A multifaceted training tool to reduce weight bias among healthcare students: A randomized controlled trial

BACKGROUND

Weight bias toward people with obesity (PwO) is common in healthcare settings. Efforts to address weight bias in healthcare settings should begin during university studies. This study aimed to explore the effect of a multifaceted intervention on weight bias among undergraduate healthcare students.

METHODS

An open label randomized controlled trial. The intervention tool consisted of short video lectures on obesity, vignettes simulating interactions between health professionals and PwO, and open discourse with a PwO. The control group received a short-written document on obesity. Online questionnaires on Anti-Fat Attitudes ('AFA'), short form of the Fat-Phobia Scale ('FPS'), Weight Implicit Association Test ('Weight-IAT'), and knowledge about obesity were administered at baseline, 1-week, and 6-week post-intervention.

RESULTS

A total of 162, 152, and 146 students participated in the study at baseline, 1-week, and 6-week post-intervention, respectively. Their mean age was 25.8 ± 6.7 years and 88.3% were women. Means of AFA total scores and FPS scores decreased significantly over time only within the intervention group (P Time*Group = 0.002 and 0.014). Both groups showed a similar trend over time in mean scores of Weight-IAT (P Time*Group = 0.868) and knowledge about obesity (P Time*Group = 0.115).

CONCLUSIONS

A multifaceted intervention resulted in a significant reduction in explicit weight bias but did not yield any additional advantages over the control group in implicit weight bias and knowledge about obesity.

CLINICALTRIALS

GOV NUMBER

NCT05482802.

Systematic Review and Meta-Analysis: Malnutrition and In-Hospital Death in Adults Hospitalized with COVID-19

BACKGROUND

Malnutrition and increased malnutrition risk are frequently identified in hospitalized adults. The increase in hospitalization rates during the COVID-19 pandemic was accompanied by the documentation of adverse hospitalization outcomes in the presence of certain co-morbidities, including obesity and type 2 diabetes. It was not clear whether the presence of malnutrition increased in-hospital death in patients hospitalized with COVID-19.

OBJECTIVES

To estimate the effect of malnutrition on in-hospital mortality in adults hospitalized with COVID-19; and secondarily, to estimate the prevalence of malnutrition in adults hospitalized with malnutrition during the COVID-19 pandemic.

METHODS

EMBASE, MEDLINE, PubMed, Google Scholar, and Cochrane Collaboration databases were queried using the search terms malnutrition and COVID-19 and hospitalized adults and mortality. Studies were reviewed using the 14-question Quality Assessment Tool for Studies with Diverse Designs (QATSDD) (questions appropriate for quantitative studies). Author names; date of publication; country; sample size; malnutrition prevalence; malnutrition screening/diagnostic method; number of deaths in malnourished patients; and number of deaths in adequately nourished patients were extracted. Data were analyzed using MedCalc software v20.210 (Ostend, Belgium). The Q and I² tests were calculated; a forest plot was generated, and the pooled odds ratio (OR) with 95% confidence intervals (95%CI) were calculated using the random effects model.

RESULTS

Of the 90 studies identified, 12 were finally included in the meta-analysis. In the random effects model, malnutrition or increased malnutrition risk increased odds of in-hospital death by more than three-fold: OR 3.43 (95% CI 2.549-4.60), p < 0.001. The pooled prevalence estimate for malnutrition or increased malnutrition risk was 52.61% (95% CI 29.50-75.14%).

DISCUSSION AND CONCLUSIONS

It is clear that malnutrition is an ominous prognostic sign in patients hospitalized with COVID. This meta-analysis, which included studies from nine countries on four continents with data from 354,332 patients, is generalizable.

The Effect of Percutaneous Endoscopic Gastrostomy on Prognosis of Patients at Risk of Malnutrition

BACKGROUND

Despite its wide use, evidence is inconclusive regarding the effect of percutaneous endoscopic gastrostomy (PEG) in patients with chronic diseases and dementia among hospitalized patients with malnutrition.

OBJECTIVES

To examine the effect of PEG insertion on prognosis after the procedure.

METHODS

This retrospective analysis of medical records included all adult patients who underwent PEG insertion between 1 January 2009 and 31 December 2013 during their hospitalization. For each PEG patient, two controls similar in age, sex, referring department, and underlying condition were randomly selected from the entire dataset of patients admitted. The effect of PEG on mortality and repeated admissions was examined.

