Normative data for the Brief Symptom Inventory for patients with Crohn's disease

OBJECTIVE

The Brief Symptom Inventory (BSI) is a self-report measure of psychological symptoms in clinical and non-clinical populations. However, norms for BSI are lacking for patients with chronic illness, such as Crohn's disease (CD). This study aimed to provide BSI clinical norms using a cohort of CD patients.

DESIGN

Adult Israeli CD patients (n = 430) completed questionnaires regarding clinical, demographic and psychological aspects of disease, including BSI. Their BSI data were compared with published norms from adult Israeli population and British psychiatric outpatients.

RESULTS

CD patients in active disease state had higher levels of mental health symptoms than those in remission. Interestingly, levels of symptomatology did not differ with respect to disease duration. No significant sex differences in BSI dimensions were found, with the exception of somatization. Being younger than 60 years and having lower economic status were associated with more severe psychological symptoms. Psychological symptom levels in CD patients were high in comparison to the Israeli general population, but low compared to British psychiatric outpatients.

CONCLUSION

Results confirm the link between CD and elevated psychological symptoms. The findings highlight the need to use appropriate BSI norms when assessing clinically significant levels of psychological symptoms in non-psychiatric patients with chronic illness.

Health-care costs of inflammatory bowel disease in a pan-European, community-based, inception cohort during 5 years of follow-up: a population-based study

BACKGROUND

Inflammatory bowel disease (IBD) places a significant burden on health-care systems because of its chronicity and need for expensive therapies and surgery. With increasing use of biological therapies, contemporary data on IBD health-care costs are important for those responsible for allocating resources in Europe. To our knowledge, no prospective long-term analysis of the health-care costs of patients with IBD in the era of biologicals has been done in Europe. We aimed to investigate cost profiles of a pan-European, community-based inception cohort during 5 years of follow-up.

METHODS

The Epi-IBD cohort is a community-based, prospective inception cohort of unselected patients with IBD diagnosed in 2010 at centres in 20 European countries plus Israel. Incident patients who were diagnosed with IBD according to the Copenhagen Diagnostic Criteria between Jan 1, and Dec 31, 2010, and were aged 15 years or older the time of diagnosis were prospectively included. Data on clinical characteristics and direct costs (investigations and outpatient visits, blood tests, treatments, hospitalisations, and surgeries) were collected prospectively using electronic case-report forms. Patient-level costs incorporated procedures leading to the initial diagnosis of IBD and costs of IBD management during the 5-year follow-up period. Costs incurred by comorbidities and unrelated to IBD were excluded. We grouped direct costs into the following five categories: investigations (including outpatient visits and blood tests), conventional medical treatment, biological therapy, hospitalisation, and surgery.

FINDINGS

The study population consisted of 1289 patients with IBD, with 1073 (83%) patients from western Europe and 216 (17%) from eastern Europe. 488 (38%) patients had Crohn's disease, 717 (56%) had ulcerative colitis, and 84 (6%) had IBD unclassified. The mean cost per patient-year during follow-up for patients with IBD was €2609 (SD 7389; median €446 [IQR 164-1849]). The mean cost per patient-year during follow-up was €3542 (8058; median €717 [214-3512]) for patients with Crohn's disease, €2088 (7058; median €408 [133-1161]) for patients with ulcerative colitis, and €1609 (5010; median €415 [92-1228]) for patients with IBD unclassified (p<0·0001). Costs were highest in the first year and then decreased significantly during follow-up. Hospitalisations and diagnostic procedures accounted for more than 50% of costs during the first year. However, in subsequent years there was a steady increase in expenditure on biologicals, which accounted for 73% of costs in Crohn's disease and 48% in ulcerative colitis, in year 5. The mean annual cost per patient-year for biologicals was €866 (SD 3056). The mean yearly costs of biological therapy were higher in patients with Crohn's disease (€1782 [SD 4370]) than in patients with ulcerative colitis (€286 [1427]) or IBD unclassified (€521 [2807]; p<0·0001).

INTERPRETATION

Overall direct expenditure on health care decreased over a 5-year follow-up period. This period was characterised by increasing expenditure on biologicals and decreasing expenditure on conventional medical treatments, hospitalisations, and surgeries. In light of the expenditures associated with biological therapy, cost-effective treatment strategies are needed to reduce the economic burden of inflammatory bowel disease.

FUNDING

Kirsten og Freddy Johansens Fond and Nordsjællands Hospital Forskningsråd.

Effect of Social Support on Psychological Distress and Disease Activity in Inflammatory Bowel Disease Patients

BACKGROUND

Psychological distress increases morbidity in ulcerative colitis (UC) and Crohn's disease (CD). We examined whether social support is associated with distress and disease activity.

METHODS

There were 110 UC and 147 CD patients who completed sociodemography, economic status, disease activity (UC: Patient Simple Clinical Colitis Activity Index (P-SCCAI), CD: Patient Harvey-Bradshaw Index . (P-HBI), Multidimensional Scale of Perceived Social Support (MSPSS), Brief Symptom Inventory with Global Severity Index (GSI) of psychological distress, and 2 health-related quality-of-life scales (SF-36 Physical Health and Mental Health, and Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Analysis included multiple linear regressions and structural equation modeling.

RESULTS

Disease activity was mild: UC: P-SCCAI 2.9 ± 3.5, CD: P-HBI 4.7 ± 4.7. Physical Health was better in UC 46.6 ± 11.4 versus CD 43.7 ± 10.9 (P < .02). GSI was lower in UC 0.6 ± 0.7 than CD 0.8 ± 0.7 (P = .002). MSPSS total score was equal in UC (5.9 ± 1.2) and CD (5.9 ± 1.1). MSPSS total correlated with P-SCCAI (correlation coefficient ‒0.240), GSI in UC (‒0.470), and GSI in CD (‒0.333). Economic status correlated with GSI in UC (‒0.408) and CD (‒0.356). MSPSS predicted GSI, Mental Health, and SIBDQ in UC and CD, and predicted P-SCCAI but not P-HBI; economic status predicted all the foregoing. Path analysis depicted GSI as mediating the effects of MSPSS and economic status on disease activity in both UC and CD. MSPSS (UC: β ‒0.34, CD: β ‒0.37) and economic status (UC: β ‒0.38, CD: β ‒0.22) reduced GSI, which then increased the disease activity (UC: β 0.56, CD: β 0.42).

CONCLUSIONS

Social support and economic status are linked to UC and CD patients' well-being. Interventions addressing these issues should be part of management.

Daily hassles score associates with the somatic and psychological health of patients with Crohn's disease

OBJECTIVE

To examine the associations of daily hassles with the somatic and psychological health of Crohn's disease (CD) patients.

METHOD

A cross-sectional study of 400 self-selected adult CD patients was performed with completion of demographic, medical, and psychosocial questionnaires: economic status; Patient Harvey-Bradshaw Index of disease activity; Daily Hassles Scale (DHS); Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and Short-Form Health Survey (SF-36 Physical and Mental Health) quality of life measures; Brief Symptom Inventory of psychological stress with summary Global Severity Index (GSI); Family Assessment Device; and List of Threatening Life Experiences. Analyses included correlations, regressions, and Sobel test statistic.

RESULTS

The patients were aged 38.7 ± 14.1 years, 61% female and 67% working. The Patient Harvey-Bradshaw Index was 5.52 ± 4.87. The DHS was 88.0 ± 23.2, similar in men and women, higher in smokers, and increased with greater disease activity (p < .001). The most commonly reported hassles were time, social, and work. DHS had significant negative correlations with age, disease duration, and economic status and positive correlations with GSI, SF-36, and SIBDQ. An increased Daily Hassles score was associated with reduced SIBDQ (p < .001) and SF-36 Mental Health (p < .001) and increased GSI (p < .001) and Patient Harvey-Bradshaw Index (p < .001). This effect of DHS on Patient Harvey-Bradshaw Index was mediated by GSI (Sobel t = 6.09, p < 0.001).

CONCLUSION

Daily hassles in CD patients are shown for the first time to be associated with increased psychological stress and disease activity and reduced quality of life and lower economic status. This has psychotherapeutic implications.

[TRAINING WORKSHOPS FOR BEDOUIN MOTHERS: PREVENTION OF IRON DEFICIENCY ANEMIA IN CHILDREN - RESULTS FROM A COMMUNITY TRIAL STUDY]

INTRODUCTION

Anemia is the most common nutritional deficiency in the world, contributing to childhood morbidity and mortality. Knowledge, attitudes and behavior of caretakers and parents of toddlers can significantly prevent anemia.

