation throughout the study period. Repeat echocardiography demonstrated progressive widening of the aortic diameter in five of the eight aviators. No worsening of valve dysfunction was seen in those with mild aortic regurgitation at diagnosis. Left ventricular dimensions and function did not deteriorate. No new valve complications, including infectious endocarditis, were seen. The age at diagnosis strongly correlated with the root diameter change; both total (r = 0.74, p = 0.02) and annualized (r = 0.78, p = 0.02) change. Over a mean follow-up period of 12.1 years, no difference was seen in the progression of BAV in high-performance as compared to low-performance aviators. CONCLUSIONS: Exposure to G-force and anti-G maneuvers does not appear to worsen cardiac and valve function in aviators with BAV.

Long-term survivors of childhood malignancies--aeromedical dilemmas and implications.

Survival rates from childhood cancer have dramatically improved over the past three decades; average overall 5-yr survival rates are now > 75%. However, this has been achieved by treatments associated with significant morbidity that may present many years later. This review seeks to delineate the basic information necessary to evaluate flight-training candidates with a history of childhood cancer. We performed a literature review using the Medline database with appropriate search terms related to delayed morbidity and mortality associated with childhood cancer; we did not attempt to evaluate the risk of recurrent cancer. The neurological, cardiovascular, and pulmonary systems were identified areas of aeromedical concern. Central nervous disease and treatment-related effects may increase the risk of seizures or other neurocognitive sequelae. The cardiac toxicity of chemotherapeutic agents such as anthracyclines and radiation may cause late-occurring arrhythmia, cardiac failure, and sudden death, while available screening modalities are of limited value. Pulmonary disease and related treatment effects may cause a 9-fold increase of late-occurring pulmonary fibrosis and lung cancer, with increasing prevalence as long as 25 yr following the cancer diagnosis. Additionally, second malignancies may occur in up to 12.5% of cancer survivors at 25 yr after cancer diagnosis, affecting medical clearance for flight training. In summary, this review discusses the relevant aeromedical issues, including disabilities with specific relevance to the flying environment, risk estimation of late-occurring treatment complications, and possible interactions with occupational exposures in aircrew.

Cervical and lumbar MRI findings in aviators as a function of aircraft type.

BACKGROUND & AIMS: Neck pain and lower back pain (LBP) are frequently reported by military helicopter pilots (HP) and fighter pilots. A small number of studies have used imaging methods to evaluate spinal cervical degenerative findings in pilots exposed to high +Gz, with results indicating an increase in cervical disk protrusions in this population. We evaluated the cervical and lumbar spine with magnetic resonance imaging (MRI) to assess the prevalence of degenerative changes in three subpopulations of pilots. METHODS: Fighter pilots (FP), transport pilots (TP), and HP (10 pilots in each group) underwent cervical and lumbar MRI. Degenerative pathologic changes (disk herniation, cord compression, foraminal stenosis, and the presence of osteophytes) were evaluated in each group by two independent experienced radiologists. RESULTS: Cervical spine degenerative changes seemed to be associated with older age rather then aircraft type, affecting the older group of TP (8/10 pilots) more than the younger FP group who were exposed to high +Gz (3/10 pilots). In contrast, for lumbar spine degenerative changes, we found an uncommon pattern of lumbar spine degeneration in HP, affecting the upper part of the lumbar spine (10/13 disks found at L1-L4). CONCLUSIONS: The results of this study suggest that HP may have detectable degenerative lumbar findings. More research is needed to validate these findings as well as to explore the possible pathophysiological link between occupational exposures and the specific involvement of the upper lumbar spine.

Pre-hypertension as a predictor of hypertension in military aviators: a longitudinal study of 367 men.

BACKGROUND: Recently, the seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure introduced the term "pre-hypertension" for systolic blood pressure (BP) levels of 120-139 and diastolic BP levels of 80-89 mmHg. Our aim was to establish the prevalence of this novel entity among young subjects, and to assess the rate of progression to hypertension. METHODS: We retrospectively analyzed the data of a group of 367 male aviators who were examined at the age of 18 and who were followed for an average of 18 +/- 7 yr (range 3-37 yr). Systolic and diastolic BP, heart rate, and body mass index (BMI) were measured at the age of 18 and at the end of the follow-up. RESULTS: At the age of 18, 176 subjects (48%) had pre-hypertension. Subjects with pre-hypertension had higher BP levels (132 +/- 6/76 +/- 8 vs. 115 +/- 6/72 +/- 7 mmHg; p < 0.001), heart rate (71 +/- 12 vs. 65 +/- 12 bpm; p < 0.001) and BMI (22.4 +/- 2.9 vs. 21.7 +/- 2.5 kg x m(-2); p < 0.05) than the subjects with normal BP. During the follow-up period, 110 subjects (30%), 77 with pre-hypertension and 33 with normal BP, developed hypertension. Pre-hypertensive subjects had an odds ratio of 3.7 (95% CI; 2.3-6.2) to develop hypertension as compared with subjects with normal BP. CONCLUSIONS: Pre-hypertension is common and it predicts the development of frank hypertension. Thus, subjects with pre-hypertension should be closely followed and encouraged to begin lifestyle modification in order to prevent future complications.

Evaluation of systemic allergy in a jet aviator.

Cholinergic urticaria and exercise-induced anaphylaxis (EIA) are related conditions. Cholinergic urticaria is caused by a rise in body core temperature and usually results in pruritus, skin lesions and, rarely, in serious respiratory and cardiovascular compromise. EIA can result in a cardiovascular compromise and syncope. Ingestion of certain foods may be associated with EIA. A 41-year-old jet pilot complained of 3-month onset of pruritus and urticaria during treadmill exercise. On one occasion, after a routine exercise bout, albeit with pruritus and urticaria, he experienced two short episodes of syncope. Treatment with a nonsedating H1-receptor antagonist was started. He underwent a unique challenge test that we designed. This included passive warming as well as exercising in a hot (temperature of 40 degrees C at 40% humidity) environment. After passing this test uneventfully, the pilot was returned to jet flight with a copilot and, subsequently, to full active duty.