RESULTS

The study comprised 154 patients, 49 referred for PEG insertion and 105 controls (mean age 74.8 ± 19.8 years; 72.7% females; 78.6% admitted to internal medicine units). Compared to controls, the PEG group had a higher 2-year mortality rate (59.2% vs. 17.1%, P < 0.001) but the 2-year readmission rate did not differ significantly (44.9% vs. 56.2% respectively, P = 0.191). Regression analysis showed PEG was associated with increased risk of the composite endpoint of death or readmission (hazard ratio 1.514, 95% confidence interval 1.016-2.255, P = 0.041). No specific characteristic of admission was associated with increased likelihood of death or readmission. Among readmitted patients, reasons for admission and baseline laboratory data, including albumin and cholesterol, did not differ between the PEG patients and controls.

CONCLUSIONS

In-hospital PEG insertion was associated with increased mortality at 2 years but had no effect on readmissions.

Outcomes of ICU patients treated with intravenous immunoglobulin for sepsis or autoimmune diseases

OBJECTIVES

To evaluate the outcomes of hospitalized patients in two intensive care units (ICU) treated with intravenous immunoglobulin (IVIg) added to standard-of-care therapy. The indications for IVIg therapy were sepsis or autoimmune disease.

METHODS

We conducted a retrospective study involving adult patients with sepsis and autoimmune diseases, who received IVIg in the ICU at Wolfson and Sheba Medical Centers. A predefined chart was compiled on Excel to include a complete demographic collection, patient comorbidities, chronic medication use, disease severity scores (Charlson Comorbidity Index; SOFA and APACHE II index scores), indication and dosage of IVIg administration, duration of hospitalization and mortality rates.

RESULTS

Patients (n - 111) were divided into 2 groups: patients with sepsis only (n-67) and patients with autoimmune disease only (n-44). Septic patients had a shorter ICU stay, received IVIg early, and had reduced mortality if treated with high dose IVIg. Patients with autoimmune diseases did not have a favorable outcome despite IVIg treatment. In this group, IVIg was administered later than in the sepsis group.

CONCLUSIONS

IVIg therapy improved the outcomes for ICU patients with sepsis.

Opportunities and challenges in delivering remote primary care during the Coronavirus outbreak

Background

Social distancing and lockdowns were implemented during the first period of the COVID-19 pandemic. Primary care physicians needed to adapt quickly to deliver remote care/telemedicine.

Methods

A cross-sectional, 47-item online Google Survey was distributed through the Israel Association of Family Physicians (IAFP) mailing list between March 31-May 5, 2020. The questionnaire included demographics, physician characteristics, and information on usage and perceived telemedicine quality. Sampling weights by sex and age groups were applied.

Results

One hundred fifty-nine primary care physicians (10.6% of registered IAFP members; 63.5% women; mean age 53.4 ± 10.4 years and median professional experience 21.3 years) replied to the survey. The majority (59.7%) of the participants performed a mixture of in-person along with phone counseling. About 40% had no former telemedicine experience. The majority indicated that telephone and video formats were inferior to in-person consultation (68%, 57.1% online and phone, respectively). The overall counseling quality grade (on a 1–10 scale,)median (IQR)) was 6.2 (3) for telephone and 7(2) for video. While 66.9% reported experiencing no challenges, 10% had technical problems, 10% interpersonal problems, 5.6% scheduling difficulties, and 7.5% other difficulties. Majority of 56.6% physicians indicated they prescribed more antibiotics,16.4% sent more blood tests, 24.5% referred more to experts, and 49.7% referred more to imaging in comparison to usual counseling. Higher phone quality score was significantly associated with physicians who indicated not prescribing more antibiotics during the pandemic (OR = 0.30, 95%CI 0.134–0.688, p = 0.004).

Higher online quality score was associated with physicians who indicated not sending more blood tests during the pandemic (OR = 0.06 95%CI 0.008–0.378, P = 0.003).

Conclusions

Our findings suggest telehealth holds considerable promise for counseling in the primary care setting. However, interpersonal challenges raised by physicians should be understood in-depth to develop tailored training and further examine it in randomized trials while integrating patient-reported outcomes. Finally, further research on utility, cost, and cost-efficiency during remote counseling with follow-ups, medical prescribing, and additional referrals is needed.