OBJECTIVES

Assessment of workshop intervention to alter knowledge, attitudes and behavior in mothers of toddlers in the Bedouin population.

METHODS

Community trial study. The intervention group included: 150 mothers of healthy one-year-old toddlers receiving workshops culturally tailored for a month in addition to standard training in "Tipat-Halav" (Baby clinic). The control group included: 101 mothers of healthy one-year-old toddlers who received standard training. At the endpoint, mothers were tested in both groups to determine levels of knowledge based on the knowledge and attitudes questionnaire, and the food intake of their children was reviewed according to the Food Frequency Questionnaire (FFQ).

RESULTS

Intervention group mothers correctly answered significantly more questions on knowledge and attitudes than the control group; 87.3% of the intervention group recognized the importance of giving iron supplements to prevent anemia compared to 73.3% in the control group (p=0.004). Over three-quarters of the intervention group and half of the control group knew that food affects mental development (p=0.001). In logistic regression, neutralization of SES variables, the intervention increased the rate mothers correctly answered questions 2 to 2.6 fold compared with the control group (p˂0.05). According to the FFQ, children in the intervention group ate more iron-rich foods of animal and vegetarian origin compared to the control group (p<0.05).

CONCLUSIONS

The intervention improved the knowledge and behavior of mothers in preventing anemia in toddlers. It should be required to provide information and training activities for mothers of toddlers beyond standard training, increasing the awareness of foods rich in iron. This activity can be performed using cultural workshops on iron deficiency, as was performed in this study.

[IS THERE A WAY TO REDUCE IRON DEFICIENCY ANEMIA RATES IN THE SECOND YEAR OF LIFE OF BEDOUIN CHILDREN IN THE NEGEV?]

INTRODUCTION

Iron deficiency anemia is the most common worldwide nutritional deficiency contributing to childhood morbidity and mortality. According to the official health policy in Israel, providing iron for all babies from the age of 4 months to the age of one year old is recommended. This policy also recommends providing iron supplementation for an additional 6 months for toddlers (who are one year old) with anemia (hemoglobin<11mg/dl). Despite this policy, there is still a high rate of anemia in the Negev's two year old children, especially in the Bedouin population.

OBJECTIVES

Assessment of the intervention program to reduce iron deficiency anemia rates, that provides iron supplementation to Bedouin toddlers with no anemia, from the age of 1 year to 18 months and maternal knowledge about the prevention of anemia.

METHODS

Type of Research: Community intervention trial study. Population study: A total of 251 toddlers aged one year old with no anemia from 6 recognized and unrecognized Bedouin villages. Intervention group: 250 toddlers who received iron supplementation; Prophylactic dosage (15 mg per day) for 6 months from the age of 1 year. Control group: 101 toddlers who did not receive iron supplementation. The hemoglobin (Hb) level was measured before and after the intervention for both groups.

RESULTS

At the beginning of the study, at the age of one year there was no difference between the two groups in the average Hb level (11.8±0.5mg/dl). After the intervention of 6 months, an Hb decrease was observed in both groups: 11.5±0.8 mg/dl compared to 11.0±1.0 mg/dl in the intervention group and in the control group (p<0.001), respectively. At the study endpoint the rates of anemia in the intervention group were lower compared to the control group: 40.6% and 15.3% (p<0.001), respectively. A positive correlation was found between the toddlers Hb level and the amount of iron supplementation received through the study.

CONCLUSIONS

Providing iron supplementation, from the age of 1 year for 6 months reduces the anemia risk during the second year of life. We suggest changing the recommendation to continue iron supplementation for toddlers (beyond one year old) only for children with anemia to a new policy and propose continuing iron supplementation beyond one year old to all toddlers at this age.

Simple pain measures reveal psycho-social pathology in patients with Crohn’s disease

AIM

To determine whether pain has psycho-social associations in adult Crohn’s disease (CD) patients.

METHODS

Patients completed demographics, disease status, Patient Harvey-Bradshaw Index (P-HBI), Short Form Health Survey (SF-36), Short Inflammatory Bowel Disease Questionnaire (SIBDQ), and five socio-psychological questionnaires: Brief Symptom Inventory, Brief COPE Inventory, Family Assessment Device, Satisfaction with Life Scale, and Work Productivity and Activity Impairment Questionnaire. Pain sub-scales in P-HBI, SF-36 and SIBDQ measures were recoded into 4 identical scores for univariate and multinomial logistic regression analysis of associations with psycho-social variables.

RESULTS

The cohort comprised 594 patients, mean age 38.6 ± 14.8 years, women 52.5%, P-HBI 5.76 ± 5.15. P-HBI, SF-36 and SIBDQ broadly agreed in their assessment of pain intensity. More severe pain was significantly associated with female gender, low socio-economic status, unemployment, Israeli birth and smoking. Higher pain scores correlated positively with psychological stress, dysfunctional coping strategies, poor family relationships, absenteeism, presenteeism, productivity loss and activity impairment and all WPAI sub-scores. Patients exhibiting greater satisfaction with life had less pain. The regression showed increasing odds ratios for psychological stress (lowest 2.26, highest 12.17) and female gender (highest 3.19) with increasing pain. Internet-recruited patients were sicker and differed from hardcopy questionnaire patients in their associations with pain.

CONCLUSION

Pain measures in P-HBI, SF-36 and SIBDQ correlate with psycho-social pathology in CD. Physicians should be aware also of these relationships in approaching CD patients with pain.

Health-Related Utility Weights in a Cohort of Real-World Crohn's Disease Patients

BACKGROUND AND AIMS

Estimating health-related utility weights in Crohn's Disease [CD] patients is crucial for assessing the cost-effectiveness of new pharmaceutical interventions. Values used in most analyses are based on secondary data and vary substantially among studies. We estimated utility weights in a consecutive sample of real-world CD patients.

METHODS

Patients enrolled in an ongoing socioeconomic study of CD in the Israeli adult patient population completed a self-administered Short Form 36 health survey [SF-36] and Short Inflammatory Bowel Disease [SIBDQ] questionnaires and were assessed for their current clinical status, including the Harvey-Bradshaw Index [HBI] of disease severity. For each patient enrolled we calculated a utility weight using the SF-6D scoring system.

RESULTS

The cohort comprised 425 patients [40% male] with mean age of 39.1 [± 14.0] years. The average HBI was 6.1 [± 5.4]; 198 [47%] patients were in remission state [HBI < 5], 99 [23%] had mild disease [HBI 5-7], 102 [25%] moderate [HBI 8-16], and 26 [6%] severe disease [HBI > 16]. Mean utility weights were: 0.667 in all patients, 0.744 in patients with disease remission, 0.638 in mild disease, 0.587 in moderate disease, and 0.505 in severe disease. The significant predictors of utility weights in a multivariable regression analysis were the HBI [β = -0.494; p < 0.001], economic status [β = 0.198; p < 0.001], time since diagnosis [β = 0.106; p < 0.001], male [compared with female] gender [β = 0.099; p = 0.009], hospital admission in the past year for any cause [β = -0.086; p = 0.027], and treatment with steroids [β = -0.100; p = 0.012] where β denotes the standardised regression coefficients; model adjusted R(2) = 0.428.

CONCLUSIONS

Utility weights for patients in the remission and mild disease states were generally lower as compared with values used in published cost-effectiveness analyses. These values should be considered when assessing the value for money of future interventions for CD.

Mediterranean diet and functional indicators among older adults in non-Mediterranean and Mediterranean countries

BACKGROUND/OBJECTIVES

The Mediterranean diet (MEDDIET) has been shown to be related to longevity. This study aimed to determine the association between adherence to MEDDIET and physical function of older adults in the United-States and Israel.

METHODS

Data from the US National Health and Nutrition Survey (NHANES) 1999-2002 and from the Israeli National Health and Nutrition Survey (MABAT ZAHAV) 2005-2006 were used. Participants with nutritional and functional data were included. Adherence to the MEDDIET was assessed by a 9-unit score (MDS).

RESULTS

Among 2791 NHANES and 1786 MABAT ZAHAV participants, mean age=71.2 y and 74.9 y, 20% and 27% had low MDS (0-2), 66% and 62% had a medium score (3-5), and 14% and 11% had a high score (6-9), respectively. Higher MDS was associated with higher education and better lifestyle behaviors. Cognitive and physical functions were significantly better in NHANES and MABAT ZAHAV among the highest MDS. In NHANES, MDS (high vs. low) was associated with faster walking speed after adjusting for confounders in a logistic regression model [Odds Ratio (OR)=0.71, P=0.034, Cl 95% 0.511-0.974]. When cognitive function was added, the association was attenuated (OR=0.75, P=0.093, Cl 95% 0.540-1.049). In MABAT ZAHAV, in a logistic regression model adjusted among other to cognitive function, MDS (high vs. low) was associated with fewer disabilities (OR=0.51, P=0.029, Cl 95% 0.276-0.934).

