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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.

Whilst systemic septic embolization is a common complication of infective endocarditis, a second, less frequently reported, complication is the embolization of vegetative material to the coronary arteries that rarely results in acute myocardial infarction and sudden death. The case is presented of an acute cardiac death in a patient with aortic valve endocarditis, caused by acute occlusion of the left main coronary artery with vegetative material.

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.

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.

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.

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.

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.

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.

Objective: To identify atherosclerosis in the common carotid (CCA) and common femoral arteries (CFA) of patients with systemic lupus erythematosus (SLE) and matched controls., Methods: Fifty-one consecutive patients with SLE were enrolled in the study. Controls were matched by age, sex, ethnicity, and atherosclerosis risk factors. All patients and controls underwent ultrasonic biopsy (U-B) of the CFA and CCA, a noninvasive screening technique that detects early atherosclerotic plaques and changes. 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 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 was calculated. Classes A and B indicate an intact media; classes D to F point to a significant medial involvement; class C signifies a borderline lesion with a potential for regression to normal or progression to a plaque., Results: Mean ages were 40.5 years for SLE patients and 41 years for controls (p = 0.6). Ninety-six percent of the patients and controls were women. The mean disease duration of SLE was 8.65 years. Frequencies of risk factors among the SLE patients compared to controls were hypertension (30% vs 24%), smoking (23% vs 24%), and dyslipidemia (17.7% vs 17%). No patient had diabetes mellitus or family history of cardiovascular disease. A 3.17-fold increased rate of atherosclerotic plaques was detected in the SLE patients compared with controls (95% CI 1.08-10.9). Twenty-eight percent of SLE patients had at least a single class D-F lesion in one of the 4 vessels tested, compared with 10% in the control group (p = 0.02). In addition, the mean total U-B score of the SLE patients was significantly higher than that of the controls (5.65 vs 3.14; p = 0.02). Univariate analyses showed that the development of plaques in SLE was associated with a history of ischemic heart disease, hypertension, cardiovascular accident, and anemia. Multivariate analysis found plaques to be strongly associated with age, particularly in those older than 50 (OR 2.66, p = 0.000)., Conclusion: Patients with SLE have a high rate of atherosclerotic changes compared to controls. The development of atherosclerosis is strongly associated with age.

Mud pack therapy is an alternative mode of treatment for rheumatic diseases. It is based on the application of heated mud packs to the entire body or to specific areas, such as over joints. The aim of the current study was to evaluate the efficacy of treatment with mud compresses at patients' homes for osteoarthritis of the knee. Fifty-eight patients with osteoarthritis of the knee were enrolled in a prospective, double-blinded, controlled study. Forty patients were treated with natural mineral-rich mud compresses and 18 patients were treated with mineral-depleted mud compresses. Mud compresses were applied 5 times each week during 3 weeks for a total of 15 treatments. Patients were assessed at baseline, at completion of the 3-week treatment period, and twice after the conclusion of the treatment period-after 1 month and after 3 months. The main outcome measures were the Lequesne Index of severity of knee osteoarthritis, patient self-assessment of pain, and severity of knee pain on a visual analog scale. A reduction of 20% or more in the pain scores was considered clinically significant. In the group treated with natural mud compresses, a significant reduction in knee pain was observed at all assessments. Similarly, improvement in the Lequesne Index was seen at the end of therapy and a month after treatment. In the control group, given mineral-depleted mud compresses, no significant change in knee pain was seen at any assessment. Improvement in the Lequesne Index was seen 1 and 3 months after completion of the therapy, but not at the end of therapy. Seventy-two percent of the patients in the treatment group had an improvement of >20% in self-assessment of knee pain, compared with 33% in the control group (p = 0.005). The data suggest that treatment with mud compresses, but only in their natural form, temporarily relieves pain in patients with osteoarthritis of the knees. We believe that treatment with mud compresses might augment conventional medical therapy in these patients.