Changes in Serum Creatinine May Cause Hypoglycemia among Non-Critically Ill Patients Admitted to Internal Medicine Units

Background: The association between changes in serum creatinine levels and hypoglycemia during hospitalization was investigated. Methods: This was a retrospective analysis of medical charts. Patients were categorized as having significant change in creatinine (SCIC) when serum creatinine levels rose or dropped ≥ 0.3 mg/dL from admission values at any time during their hospitalization. Patients were considered hypoglycemic if they had at least one documented glucose level ≤ 70 mg/dL during the hospitalization. Multiple logistic, linear and Cox regression analyses were used to ascertain the association between incident SCIC, severity and timing with incident hypoglycemia. Results: Included were 25,400 (mean age 69.9 ± 18.0, 49.3% were males). The rate of SCIC was 22.2%, and 62.2% of them were diagnosed upon admission. Patients with SCIC had a higher incidence of hypoglycemia compared to patients without (13.1% vs. 4.1%, respectively, p < 0.001). Patients with SCIC had an increased risk of hypoglycemia (OR 1.853, 95% CI 1.586−2.166, p < 0.001). The magnitude of SCIC was associated with the incidence (OR 1.316, 95% CI 1.197−1.447, p < 0.001) and the number of events (HR 0.054, 95% CI 0.021−0.087, p = 0.001). More than 60% of patients with hypoglycemia had their first event documented during days 0−6 after SCIC occurrence. Of those, the majority of events occurred on day 0−1, and the rate showed a gradual decrease throughout the first 5 days from SCIC occurrence. The results were similar for patients with and without DM. Conclusions: Changes in creatinine during hospitalization may cause hypoglycemia among patients admitted to internal medicine departments, regardless of DM status.

Mediterranean diet and health – a narrative review

The Mediterranean Diet is a dietary pattern characterized by increased intake of olive oil, vegetables, fruits, cereals, nuts and pulses/legumes; as well as moderate intake of fish and other meat, dairy products and red wine. This dietary pattern has been associated with reduced risk for non-communicable diseases, including cardiovascular disease, type 2 diabetes mellitus, certain cancers, and dementia. The importance of modifying lifestyle risk factors to reduce these diseases is evidence by the increased obesity rates and aging of the global population. To examine associations between adherence to the Mediterranean Diet and non-communicable disease risk. There is evidence supporting a role for the Mediterranean Diet in primary and secondary non-communicable disease prevention; Furthermore, the Mediterranean Diet has been associated with reduced all-cause mortality.Conclusions: The Mediterranean Diet is associated with demonstrable and measurable health benefits, including non-communicable disease prevention and reduced mortality risk. The Mediterranean Diet is frequently consumed by individuals in Blue Zones.Keywords: Mediterranean diet; olive oil; non-communicable disease risk

Alcohol Drinks Induce Acute Lowering in Circulating l-Arginine in Obese and Type 2 Diabetic Subjects

Since low serum l-arginine (Arg) and high asymmetric dimethylarginine (ADMA) can predict microvascular complications in type 2 diabetes mellitus (T2DM), we tested whether Arg and ADMA are affected by diet and physical activity in overweight/obese and T2DM subjects. We tested the effects on serum Arg and ADMA of single loads of dextrose, protein, fat, or alcohol (∼300 calories each); one episode of physical exercise; and 12 weeks of standard lifestyle modification (dietary and physical activity counseling). Alcohol drink was followed by ∼30% lowering in Arg. Arg and ADMA increased after a protein load but remained stable after glucose or fat load or 30 min of treadmill walk. Following 12 weeks of lifestyle modification, ADMA declined only in subjects achieving weight loss >5%. In conclusion, alcohol is a previously unrecognized acute suppressor of serum Arg. Lifestyle modification lowers ADMA in subjects who achieve weight loss >5%. Clinical Trial Registration Number: NCT04406402.

The Effect of an Education Module to Reduce Weight Bias among Medical Centers Employees: A Randomized Controlled Trial

INTRODUCTION

Weight bias, stigma, and discrimination are common among healthcare professionals. We aimed to evaluate whether an online education module affects weight bias and knowledge about obesity in a private medical center setting.

METHODS

An open-label randomized controlled trial was conducted among all employees of a chain of private medical centers in Israel (n = 3,290). Employees who confirmed their consent to participate in the study were randomized into intervention or control (i.e., "no intervention") arms. The study intervention was an online 15-min educational module that included obesity, weight bias, stigma, and discrimination information. Questionnaires on Anti-Fat Attitudes (AFA), fat-phobia scale (F-scale), and beliefs about the causes of obesity were answered at baseline (i.e., right before the intervention), 7 days, and 30 days post-intervention.