CONCLUSIONS

Adherence to the MEDDIET is associated with better health characteristics and better functioning. Further cohort and intervention studies may shed light on temporal and causal relationships between MEDDIET and these parameters.

Posttraumatic stress disorder among preschoolers exposed to ongoing missile attacks in the Gaza war

BACKGROUND

The prevalence and manifestation of posttraumatic stress symptoms in young children may differ from that observed in adults. This study examined sociodemographic, familial, and psychosomatic correlates of posttraumatic stress disorder (PTSD) among preschool children and their mothers who had been exposed to ongoing missile attacks in the Gaza war.

METHODS

One hundred and sixty-seven mothers of preschoolers (aged 4.0-6.5 years) were interviewed regarding PTSD and psychosomatic symptomatology of their children, as well as their own reactions to trauma.

RESULTS

Fourteen mothers (8.4%) and 35 children (21.0%) screened positive for PTSD. Sociodemographic characteristics were not associated with PTSD among mothers or children. Among children, the only significant risk factor was having a mother with PTSD (OR = 12.22, 95% CI 2.75-54.28). Compared to children who did not screen positive for PTSD, those who did screen positive displayed significantly higher rates of psychosomatic reactions to trauma, most notably constipation or diarrhea (OR = 4.36, 95% CI 1.64-11.60) and headaches (OR = 2.91, 95% CI 1.07-7.94).

CONCLUSIONS

Results of this study add to the burgeoning literature on child PTSD, emphasizing the important role of maternal anxiety and the psychosomatic reactions associated with exposure to ongoing traumatic experiences in young children.

Factors associated with childhood overweight and obesity among acculturated and new immigrants

OBJECTIVE

To examine the relationship between acculturation and obesity among low socioeconomic status (LSES) children.

DESIGN

Cross-sectional study.

SETTING

Children from 12 preschools in LSES neighborhoods were recruited.

PARTICIPANTS

Anthropometric measurements were obtained from 238 children (aged 4-7 years) and 224 mothers. Sociodemographic characteristics and perceptions of child's weight were collected from mothers. We compared native Israelis and immigrants for risk factors for obesity, using a 9-year cut-off to define new and acculturated immigrants.

RESULTS

The combined prevalence of overweight and obesity (OWOB) among children was 29.8% (71/238) using the World Health Organization (WHO) growth standard. Mean age, sleeping hours, sex distribution and poverty level were similar between immigrants and natives. Prevalence of OWOB and current parental smoking were significantly lower among children of new immigrants (P = .02). More than 82% of mothers underestimated their child's weight status, 74.2% of OWOB children were perceived as normal-weight (NW) and 8% as thin. In a multivariable logistic-regression analysis comparing NW to OWOB children, maternal underestimation of the child's weight status (OR = 7.5; 95%CI: 3.4-16.5, P < .0001) and being born to acculturated immigrants (OR = 2.3 95% CI: 1.1-4.7, P = .03) were associated with OWOB. Ethiopian children were at lower risk for obesity. Paternal smoking increased the risk for obesity by 2-fold in non-Ethiopian, and 5-fold in Ethiopian children (OR = 2.0 and 5.0, respectively; P for interaction = .026).

CONCLUSIONS

Acculturation, perception of child's weight status and parental smoking are associated with childhood OWOB. Immigration status should be considered when programs to prevent childhood obesity are implemented in mixed populations.

Adherence to mediterranean diet and decline in walking speed over 8 years in community-dwelling older adults

OBJECTIVES

To determine the association between Mediterranean diet (MedDiet) score and 20-m walking speed over 8 years.

DESIGN

Health, Aging and Body Composition Study (Health ABC) beginning in 1997/98.

SETTING

Community.

PARTICIPANTS

Two thousand two hundred twenty-five well-functioning individuals aged 70 and older.

MEASUREMENTS

Walking speed was assessed in relation to low, medium, and high adherence to the MedDiet (0-2, 3-5, 6-9 points, respectively).

RESULTS

Individuals in the highest MedDiet adherence group were more likely to be male; less likely to smoke; and more likely to have lower body mass index, higher energy intake, and greater physical activity (P < .05). Usual and rapid 20-m walking speed were highest in the high MedDiet adherence group than in the other groups (high, 1.19 ± 0.19 m/s; medium, 1.16 ± 0.21 m/s; low, 1.15 ± 0.19 m/s, P = .02, for usual speed; high, 1.65 ±0.30 m/s; medium, 1.59 ± 0.32 m/s; low, 1.55 ± 0.30 m/s, P = .001, for rapid speed). Over 8 years, usual and rapid 20-m walking speed declined in all MedDiet adherence groups. Higher MedDiet adherence was an independent predictor of less decline in usual 20-m walking speed (P = .049) in generalized estimating equations adjusted for age, race, sex, site, education, smoking, physical activity, energy intake, health status, depression and cognitive score. The effect decreased after adding total body fat percentage to the model (P = .13). Similar results were observed for MedDiet adherence and rapid 20-m walking speed; the association remained significant after adjustment for total body fat percentage (P = .01). The interaction between time and MedDiet adherence was not significant in any of the models.

CONCLUSION

Walking speed over 8 years was faster in those with higher MedDiet adherence at baseline. The differences remained significant over 8 years, suggesting a long-term effect of diet on mobility performance with aging.

Probiotics improve bowel movements in hospitalized elderly patients--the PROAGE study

OBJECTIVE

To determine the impact of probiotics on the prevention of problems with bowel movements malnutrition and infection.

DESIGN

A randomized, double-blind, placebo-controlled trial.

SETTING

Peripheral Geriatric Hospital.

PARTICIPANTS

243 elderly patients age ≥ 65 y who were hospitalized in a Geriatric Orthopedic Rehabilitation Department.

INTERVENTION

Participants were randomized into treatment or control groups (daily probiotics or placebo for 45 consecutive days, respectively).

MEASUREMENTS

The main outcomes were: number of days of constipation or diarrhea and the number of days of laxative use. Secondary measures were nutritional status and blood measurements.

RESULTS

Of 599 patients admitted to the Geriatric Rehabilitation ward, 345 were eligible and agreed to participate. During a 7-day pre-trial period, 102 patients dropped out (45 and 57 in the probiotic and placebo groups respectively). Out of the 243 patients who entered the study, 28 dropped out during the study (11.5%), leaving 215 patients. Throughout the 45 days of follow-up, the incidence of diarrhea was significantly lower among the study group (HR=0.42, p=0.04) with a more pronounced difference among participants aged ≥ 80 y (HR=0.32, p=0.026). Laxative use (as an indicator of constipation severity) was significantly lower in the study group compared with the control group (HR=0.74, p=0.032). Serum albumin, prealbumin and protein increased significantly more in the treatment group compared with the control group among participants age ≥ 80 y (P=0.047, p=0.07, p=0.03 respectively) but not in the younger age group.

CONCLUSION

We showed that probiotic supplements may have a positive effect on bowel movements among orthopedic rehabilitation elderly patients.

Dairy calcium intake, serum vitamin D, and successful weight loss

BACKGROUND

The role of dairy calcium intake and serum vitamin D concentrations in weight loss is controversial.

OBJECTIVE

The objective was to assess the association of dairy calcium intake and serum vitamin D with weight loss.

DESIGN

We analyzed data from participants in the 2-y Dietary Intervention Randomized Controlled Trial (DIRECT) [n = 322; mean body mass index (BMI; in kg/m²): 31; mean age: 52 y]. A representative sample (n = 126) was followed for 6 mo for serum vitamin D changes.

RESULTS

Baseline serum 25-hydroxyvitamin D [25(OH)D] concentrations decreased significantly across the tertiles of baseline BMI (25.6 ± 8.0, 24.1 ± 8.9, and 22.9 ± 6.8 ng/mL, respectively; P for trend = 0.02). Baseline concentrations of vitamin D and dairy calcium intake were not associated with subsequent weight loss. However, in repeated-measures models adjusted for age, sex, baseline BMI, total fat intake, and diet group assignment, higher 6-mo tertile levels of dairy calcium intake (median for tertiles: 156.5, 358.0, and 582.9 mg/d, respectively) and serum 25(OH)D (14.5, 21.2, and 30.2 ng/mL, respectively) were associated with increased weight loss across the 2-y intervention (-3.3, -3.5, and -5.3 kg, respectively, for dairy calcium; P = 0.043; -3.1, -3.8, and -5.6 kg, respectively, for vitamin D; P = 0.013). In a multivariate logistic regression adjusted simultaneously for age, sex, baseline BMI, total fat intake, diet group, vitamin D concentration, and dairy calcium, an increase of 1 SD in dairy calcium intake increased the likelihood of weight loss of >4.5 kg in the preceding 6 mo [odds ratio (OR): 1.45; P = 0.046]. A similar increase was seen for serum 25(OH)D at the 6-mo point (OR: 1.7; P = 0.009).