RESULTS

A total of 506, 230, and 145 employees responded to the baseline, 7-day, and 30-day post-intervention questionnaires, respectively. Mean participant age was 43.3 ± 11.6 years, 84.6% were women, and 67.4% held an academic degree. Mean F-scale scores and percentage of participants with above-average fat-phobic attitudes (≥3.6) significantly decreased only within the intervention group over time (p ≤ 0.042). However, no significant differences between groups over time were observed for AFA scores or factors beliefs to cause obesity.

CONCLUSIONS

A single exposure to an online education module on weight bias and knowledge about obesity may confer only a modest short-term improvement in medical center employees' fat-phobic attitudes toward people with obesity. Future studies should examine if reexposure to such intervention could impact weight bias, stigma, and discrimination among medical center staff in the long-term.

Dietary Changes and Anxiety during the Coronavirus Pandemic: Differences between the Sexes

The SARS-CoV-2 (COVID-19) pandemic has been associated with both increased anxiety, deterioration in diet and weight gain. These associations may differ by sex. The present report examines differences by sex in diet quality in order to determine whether associations between diet and psychological stress during the initial phase of the COVID-19 pandemic differed by sex. This online study is available internationally in seven languages. The Mediterranean Diet Score was used to measure diet quality, while the General Anxiety Disorder 7-point scale (GAD-7) was used to measure anxiety. Findings were compared by self-reported sex (male vs. female). A total of 3797 respondents provided informed consent and met eligibility criteria, of whom 526 women were omitted due to being pregnant or six months or less post-partum, or due to reproductive status not being reported. Thus, 3271 individuals are included in the present report, of whom 71.2% were women. The median age of women was 30 (interquartile range (IQR) = 16) years vs. 31 (IQR = 19) years, p = 0.079. The median diet quality score was 9 (IQ = 3) in both women and men (p = 0.75). Despite the overall similarity in diet score, several components of the score differed significantly by sex. Women reported consuming significantly more olive oil, daily servings of vegetables, and weekly servings of sweet baked goods. Men reported consuming significantly more sweetened/carbonated drinks, red meat, alcohol, legumes, and hummus/tahini. Women reported a GAD-7 score of 6 (IQR = 8), while men reported 3 (6), p < 0.001. An inverse association was detected between the Mediterranean diet score and the GAD-7 score in both women (rho = −0.166, p < 0.001) and men (rho = −0.154, p < 0.001), and the correlation coefficients did not differ by sex (p = 0.76). Mediterranean diet score and age both reduced the odds of elevated anxiety (GAD-7 ≥ 10), while female sex, deterioration of diet quality during the outbreak, unemployment, and completing the survey in English increased the odds of this outcome. During the COVID-19 lockdowns, overall diet quality did not differ by sex; however, some differences by sex in components of the total score were detected. Moderate to severe anxiety was positively associated with female sex and poorer diet quality even after controlling for age, employment status, and the language in which the survey was performed.

Association between estimated GFR and incident hypoglycaemia during hospitalization

BACKGROUND

Kidney function is a significant factor associated with increased incidence of hypoglycaemia, especially among patients with diabetes mellitus (DM). We here quantified the association between elevated creatinine and incident hypoglycaemia among patients admitted to internal medicine departments, with and without DM.

METHODS

This is a retrospective cohort analysis study. Included were all patients discharged from internal medicine units between 2010 and 2013. Patients were excluded if creatinine levels rose or dropped more than 0.3 mg/dL during hospitalization. The CKD-EPI equation was used to calculate glomerular filtration rate (eGFR). Logistic regression analysis (backward LR method) was used to study the association between eGFR and hypoglycaemia incidence.

RESULTS

Included were 39 316 patients (mean age 68.0 ± 18.0 years, 49.3% males, 25.9% with DM, eGFR 69.5 ± 24.9 mL/min/1.73 m² ). Among study participants, 6.5% had at least one hypoglycaemic event. Logistic regression modelling showed that eGFR was inversely associated with incident hypoglycaemia (OR 0.988, 95% CI 0.986-0.990, p < .001). Results were similar for patients with and without DM. Estimated GFR was negatively correlated with admission CRP levels for patients with (r = -.143, p < .001) and without DM (r = -.166, p < .001). Estimated GFR was also positively correlated with admission serum albumin levels for both patients with (r = .304, p < .001) and without DM (r = .354, p < .001).