CONCLUSION

Our study suggests that both higher dairy calcium intake and increased serum vitamin D are related to greater diet-induced weight loss. This trial was registered at clinicaltrials.gov as NCT00160108.

Efficacy of multiple micronutrient supplementations on child health: study design and baseline characteristics

BACKGROUND

The rates of anemia in children in southern Israel are high despite the current prevention strategy. A daily dose of "Sprinkles" (SuppleForte, Heinz, Canada), a micronutrient home supplementation, was proven effective for the treatment of anemia worldwide.

OBJECTIVES

To assess the efficacy of Sprinkles, a novel supplementation formulation, in the primary prevention of anemia in infants who have free access to health care services.

METHODS

A two-arm open-labeled cluster randomized controlled clinical trial was performed in 6 month old Bedouin and Jewish infants. The Sprinkles arm received sachets with iron, vitamins A and C, folic acid and zinc, and the control arm received standard treatment (liquid iron and vitamins A and D). The infants were from families attending Mother and Child Health clinics during 2005-2007. Intervention and follow-up were conducted for babies aged 6-12 months. Health outcomes (hematologic and nutritional indicators, growth parameters, morbidity rates) were evaluated at 12 and 18 months.

RESULTS

The final study population numbered 621 infants (328 Bedouin and 293 Jewish); of the parents approached 88.5% agreed to participate. Hemoglobin > 11 g/dl was found in 55% of Bedouin and 40% of Jewish infants (P < 0.01). Bedouin infants had significantly lower serum concentration of iron, folic acid and zinc. All background, hematologic and micronutrient indicators were similar in the two study arms except for a slightly but not clinically significant difference in hemoglobin and hematocrit levels in Bedouins.

CONCLUSIONS

Our findings indicate the need to improve the micronutrient status of infants living in the Negev. A cluster randomized trial in MCH clinics is a feasible option.

Clinical and economic outcomes in a population-based European cohort of 948 ulcerative colitis and Crohn's disease patients by Markov analysis

BACKGROUND

Forecasting clinical and economic outcomes in ulcerative colitis (UC) and Crohn's disease (CD) patients is complex, but necessary.

AIMS

To determine: the frequency of treatment-classified clinical states; the probability of transition between states; and the economic outcomes.

METHODS

Newly diagnosed UC and CD patients, allocated into seven clinical states by medical and surgical treatments recorded in serial 3-month cycles, underwent Markov analysis.

RESULTS

Over 10 years, 630 UC and 318 CD patients had 22,823 and 11,871 cycles. The most frequent clinical outcomes were medical/surgical remission (medication-free) and mild disease (on 5-aminosalicylates, antibiotics, topical corticosteroids), comprising 28% and 62% of UC cycles and 24% and 51% of CD cycles respectively. The probability of drug-response in patients receiving systemic corticosteroids/immunomodulators was 0.74 in UC, 0.66 in CD. Both diseases had similar likelihood of persistent drug-dependency or drug-refractoriness. Surgery was more probable in CD, 0.20, than UC, 0.08. In terms of economic outcomes, surgery was costlier in UC per cycle, but the outlay over 10 years was greater in CD. Drug-refractory UC and CD cases engendered high costs in the cohort.

CONCLUSIONS

Most patients on 5-aminosalicylates, corticosteroids and immunomodulators had favourable clinical and economic outcomes over 10 years. Drug-refractory and surgical patients exhibited greater long-term expenses.

Suspected macrosomia? Better not tell

OBJECTIVE

To evaluate the management policy of delivery in a suspected macrosomic fetus and to describe the outcome of this policy.

STUDY DESIGN

For this prospective observational study we followed the management by reviewing the medical records of 145 women and their infants. The study population included women at term admitted to the obstetrics department with suspected macrosomic infants, as was diagnosed by an obstetrician and/or by fetal sonographic weight estimation of > or =4,000 g. The comparison group (n = 5,943) consisted of all women who gave birth during the data collection period.

RESULTS

Induction of labor and cesarean delivery rates in the macrosomic pregnancies (actual birth weight >4,000 g) of the study group were significantly higher when compared with the macrosomic pregnancies of the comparison group. When comparing the non-macrosomic to the macrosomic pregnancies (actual birth weight </>4,000 g) of the study group no significant difference was demonstrated regarding maternal or infant complications. The sensitivity, specificity and positive predictive value of the methods used for detecting macrosomia were 21.6, 98.6 and 43.5%, respectively.

CONCLUSION

Our ability to predict macrosomia is poor. Our management policy of suspected macrosomic pregnancies raises induction of labor and cesarean delivery rates without improving maternal or fetal outcome.

Effect of phenotype on health care costs in Crohn's disease: A European study using the Montreal classification

BACKGROUND

Crohn's disease (CD) is a chronic inflammation of the gastrointestinal tract associated with life-long high health care costs. We aimed to determine the effect of disease phenotype on cost.

METHODS

Clinical and economic data of a community-based CD cohort with 10-year follow-up were analyzed retrospectively in relation to Montreal classification phenotypes.

RESULTS

In 418 patients, mean total costs of health care for the behavior phenotypes were: nonstricturing-nonpenetrating 1690, stricturing 2081, penetrating 3133 and penetrating-with-perianal-fistula 3356 €/patient-phenotype-year (P<0.001), and mean costs of surgical hospitalization 215, 751, 1293 and 1275 €/patient-phenotype-year respectively (P<0.001). Penetrating-with-perianal-fistula patients incurred significantly greater expenses than penetrating patients for total care, diagnosis and drugs, but not surgical hospitalization. Total costs were similar in the location phenotypes: ileum 1893, colon 1748, ileo-colonic 2010 and upper gastrointestinal tract 1758 €/patient-phenotype-year, but surgical hospitalization costs differed significantly, 558, 209, 492 and 542 €/patient-phenotype-year respectively (P<0.001). By multivariate analysis, the behavior phenotype significantly impacted total, medical and surgical hospitalization costs, whereas the location phenotype affected only surgical costs. Younger age at diagnosis predicted greater surgical expenses.

CONCLUSIONS

Behavior is the dominant phenotype driving health care cost. Use of the Montreal classification permits detection of cost differences caused by perianal fistula.

Role of ASCA and the NOD2/CARD15 mutation Gly908Arg in predicting increased surgical costs in Crohn's disease patients: a project of the European Collaborative Study Group on Inflammatory Bowel Disease

BACKGROUND

NOD2/CARD15, the first identified susceptibility gene in Crohn's disease (CD), is associated with ileal stenosis and increased frequency of surgery. Anti-Saccharomyces cerevisiae antibody (ASCA), a serological marker for CD, is associated with ileal location and a high likelihood for surgery. We hypothesized that the presence of ASCA and NOD2/CARD15 mutations could predict increased health care cost in CD.

METHODS

CD patients in a prospectively designed community-based multinational European and Israeli cohort (n = 228) followed for mean 8.3 (SD 2.6) years had blood drawn for measurement of ASCA (IgG, IgA), Arg702Trp, Gly908Arg, and Leu1007fsinsC. Days spent in the hospital and the costs of medical and surgical hospitalizations and medications were calculated.

RESULTS

The median duration of surgical hospitalizations was longer in Gly908Arg-positive than -negative patients, 3.5 and 1.5 days/patient-year (P < 0.01), and in ASCA-positive than -negative patients, 1.1 and 0 days/patient-year (P < 0.001). Median surgical hospitalization cost was 1,580 euro/patient-year in Gly908Arg-positive versus 0 euro/patient-year in -negative patients (P < 0.01), and 663 euro/patient-year in ASCA-positive versus 0 euro/patient-year in -negative patients (P < 0.001). Differences in cost of medications between groups were not significant. The effect of Gly908Arg was expressed in countries with higher Gly908Arg carriage rates. ASCA raised surgical costs independently of the age at diagnosis of disease. Arg702Trp and Leu1007fsinsC did not affect the cost of health care.

CONCLUSIONS

Since CD patients positive for Gly908Arg and ASCA demonstrated higher health care costs, it is possible that measurement of Gly908Arg and ASCA at disease diagnosis can forecast the expensive CD patients.

Does dairy calcium intake enhance weight loss among overweight diabetic patients?

OBJECTIVE

To examine the effect of dairy calcium consumption on weight loss and improvement in cardiovascular disease (CVD) and diabetes indicators among overweight diabetic patients.

RESEARCH DESIGN AND METHODS

This was an ancillary study of a 6-month randomized clinical trial assessing the effect of three isocaloric diets in type 2 diabetic patients: 1) mixed glycemic index carbohydrate diet, 2) low-glycemic index diet, and 3) modified Mediterranean diet. Low-fat dairy product consumption varied within and across the groups by personal choice. Dietary intake, weight, CVD risk factors, and diabetes indexes were measured at baseline and at 6 months.

RESULTS

A total of 259 diabetic patients were recruited with an average BMI >31 kg/m2 and mean age of 55 years. No difference was found at baseline between the intervention groups in CVD risk factors, diabetes indicators, macronutrient intake, and nutrient intake from dairy products. Dairy calcium intake was associated with percentage of weight loss. Among the high tertile of dairy calcium intake, the odds ratio for weight loss of >8% was 2.4, P = 0.04, compared with the first tertile, after controlling for nondairy calcium intake, diet type, and the change in energy intake from baseline. No association was noted between dairy calcium and other health indexes except for triglyceride levels.

CONCLUSIONS

A diet rich in dairy calcium intake enhances weight reduction in type 2 diabetic patients. Such a diet could be tried in diabetic patients, especially those with difficulty adhering to other weight reduction diets.

Cost analysis and cost determinants in a European inflammatory bowel disease inception cohort with 10 years of follow-up evaluation

BACKGROUND & AIMS

Economic analysis in chronic diseases is a prerequisite for planning a proper distribution of health care resources. We aimed to determine the cost of inflammatory bowel disease, a lifetime illness with considerable morbidity.

METHODS

We studied 1321 patients from an inception cohort in 8 European countries and Israel over 10 years. Data on consumption of resources were obtained retrospectively. The cost of health care was calculated from the use of resources and their median prices. Data were analyzed using regression models based on the generalized estimating equations approach.

RESULTS

The mean annual total expenditure on health care was 1871 Euro/patient-year for inflammatory bowel disease, 1524 Euro/patient-year for ulcerative colitis, and 2548 Euro/patient-year for Crohn's disease (P < .001). The most expensive resources were medical and surgical hospitalizations, together accounting for 63% of the cost in Crohn's disease and 45% in ulcerative colitis. Total and hospitalization costs were much higher in the first year after diagnosis than in subsequent years. Differences in medical and surgical hospitalizations were the primary cause of substantial intercountry variations of cost; the mean cost of health care was 3705 Euro/patient-year in Denmark and 888 Euro/patient-year in Norway. The outlay for mesalamine, a costly medication with extensive use, was greater than for all other drugs combined. Patient age at diagnosis and sex did not affect costs.

CONCLUSIONS

In this multinational, population-based, time-dependent characterization of the health care cost of inflammatory bowel disease, increased expenditure was driven largely by country, diagnosis, hospitalization, and follow-up year.

Risk factors for early neonatal sepsis

OBJECTIVE

The aim of this study was to identify maternal risk factors for early neonatal sepsis and perinatal outcome in a population of very low birth-weight newborns.

STUDY DESIGN

During January 1995 to December 2000, 786 live preterm neonates were born in our institute with birth-weight < or =1,500 g. A cross-sectional study was designed and two groups were identified: 50 neonates who developed early neonatal sepsis and 736 neonates without early sepsis.

RESULTS

The prevalence of early sepsis among the neonates was 6.3% (50/786). The following maternal risk factors were significantly associated with early neonatal sepsis: advanced maternal age, high gravidity, the administration of multiple courses of prenatal steroids and tocolytic agents, (i.e., magnesium and indomethacin) and chorioamionitis with premature rupture of membranes. Using a multivariate analysis, the use of tocolytic drugs was found as an independent risk factor for early neonatal sepsis (OR=4.8; 95% CI 1.1-1.6; P=0.019) and so was low gestational age (OR 0.98; 95% CI 0.007-0.017; P=0.017). The following variables of the neonate were significantly associated with early neonatal sepsis: low birth-weight, umbilical blood pH of less than 7.2 and the use of oxygen.

CONCLUSIONS

The use of tocolytic drugs and low gestational age are independent risk factors for early neonatal sepsis.

Diet and eating habits in high and low socioeconomic groups

OBJECTIVE

We measured the difference of dietary intake and eating habits across socioeconomic statuses (SESs) in Israel.

METHODS

Participants were randomly recruited from three high SES municipalities and three low SES municipalities in the Negev. Participants were interviewed at home with 24-h food questionnaires that included additional questions regarding health and eating habits. Nutrient and energy intakes were compared between groups, as were major contributors to the energy and food groups.

RESULTS

One hundred sixteen participants from the high SES group and 206 from the low SES entered the study. Those in the low SES group were older, heavier, less educated, and less physically active. Dietary intake among the participants in the low SES group was significantly lower in protein, monounsaturated fat, and most vitamins and minerals (thiamine, riboflavin, niacin, vitamin C, calcium, magnesium, and iron). Conversely, vitamin E intake was higher in the low SES group. In the low SES group, the main contributors to energy intake were breads, oils, and sugars. Oils, fats, and citrus fruits were consumed more among subjects in the low SES group, whereas dairy products, grains, and legumes were consumed less by subjects in the high SES group.

CONCLUSION

In a detailed survey conducted in two distinct populations, we found poorer diet quality in the low SES group. The root causes for such divergence need further study. As smoking declines in the modern world, nutrition will become the key risk factor in many diseases. Further research and educational and legislative initiatives are needed to curtail this risk.

Factors associated with low reported energy intake in the elderly

BACKGROUND

Underreporting of dietary intake can be estimated by the Energy Ratio (ER) between reported energy intake (EI) and calculated total energy expenditure (TEE). The gap between EI and TEE is usually attributed to underreporting. In elderly populations, compromised dietary intake and health status may offer alternative explanations to this gap.

OBJECTIVE

This study aimed to characterize "underreporting" of dietary intake and low energy reporters (LER) among the elderly.

DESIGN

Participants aged 65 years and over, were recruited using random population sampling of the Negev population. Data were collected using the 24-h recall method with additional demographic and age-specific health questionnaires. ER was calculated using the ratio between reported energy intake and calculated TEE computed by the Schofield formula. LER were defined as those with reported energy intake of less than 0.8 calculated BMR using the Schofield formula.

RESULTS

We restricted our analysis to 191 elderly aged 65-74 y and 177 aged 75 y and older who reported their diet to be "as usual." In univariate analyses, BMI < 22, better health status, use of fewer than four medications and good reported appetite were significantly related to higher ER. No difference was shown in ER by gender, level of education, and family status. Weight loss superior 5 kg was associated with low ER (p = 0.049). In a linear regression model, low ER (indicating "underreporting") was significantly associated with higher activity level and use of over four medications. Using a dichotomous approach, Low Energy Reporters (LER) used a higher number of medications, ate fewer food items per day and suffered from poorer appetite.

CONCLUSIONS

In the elderly, ER < 1 may indicate underreporting in dietary intake, and indeed, is frequent among the obese. Nonetheless, among the elderly, ER < 1 may reflect truly low caloric intake. Our results suggest that, to some degree, health status variables are associated with decreased ER, supporting a true caloric deprivation state.

Mediterranean diet and cardiovascular diseases in an Israeli population

BACKGROUND

Israel is in the Mediterranean basin, but its population immigrated mostly from Europe, Asia, and Africa. We surveyed the adherence of the Israeli Jewish population to Mediterranean Diet (MD) and its association with cardiovascular disease.

METHODS

We studied a random sample of Jewish adults, aged 35+ using a 24-h recall questionnaire. A MD score (scale 0-8) was computed reflecting high ratio of monounsaturated to saturated fat; high intake of alcohol, legumes, cereals, vegetables, and fruits; low intakes of meat and it's products, milk and dairy products. Scoring <5 was defined as Low-MD consuming, while 5+ as High-MD consuming.

RESULTS

Five hundred twenty men and 639 women participated in the study, with High-MD consumers constituting 19% and 17% by sex, respectively. The risk for myocardial infarction, coronary bypass, angioplasty, and any cardiovascular disease in men increased by 1.2 (P = 0.04), 1.6 (P = 0.01), 1.4 (P = 0.003), and 1.3 (P = 0.01), respectively, for each MD score decrease. In women, crude odds ratios ranged from 1.4 to 1.9 but were not statistically significant.