CONCLUSION

Among non-critically-ill patients hospitalized in internal medicine departments, reduced eGFR is associated with increased risk of hypoglycaemia. Glucose monitoring for all inpatients with CKD is suggested, regardless of DM status.

Status of Nutrition In Hemodialysis Patients Survey (SNIPS): Malnutrition risk by diabetes status

BACKGROUND

Increased malnutrition risk has been observed in more than 40% people on haemodialysis in Israel. It is not clear that this risk is homogeneously distributed among people with versus without diabetes.

OBJECTIVES

To examine the influence of diabetes on malnutrition risk among people on haemodialysis.

METHODS

This cross-sectional study included a representative sample of 375 individuals on haemodialysis treated in hospital dialysis centres throughout Israel. Of these, 126 had diabetes. Dietary intake, biochemistry, anthropometric and hemodynamic measures were recorded. Malnutrition risk categories were defined: "minimal": body mass index (BMI) ≥23 kg/m2 and serum albumin ≥38 mmol/L; "mild": BMI <23 kg/m2 and albumin ≥38 mmol/L; "moderate": BMI ≥23 kg/m2 and albumin <38 mmol/L; "severe": BMI<23 k/m2 and serum albumin <38 mmol/L. These categories were dichotomized to "minimal" versus elevated malnutrition risk.

RESULTS

Despite greater BMI, elevated malnutrition risk was identified in 58.8% of individuals with versus 39.3% without diabetes. Adherence to International Society for Renal Nutrition and Metabolism nutrition guidelines was poor regardless of diabetes status. In multivariable logistic regression analysis, diabetes: OR 2.15; C-reactive protein (nmol/L): OR 1.02; delivered dialysis dose (Kt/V): OR 6.07; and haemoglobin (g/L): OR 0.79, predicted elevated malnutrition risk, even after controlling for age, sex and years on haemodialysis.

DISCUSSION

Individuals on haemodialysis who have diabetes have elevated malnutrition risk compared to those without diabetes despite greater BMI.

Multinational dietary changes and anxiety during the coronavirus pandemic-findings from Israel

BACKGROUND

Increased anxiety was frequently reported during the 2020 global COVID-19 pandemic. An association between anxiety and increased body weight has been documented. Identifying associations between diet quality and anxiety may facilitate the development of preventive dietary policy, particularly relevant since obesity appears to increase the risk of adverse COVID-19 outcomes. In this study we aim to examine associations between changes in diet pattern and body weight and anxiety levels during the COVID-19 pandemic among Israeli respondents to an international online survey.

METHODS

Conducted between March 30-April 252,020, this was cross-sectional, international and online study. The questionnaire was developed and tested in Hebrew and translated into six other languages: English, Arabic, Spanish, French, Italian, and Russian. The survey was conducted on a Google Survey platform, the link to which was posted on several social media platforms. Adults aged 18 or older who saw and responded to the link on a social media site comprised the study population.

RESULTS

Of the 3979 eligible respondents, 1895 indicated their current location as Israel. Most Israeli respondents completed the survey in Hebrew (83.2%) followed by Arabic (9.4%), though responses were recorded in all seven of the survey languages. The median age was 33 (IQ = 22) years, and 75.7% were female. Almost 60% indicated that their pre-pandemic diet was healthier than their current diet, and 25.2% indicated they had gained weight during the pandemic. The median Mediterranean diet score was 9 (IQ = 3). While the median General Anxiety Disorder (GAD-7) score was 5 (IQ = 8), only 37.3% of participants reported at least mild anxiety (a GAD-7 score of 5 or more), while 10.7% reported moderate anxiety or greater (a GAD-7 score of 10 or more). In a multivariate logistic regression model of at least mild anxiety, being male and completing the survey in Hebrew significantly reduced odds of at least mild anxiety, while a worsening of diet quality during the pandemic, weight gain, and isolation significantly increased odds of at least mild anxiety.