CONCLUSIONS

The current rate of MD in Israel is fairly low. Given the MD's proven preventive effect and local availability of foods, a reasonably priced MD diet can be devised and recommended widely in our population.

Selection of food items for inclusion in a newly developed food-frequency questionnaire

OBJECTIVES

To highlight the differences between the food list required in a food-frequency questionnaire (FFQ) to rank people by their intake and the food items that contribute to absolute intake, and to discuss possible applications.

METHODS

We conducted a nutritional survey among 1173 adults using an adapted 24-hour recall questionnaire.

STATISTICAL ANALYSIS

To develop an FFQ, we analysed the 24-hour recall survey data by performing a stepwise multiple regression after grouping conceptually similar food items into 175 food groups.

RESULTS

In total, 126 food groups were included in the developed FFQ in order to explain at least 80% of the variance in the consumption of each of 27 nutrients. The nutrients that were explained by a few food groups were vitamin A (one food group), alcohol (two), beta-carotene (two), vitamin E (three) and cholesterol (five). Nutrients that were explained by a large number of food groups were energy (37 food groups), potassium (31), magnesium (31), dietary fibre (30), phosphorus (31) and sodium (29). Using energy intake as an example, soft drinks were the best between-person energy classifiers, while providing only 2.4% of the total energy intake. Wine, seeds and nuts, which contributed highly to the variance, were minor energy contributors. In contrast, milk, sugar, fried chicken/turkey breast or whole chicken/turkey, which explained little of the variation in the population, were major energy contributors.

CONCLUSIONS

Developing an FFQ on the basis of common foods may not explain the between-person variation required for ranking individual intake in diet-disease studies. Producing lists of "discriminating items" can be a useful application in developing mini-FFQs for selected nutrients.

Development of a food frequency questionnaire (FFQ) for an elderly population based on a population survey

Older people have different eating patterns than their younger counterparts, although in most nutritional studies of older populations, food frequency questionnaires (FFQ) that were developed and validated for the general adult population are used. In this paper, we present the advantages of developing an FFQ for an older population based on a population survey. A random sample of the Negev's (Southern Israel) Jewish population > or = 35 y old was recruited and interviewed for their dietary intake using 24-h recalls. Foods eaten were aggregated into conceptually similar groups and entered into stepwise regression models to predict variation in nutrient intake. We interviewed 796 people age 35-64 y and 377 people > or = 65 y old for the study. Significantly more items were required to reach 80% between-person variability for zinc, magnesium, vitamin E and protein for the elderly compared with the younger age group. Portion sizes of most items consumed by the elderly were smaller compared with the Israeli Ministry of Health portion sizes booklet and the younger age group's intake estimates. The nutrient values assigned for each line based on a weighted mean of the intake of the elderly were different from those using the most frequently used item. The above findings highlight some of the advantages of developing an FFQ for an older population based on a population survey. Further studies are required to compare the validity of existing tools adapted for the elderly to those developed on the basis of population surveys.

Risk factors for recurrent preterm delivery

OBJECTIVE

To identify risk factors for recurrent preterm delivery among primiparous women with previous preterm delivery.

STUDY DESIGN

A retrospective case-control study was designed: 152 primiparous women who delivered preterm (22-36 weeks) were divided into two groups: 81 had a second preterm delivery (study group) and 71 had a second-term delivery (control group). Exclusion criteria were induced preterm delivery, hydramnions and multiple gestations.

RESULTS

Comparing second preterm delivery before 34 weeks (n = 36) to the second delivery of the control group, higher rates of hospitalization due to preterm labor were noted in the study versus the control group (52.8% versus 16.9%,P = 0.001). The interval between pregnancies was shorter in the study subgroup, before 34 weeks gestational age, versus the controls (20.1 +/-15.7 months versus 28.9 +/- 18.7 months, P = 0.011). Multiple regression analyses, adjusted for confounding variables, found the occurrence of preterm labor and short interval between pregnancies, especially up to 12 months, as independent risk factors for the recurrence of preterm delivery (OR = 4.98; P , 0.001; OR = 5.13; P = 0.007, respectively).

CONCLUSION

When adjusted for confounding variables, short interval between pregnancies is an independent risk factor for recurrent preterm delivery.

Development of a semi-quantitative Food Frequency Questionnaire (FFQ) to assess dietary intake of multiethnic populations

The Food Frequency Questionnaire (FFQ) is one of the most commonly used methods in epidemiological studies to assess long-term nutritional exposure. The purpose of this study is to develop a general FFQ for the Israeli population and present the procedures undertaken to select foods to be included in a questionnaire for a multiethnic population. Random population cluster sampling was done using voter registration lists of the Negev Jewish population, aged 35 years and over, which were divided into three groups based on where they were born, namely: Israel, Asia Africa and Europe-America. Participants were interviewed for their dietary intake using 24 hour recalls. Foods eaten by our subjects were aggregated into conceptually similar food groups and entered in stepwise regression models to predict variation in nutrient intake. Separate models were created for each origin group. It was found that the dietary intake was significantly lower for energy and vitamin E among European-American born subjects and significantly lower for calcium intake among Asian-African born subjects. Differences between ethnic groups were seen in the list of foods, which explained the between-person variability for energy and zinc. For most nutrients, fewer items were needed to explain the between-person variation in the group of people born in Israel. The final list of foods included 126 items and explained over 90% of the between-person variability in selected nutrients for all three groups. The newly developed FFQ for the Negev population includes 126 items that are sufficient to rank the nutritional exposure of people over 35 years old from the three origin groups in Israel.

Adaptation of international nutrition databases and data-entry system tools to a specific population

OBJECTIVE

To develop a nutritional dietary intake database based on available reliable international nutritional databases adapted to the local needs of a specific population.

DESIGN

The Negev Nutritional Study (NNS) is a survey of a random sample of the Negev population regarding their dietary intake using 24-hour dietary recalls. A nutritional database for the Israeli population was developed based on adaptation and modification of the US Department of Agriculture's database. A data-entry system was developed based on the logic of the US Food Information Analysis System. The system was designed as bilingual (English and Hebrew). Local foods and recipes were collected during the NNS, which included 1465 24-hour diet interviews.

RESULTS

During the course of the NNS, 383 basic Israeli recipes were constructed. In total 1362 Israeli products were added to the database, and each was given a code, specific gravity and portion size. Most of the added products were cereals and grains and dairy products. The added recipes were collected from the interviewees in the NNS and from the most popular cookbooks.

CONCLUSIONS

This paper describes the process undertaken to develop an Israeli food composition database as well as the data-entry system. This knowledge may aid other research groups in developing a computerised, nation-specific nutritional database and data-entry system adapted to their own specific local needs.

Dietary intake and eating patterns of elderly people in Israel: who is at nutritional risk?

OBJECTIVE

To determine dietary intake and eating patterns of older persons in Israel and to identify factors associated with low intake.

DESIGN

A cross-sectional study.

SETTING

Community-dwelling participants living in the Beer-Sheva area were interviewed at home, using a 24 h food questionnaire with additional questions regarding health and eating habits. Dietary intake was compared between people aged 65-74 and 75 y and older.

SUBJECTS

A total of 377 people over the age of 65 224 aged 65-74 and 153>75, were randomly selected from the Negev population.

RESULTS

Dietary intake of energy, fat, carbohydrates, vitamins E, C and B(1) were significantly lower for people aged 75 and older compared with people aged 65-74. Low energy intake was associated with lower subjective health status for men (P<0.01), poor appetite (P<0.01) and more gastrointestinal problems (P<0.05) for women and lower snack consumption (P<0.01) for both genders. In a multivariate model, low energy intake was associated with low appetite and higher use of medication for both sexes and with frequency of eating alone and not consuming snacks for men.

CONCLUSIONS

Dietary intake is lower among individuals older than 75 than in 65-74 y old. Risk factors for low intake include poor appetite and health status, gastrointestinal problems, and eating alone. Snacking enhanced dietary intake and should be encouraged in this group.

Negev nutritional studies: nutritional deficiencies in young and elderly populations

The importance of nutrition to public health and preventive medicine is evident. Undernutrition is a main nutritional risk factor in the elderly and has been established as a cause of excess morbidity and mortality in different segments of the older population. In the infant population, inadequate nutrition is one of the causes of iron-deficiency anemia, which is associated with impaired physical and cognitive development and lowered immunity. The aim of this paper was to estimate the nutritional pattern and micronutrient deficiencies in elderly and young populations in the Negev. In southern Israel, 351 subjects over 64 years old reported mean dietary intake that was lower than that in younger persons and was independent of the presence of chronic diseases. Current data from southern Israel on healthy Jewish children revealed anemia prevalence of 15% in the second year of life. Data from recent prospective study on Bedouin children showed that anemia affected one quarter of children at age one year. Thus, infants in this area are at high risk for iron deficiency. The findings require the attention of public health authorities and food manufacturers, and should result in a range of activities including publicity and educational programs, fortification of foods, and supplementation programs in high risk-groups.

[Premature delivery in diabetes: etiology and risk factors]

Preterm birth is the leading cause of perinatal morbidity and mortality, while preterm labor and delivery in diabetes mellitus (DM) carries an increased risk of perinatal complications. We investigated the hypothesis that DM (gestational and pregestational) is an independent risk factor for preterm birth and evaluated the hypothesis that the risk factors for preterm birth in diabetics are different from those in non-diabetics. The study population consisted of all singleton deliveries at this hospital between 1990-1997. Excluded were those of mothers who had not had prenatal care, or who had only partial care or multiple gestations. There were 3 subgroups: 834 women with pregestational DM, 3,841 with gestational DM, and 66,253 non-diabetics. The combined spontaneous and induced preterm delivery rate was determined in each subgroup. Potential risk factors for spontaneous preterm deliveries were assessed by a univariate model. A logistic regression model was used to assess the unique contribution of DM (gestational and pregestational) to preterm delivery in the presence of the other risk factors, and to compare risk factors for preterm delivery between subgroups. The prevalence of spontaneous preterm delivery was: 7.1% in non-diabetics, 10.0% in those with gestational DM and 25.5% in those with pregestational DM. When adjusted by a multivariate model for other risk factors for preterm delivery, DM still remained an independent risk factor for spontaneous preterm delivery (gestational DM: odds ratio 1.28, 95% CI: 1.1-1.48; pregestational diabetes: odds ratio 3.4, 95% CI: 2.65-4.36). The main difference in risk factors for preterm birth between the 3 subgroups was the amount of amniotic fluid. Polyhydramnios was an independent risk factor for preterm delivery in non-diabetics and in pregestational DM, but not in gestational DM. On the other hand, oligohydramnios was associated with a higher risk for preterm delivery only in gestational DM compared to non-diabetics. DM (gestational and pregestational) is an independent risk factor for spontaneous preterm delivery. Polyhydramnios is an independent risk factor for preterm delivery in pregestational but not in gestational DM. Oligohydramnios is a greater risk factor for preterm delivery in gestational DM compared to non-diabetics.

Congenital anomalies are an independent risk factor for neonatal morbidity and perinatal mortality in preterm birth

OBJECTIVE

To determine whether congenital anomalies are associated with a high rate of neonatal morbidity in preterm birth.

STUDY DESIGN

312 singletons (22-36 wk) with congenital anomalies that were delivered preterm were compared with a random sample of 936 preterm singleton without congenital anomalies. Data was obtained using the computerized birth discharge records. Statistical analysis included univariate and multivariate logistic regression analyses.

RESULTS

Three thousand five hundred and seventy-eight (3578) women with preterm births met the inclusion criteria (singleton with prenatal care). The prevalence of congenital anomalies in the study population was 8.7% (312/3578). Gestational age at delivery was significantly lower in the congenital anomaly group compared with the control (32.0+/-3.7 SD vs. 34.4+/-2.7 SD; p<0.001). The following pregnancy complications were higher in the group with congenital anomalies than in those without anomalies: severe pregnancy induced hypertension (PIH), hydramnions, oligohydramnion, intrauterine growth restriction (IUGR), fetal distress, cesarean section, malpresentation and mal position, abruption placenta, meconium stained amniotic fluid, 1 min Apgar score (<2), 5 min Apgar score (<7). Perinatal mortality rates in 28-32 wk and 33-36 wk were significantly higher in the group with congenital anomalies than in the control group. Neonatal morbidity data (necrotizing enterocolitis, respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, and sepsis) was available for 909 neonates (239 with congenital anomalies and 670 without congenital anomalies). After adjusting for gestational age, the presence of congenital anomalies remained strongly associated with neonatal morbidity (having one or more of the above mentioned conditions) (adjusted OR: 5.3, 95% CI 3.4-9.2). When adjusting for other confounding variables, congenital anomalies were strongly associated with neonatal morbidity (OR: 6.44, 95% CI 3.94-10.51), and perinatal mortality (OR: 3.08, 95% CI 2.04-4.65). In terms of attributable fraction in our population of preterm births, the proportion of neonatal morbidity and the proportion of perinatal mortality attributable to congenital malformation is 32% and 15%, respectively.

CONCLUSION

Congenital anomalies in preterm birth are associated with a higher rate of pregnancy complications and are an independent risk factor for neonatal morbidity and perinatal mortality.

Perinatal outcome and peripartum complications in preterm singleton and twins deliveries: a comparative study

OBJECTIVE

Multiple pregnancy is one of the major risk factors for preterm births. The aim of the present study was to compare perinatal outcome and peripartum complications between twins and singletons, born preterm.

STUDY DESIGN

The study population consisted of preterm deliveries of 435 pairs of twins (870 neonates) and the comparison group included 4754 preterm deliveries of singletons, born in the same period (January 1, 1989-December 31, 1996). Exclusion criteria were lack of prenatal care and births following infertility treatments. The three steps in statistical analysis consisted of (1) degree of concordance between the twins; (2) comparison between each twin (I and II) to their singleton comparison groups using SPSS computer program; (3) stratified analysis to examine perinatal mortality rates at different gestational age groups.

RESULTS

The prevalence of preterm deliveries was 7.9% (6192/77610). Perinatal mortality was lower in twins of both birth orders, however, it was statistically significant only when APD is considered. Mortality rates in all gestational age groups and for both twin groups were lower than that of singleton [OR=0.45 (0.26-0.75; 95% CI) for twin-I; OR=0.36 (0.21-0.59; 95% CI) for twin-II]. Compared to singletons, twin gestations had less congenital malformations. Twin gestation had statistically lower rates of preterm premature rupture of membranes, severe pregnancy induced hypertension, oligohydramnios, placenta previa, placental abruption and clinical chorioamnionitis [12.2 vs.17.3%, 2.5 vs. 6.3%, 2.3 vs. 4.7%, 0.9 vs. 2.9%, 1.8 vs. 5%, 1.8 vs. 5.2%, respectively (P<0.01)]. Mothers of twins had less diabetes mellitus class B-R, hydramnios and chronic hypertension than that of singleton (1.8 vs. 2.6%, 5.5 vs. 7.4%, 3.7 vs. 4.8%, respectively). Cesarean section rates were significantly higher in twin's gestation. Mothers of twins tended to be older and of higher birth and gravidity order.

CONCLUSIONS

Perinatal mortality rates and peripartum complications were lower in twin compared to singleton gestations.

Quantitative determinations of microcytic-hypochromic red blood cell population and glycerol permeability in iron-deficiency anemia and beta thalassemia minor

The Hl/H2 Technicon automated cell analyzer measures, in addition to the usual red blood cell (RBC) parameters, subpopulations of microcytic (M) and hypochromic (H) red blood cells. The M/H ratio may be useful in the differential diagnosis of iron-deficiency anemia (IDA) and beta thalassemia minor (Thal). Thirty-three iron-deficient patients and 26 thalassemia patients were studied. The M/H ratio was found to be higher in thalassemia patients than in IDA patients. Using a cut-off point of 1.9 M/H ratio, the calculated discriminant efficiency was 88%. When glycerol lysis values were determined at 70 s as a cut-off point, the discriminant efficiency was slightly higher, at 91%. Thus, the combination of the M/H ratio and the glycerol lysis time (GLT) improves the discriminant efficiency and provides a good diagnostic tool to differentiate between the two microcytic-hypochromic anemias. The study suggests that the M/H ratio together with the GLT could serve as a useful screening tool, prior to the application of other more sophisticated methods.

Obstetric outcome of singleton pregnancies conceived by in vitro fertilization and ovulation induction compared with those conceived spontaneously

OBJECTIVE

To compare the obstetric characteristics of singleton pregnancies conceived by IVF and ovulation induction with those conceived spontaneously.

DESIGN

Case-control study.

SETTING

Tertiary care medical center.

PATIENT(S)

All singleton pregnancies that were achieved by IVF (n = 169) and ovulation induction (n = 646) and were delivered from January 1989 through December 1994 were evaluated. Each group was compared with a separate control group that conceived spontaneously (n = 469 and n = 1,902 for the IVF and ovulation induction groups, respectively) and delivered during the same period and was matched in terms of maternal age, gestational age, and parity.