CONCLUSIONS

During the COVID pandemic, changes in nutrition quality and habits were associated with greater anxiety. These findings suggest the need for routine and continuous surveillance of the nutritional and psychological consequences of outbreaks as part of healthcare preparedness efforts. Organizations responsible for community-based health services (such as Israeli health plans) should adopt specific interventions to improve case finding and support individuals at increased risk of anxiety and declining nutrition status within primary healthcare settings. These interventions should include the provision of appropriate diagnostic instruments, training of medical staff, feedback to physicians and nurses, and raising awareness among the relevant patient population and their caregivers. Primary care physicians should refer people with high anxiety or substantial weight gain during the pandemic to appropriate mental health and dietetic treatment, as needed.

TRIAL REGISTRATION

NCT04353934 .

The International Society of Renal Nutrition and Metabolism Commentary on the National Kidney Foundation and Academy of Nutrition and Dietetics KDOQI Clinical Practice Guideline for Nutrition in Chronic Kidney Disease

The Academy of Nutrition and Dietetics and the National Kidney Foundation collaborated to provide an update to the Clinical Practice Guidelines (CPG) for nutrition in chronic kidney disease (CKD). These guidelines provide a valuable update to many aspects of the nutrition care process. They include changes in the recommendations for nutrition screening and assessment, macronutrients, and targets for electrolytes and minerals. The International Society of Renal Nutrition and Metabolism assembled a special review panel of experts and evaluated these recommendations prior to public review. As one of the highlights of the CPG, the recommended dietary protein intake range for patients with diabetic kidney disease is 0.6-0.8 g/kg/day, whereas for CKD patients without diabetes it is 0.55-0.6 g/kg/day. The International Society of Renal Nutrition and Metabolism endorses the CPG with the suggestion that clinicians may consider a more streamlined target of 0.6-0.8 g/kg/day, regardless of CKD etiology, while striving to achieve intakes closer to 0.6 g/kg/day. For implementation of these guidelines, it will be important that all stakeholders work to detect kidney disease early to ensure effective primary and secondary prevention. Once identified, patients should be referred to registered dietitians or the region-specific equivalent, for individualized medical nutrition therapy to slow the progression of CKD. As we turn our attention to the new CPG, we as the renal nutrition community should come together to strengthen the evidence base by standardizing outcomes, increasing collaboration, and funding well-designed observational studies and randomized controlled trials with nutritional and dietary interventions in patients with CKD.

Status of Nutrition in Hemodialysis Patients Survey (SNIPS): Nutrition Intake in Obese and Overweight vs. Healthy Weight Patients

Elevated body mass index (BMI) has been associated with improved survival and fewer hospitalizations in hemodialysis patients; however, it is not clear that dietary intake is associated with increased BMI in hemodialysis patients. The present analysis was designed to compare energy and macronutrient intake and distribution, as well as compliance with the International Society of Renal Nutrition and Metabolism (ISRNM) dietary guidelines, by body weight status (overweight/obese vs. normal weight) in hemodialysis patients. The status of nutrition in hemodialysis patients survey (SNIPS) cohort is a cross-sectional study including a representative sample of individuals on hemodialysis treated in hospital dialysis centers throughout Israel. Of the 375 patients eligible for the current analysis, 60.1% had BMI ≥ 25 kg/m2 (overweight/obese). For each participant, the following measures were recorded: dietary intake, blood biochemistry, anthropometric and hemodynamic measures. These were compared by body weight status. Compared to their normal-weight counterparts, overweight/obese hemodialysis patients did not differ by energy and macronutrient intake, distribution of these nutrients in the diet. Regardless of body weight status, hemodialysis patients have poor compliance with ISRNM dietary guidelines.

Sex difference in the association between malnutrition and hypoglycemia in hospitalized patients

BACKGROUND

The aim of this paper was to examine the difference between males and females regarding association between malnutrition risk and hypoglycemia through a sub-analysis of a cross-sectional study of newly admitted patients to internal medicine departments.

METHODS

Malnutrition risk, assessed with Nutritional Risk Screening 2002 (NRS2002), and serum albumin were measured upon admission. Logistic regression was applied to men and women separately, to test the effect of malnutrition and hypoalbuminemia on incidence of hypoglycemia.