INTERVENTION(S)

Ovulation induction, IVF-ET.

MAIN OUTCOME MEASURE(S)

Obstetric complications.

RESULT(S)

Multivariate analysis showed that patients who conceived by IVF and ovulation induction had a significantly higher risk for gestational diabetes mellitus (odds ratio [OR] = 2.0; 95% confidence interval [CI] = 1.23-3.30 and OR = 1.9, 95% CI = 1.09-1.79, respectively), pregnancy-induced hypertension (OR = 2.1, 95% CI = 1.04-4.10 and OR = 1.5, 95% CI = 1.04-2.02, respectively), and cesarean section (OR = 3.6, 95% CI = 2.44-5.29 and OR = 1.4, 95% CI = 1.09-1.79, respectively) compared with their matched controls.

CONCLUSION(S)

After controlling for maternal age, gestational age, and parity, we demonstrated that singleton pregnancies conceived by IVF and ovulation induction are at increased risk for maternal gestational diabetes mellitus and pregnancy-induced hypertension, and at greater risk for delivery by cesarean section.

A new computer program for mass screening of visual defects in preschool children

AIMS

To test the effectiveness of a PC computer program for detecting vision disorders which could be used by non-trained personnel, and to determine the prevalence of visual impairment in a sample population of preschool children in the city of Beer-Sheba, Israel.

METHODS

292 preschool children, aged 4-6 years, were examined in the kindergarten setting, using the computer system and "gold standard" tests. Visual acuity and stereopsis were tested and compared using Snellen type symbol charts and random dot stereograms respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and kappa test were evaluated. A computer pseudo Worth four dot test was also performed but could not be compared with the standard Worth four dot test owing to the inability of many children to count.

RESULTS

Agreement between computer and gold standard tests was 83% and 97.3% for visual acuity and stereopsis respectively. The sensitivity of the computer stereogram was only 50%, but it had a specificity of 98.9%, whereas the sensitivity and specificity of the visual acuity test were 81.5% and 83% respectively. The positive predictive value of both tests was about 63%. 27.7% of children tested had a visual acuity of 6/12 or less and stereopsis was absent in 28% using standard tests. Impairment of fusion was found in 5% of children using the computer pseudo Worth four dot test.

CONCLUSIONS

The computer program was found to be stimulating, rapid, and easy to perform. The wide availability of computers in schools and at home allow it to be used as an additional screening tool by non-trained personnel, such as teachers and parents, but it is not a replacement for standard testing.

Hospitalizations for infectious diseases in Jewish and Bedouin children in southern Israel

Two different population groups reside in the Negev region of southern Israel and have equal, and free from financial barrier, access to tertiary care at a single regional hospital. The Jewish population has a largely urban and industrialized lifestyle, while the Moslem Bedouins are in transition from their traditional nomadic life to settlement. To examine the differences in morbidity patterns reflected in hospitalizations, the computerized hospitalization records of children <15 years of age, for 1989-1991 were used (n=15,947). Rates of hospitalizations for infectious diseases were significantly higher for Bedouins in comparison to Jews (250 and 121/10,000 child years, respectively, odds ratio (OR): 2.1, 95% confidence interval (CI): 2.0-2.2, p < 0.001). Rates of hospitalization per 10,000 child years in Bedouins and Jews for diarrhea were 114 and 32 (OR: 3.7, 95% CI: 3.3-4.0, p < 0.001), respectively, and for pneumonia 55 and 19 (OR: 2.9, 95% CI: 2.6-3.3, p < 0.001), respectively. In infants the differences were even more pronounced, especially for diarrheal diseases. In Bedouin children infectious diseases were associated with longer hospital stay, more pediatric Intensive Care hospitalizations (OR: 2.7, 95% CI: 1.7-4.5,p < 0.001), and higher in-hospital mortality (OR: 5.7, 95% CI: 2.8-12.2, p < 0.001). Thus, Bedouin children are at higher risks of hospitalizations for infectious diseases in early childhood, as compared to Jewish children. This may reflect the differences in lifestyle, environmental and social conditions of the two populations.

Polyhydramnios is an independent risk factor for perinatal mortality and intrapartum morbidity in preterm delivery

OBJECTIVE

To investigate the clinical significance of polyhydramnios as a predictor of perinatal death and intrapartum morbidity in patients with preterm delivery.

STUDY DESIGN

The study population consisted of 4211 patients with singleton gestation, intact membranes and preterm delivery (< 37 weeks). Two groups were identified and compared according to the sonographic assessment of the amniotic fluid volume: increased and normal amniotic fluid. Analyses were conducted for the entire cohort as well as for the cohort excluding from each group all cases with congenital malformations. Logistic regression was used to assess the unique contribution of polyhydramnios to mortality and morbidity in the presence of other known risk factors.

RESULTS

The prevalence of polyhydramnios among women who delivered preterm was 5% (210/4211) including and 3.7% (142/3818) excluding the cases of congenital malformations, respectively. Polyhydramnios was associated with a higher rate of diabetes, large for gestational age neonates, fetal malpresentation at delivery, previous perinatal death and with a lower Apgar score at 1 and 5 min. Polyhydramnios was an independent predictor of perinatal mortality and intrapartum morbidity. When adjusted for well recognized risk factors for perinatal mortality and intrapartum morbidity (e.g. diabetes, severe pregnancy induced hypertension, multiparity, congenital malformation, previous perinatal death, low gestational age at delivery), the presence of polyhydramnios significantly increased the rate of perinatal mortality (odds ratio (OR) 5.8; 95% confidence interval (CI) 3.68-9.11) and of intrapartum morbidity (OR 2.8; 95% CI 1.94-4.03).

CONCLUSION

In the setting of preterm delivery, polyhydramnios is an independent risk factor for perinatal mortality and intrapartum complications even in the absence of congenital malformation and other conditions traditionally associated with increased perinatal mortality and morbidity.

Intra-uterine infection in women with preterm premature rupture of membranes: maternal and neonatal characteristics

OBJECTIVE

Our purpose was to determine the prevalence of intra-uterine infection in patients with preterm premature rupture of membranes and to evaluate the clinical characteristics of women and neonates according to the presence or absence of intrauterine infection.

STUDY DESIGN

Trans-abdominal amniocentesis was performed in 90 consecutive patients admitted with preterm premature rupture of membranes. Maternal clinical parameters evaluated included maternal age, origin, gravidity, parity, habitual abortion, previous perinatal death, previous preterm birth, urinary tract infection, fetal distress, abruptio placentae, gestational diabetes, admission-delivery interval and cesarean rate. Neonatal clinical parameters evaluated were gestational age at delivery, birth weight, Apgar score, neonatal gender, perinatal death and neonatal sepsis.

RESULTS

The prevalence of intra-uterine infection was 66.6% (60/90). No differences between patients with intra-uterine infection and those without intra-uterine infection were observed in maternal age, origin, gravidity, parity, habitual abortion, previous perinatal death, fetal distress, abruptio placentae, gestational diabetes, admission-delivery interval, cesarean section, neonate's gender, Apgar score at 5 min and neonatal sepsis. On the other hand, gestational age at delivery, birth weight and Apgar score at 1 min were significantly different between the groups.

CONCLUSION

An intra-uterine infection was found in two thirds of women presenting with preterm premature rupture of membranes. Women presenting with preterm premature rupture of membranes and intra-uterine infection had a lower gestational age at delivery and consequently had a lower neonatal birth weight than those without intra-uterine infection.

Esophageal carcinoma in Indian Jews of southern Israel. An epidemiologic study

The incidence of esophageal cancer varies in different populations and localities. The varied composition of the immigrant population of southern Israel afforded us an opportunity to investigate the frequency of the disease. The results of a retrospective study (1961-1985) revealed a high mean age-adjusted incidence rate (per 10(5)) in immigrant Indian men (6.5 +/- 2.17) and Indian women (17.2 +/- 5.12). Rates in all non-Indian immigrants were significantly lower: men 2.7 +/- 1.19, women 2.1 +/- 0.24. The relative risk of developing the disease was significantly higher in Indians. The age at diagnosis was lower in Indian women (54.6 +/- 10.4 years) than Indian men and other immigrants (p less than 0.05). The clinical features were similar in all cases. The risk factors in Indian men were not apparent; in women, the indiscrete use of spices might have raised the rate of esophageal cancer. The disease is more frequent in Indian populations in several parts of the world, and vigilance is required on the part of physicians.