RESULTS

Included were 1186 patients (50.4% males, 39.2% with positive NRS2002). Rate of positive NRS2002 was similar across sexes (36.5% vs. 41.2% in males and females respectively, P=0.204). Among females, NRS2002 was associated with higher incidence of hypoglycemia (9.5% vs. 2.4% in NRS2002 negative females, P<0.001). Among males, no such difference was noted (9.2% compared to 7.1% in NRS2002 positive and negative males respectively, P=0.520). The weight loss/decreased food intake criterion of the NRS2002 was significantly higher in the hypoglycemic group within females (P=0.03). Logistic regression showed that serum albumin was inversely associated with hypoglycemia in both females (OR 0.477, 95% CI 0.282-0.806, P=0.006) and males (OR 0.532, 95% CI 0.355-0.795, P=0.002). However, increased malnutrition risk was associated with hypoglycemia only among females (OR 2.007, 95% CI 1.058-3.809, P=0.033). Diabetes status was associated with hypoglycemia (OR 1.907, 95% CI 1.056-3.445, P=0.032) only in males; this association did not occur in females.

CONCLUSIONS

Malnutrition risk, as measured by the NRS2002, is associated with significantly increased incidence of hypoglycemia in women alone. Females who lose weight prior to hospitalization have an increased risk to develop hypoglycemia.

Sex difference in the association between malnutrition and hypoglycemia in hospitalized patients

BACKGROUND

The aim of this paper was to examine the difference between males and females regarding association between malnutrition risk and hypoglycemia through a sub-analysis of a cross-sectional study of newly admitted patients to internal medicine departments.

METHODS

Malnutrition risk, assessed with Nutritional Risk Screening 2002 (NRS2002), and serum albumin were measured upon admission. Logistic regression was applied to men and women separately, to test the effect of malnutrition and hypoalbuminemia on incidence of hypoglycemia.

RESULTS

Included were 1186 patients (50.4% males, 39.2% with positive NRS2002). Rate of positive NRS2002 was similar across sexes (36.5% vs. 41.2% in males and females respectively, P=0.204). Among females, NRS2002 was associated with higher incidence of hypoglycemia (9.5% vs. 2.4% in NRS2002 negative females, P<0.001). Among males, no such difference was noted (9.2% compared to 7.1% in NRS2002 positive and negative males respectively, P=0.520). The weight loss/decreased food intake criterion of the NRS2002 was significantly higher in the hypoglycemic group within females (P=0.03). Logistic regression showed that serum albumin was inversely associated with hypoglycemia in both females (OR 0.477, 95% CI 0.282-0.806, P=0.006) and males (OR 0.532, 95% CI 0.355-0.795, P=0.002). However, increased malnutrition risk was associated with hypoglycemia only among females (OR 2.007, 95% CI 1.058-3.809, P=0.033). Diabetes status was associated with hypoglycemia (OR 1.907, 95% CI 1.056-3.445, P=0.032) only in males; this association did not occur in females.

CONCLUSIONS

Malnutrition risk, as measured by the NRS2002, is associated with significantly increased incidence of hypoglycemia in women alone. Females who lose weight prior to hospitalization have an increased risk to develop hypoglycemia.

Prediction of Hypoglycemia During Admission of Non-Critically Ill Patients: Results from the MENU Study

The objective of the work was to study admission parameters associated with an increased incidence of hypoglycemia during hospitalization of non-critically ill patients. Included in this cross-sectional study were patients admitted to internal medicine units. The Nutritional Risk Screening 2002 (NRS2002) was used for nutritional screening. Data recorded included admission serum albumin (ASA) and all glucose measurements obtained by the institutional blood glucose monitoring system. Neither of these are included in the NRS2002 metrics. Hypoalbuminemia was defined as ASA<3.5 g/dl. Patients were categorized as hypoglycemic if they had at least one documented glucose≤70 mg/dl during the hospitalization period. Included were 1342 patients [median age 75 years (IQR 61-84), 51.3% male, 52.5% with diabetes mellitus, (DM)], who were screened during three distinct periods of time from 2011-2018. The incidence of hypoglycemia was 10.8% with higher rates among DM patients (14.6 vs. 6.6%, p<0.001). Hypoglycemia incidence was negatively associated with ASA regardless of DM status. Multivariable regression showed that ASA (OR 0.550 per g/dl, 95% CI 0.387-0.781, p=0.001) and positive NRS2002 (OR 1.625, 95% CI 1.072-2.465, p=0.022) were significantly associated with hypoglycemia. The addition of hypoalbuminemia status to the NRS2002 tool improved the overall sensitivity from 0.55 to 0.71, but reduced specificity from 0.63 to 0.46. The negative predictive value was 0.93. Our data suggest that the combination of positive malnutrition screen and hypoalbuminemia upon admission are independently associated with the incidence of hypoglycemia among non-critically ill patients, regardless of diabetes mellitus status.

Frequently used medicinal herbs and spices in weight management: a review

Background: Obesity rates have increased globally during the last half, and with it there has been increased interest in herbs and dietary supplements for weight managementObjectives: The purpose of the present review is to examine evidence for the efficacy and safety of herbal preparations including cinnamon, capsaicin, black pepper, and curcumin, which are popularly used for weight reduction.Methods: A list of herbs and dietary supplements frequently used in weight management was developed by reviewing both scientific and popular literature. Included herbs/supplements were evaluated in terms of pre-clinical and clinical studies.Results: Included in the review were cinnamon, capsaicin, black pepper and curcumin. For all of the included herbs, proof of concept could be demonstrated. Few well-designed, adequately powered clinical trials were available but those that were suggested efficacy.Conclusions: While underlying metabolic/physiological mechanisms have been identified in pre-clinical studies, human studies of efficacy are sparse. An indication towards efficacy in humans exists for all of these products; however, treatment guidelines cannot be developed until better-quality randomized clinical trials can provide clear findings.Keywords: Cinnamon; Capsaicin; Black Pepper; Curcumin; Weight Management

Systemic Treatment With Glucocorticoids Is Associated With Incident Hypoglycemia and Mortality: A Historical Prospective Analysis

PURPOSE

The purpose of this study was to examine whether the increased glycemic variability associated with systemic glucocorticoid treatment is also associated with increased incidence of hypoglycemia.

METHODS

All patients discharged from internal medicine units between 2010 and 2013 were included in this retrospective analysis. Patients were assigned to 3 groups: Group 1: no steroids were prescribed;. Group 2: topical or inhaled steroids were prescribed with no systemic treatment; and Group 3: systemic steroids were prescribed, with or without topical or inhaled treatment.

RESULTS

A total of 45,272 patients were included in the study. Patients in Group 3 had significantly higher rates of hypoglycemia (10.9%) compared to patients in Group 2 (7.4%), and patients in Group 1 (7.3%). Patients with diabetes mellitus had higher rates of hypoglycemia compared to patients without diabetes mellitus (14.3% vs 4.9%) but exhibited similar trends in response to steroid treatment. Multivariate analysis showed that systemic steroids were associated with increased risk for hypoglycemia (odds ratio [OR] 1.513, 95% confidence interval [CI] 1.311-1.746, P <0.001). Hypoglycemia associated with systemic steroid treatment was also associated with increased risk of death (hazard ratio [HR] 2.328, 95% CI 1.931-2.807, P <0.001). Patients who were treated with systemic steroids but did not have hypoglycemia did not have higher mortality rates (HR 1.068, 95% CI 0.972-1.175, P = 0.171).

CONCLUSION

Treatment with systemic steroids is associated with increased hypoglycemia incidence during hospitalization. Patients treated with steroids that had incident hypoglycemia had a higher 1-year mortality risk compared to patients without hypoglycemia treated with steroids.

Orange napkins increase food intake and satisfaction with hospital food service: A randomized intervention

OBJECTIVES

Increased malnutrition risk has been identified in >30% of hospitalized adults in Israel. Because orange has been identified as an appetite stimulant, orange napkins were considered a low-cost enhancement of the meal context. The aim of this study was to assess the effect of an orange napkin on the meal tray on food intake and satisfaction with food service among adults hospitalized in an internal medicine department.

METHODS

One hundred and thirty-one patients hospitalized in Internal Medicine Department E, Edith Wolfson Medical Center, Holon, Israel, participated in the study. Patients were randomized to lunch trays with an orange (experimental) or white (control) napkin. Digital imaging was used with the modified Comstock Scale to quantify dietary intake. A validated questionnaire was used to score satisfaction with the hospital's food service. Medical history, anthropometric measures, reason for hospitalization, and meal modifications were extracted from the medical record.

RESULTS

Patients in the orange napkin group (n = 66) consumed 17.6% more hospital-provided food than those in the white napkin (control) group (n = 65), driven by the significantly greater proportion of the carbohydrate side dishes and the vegetable dishes consumed. Patients in the orange napkin group also reported significantly greater satisfaction with the hospital's food service.

CONCLUSION

The addition of an orange napkin to the meal tray of patients hospitalized in internal medicine departments can increase dietary intake and improve satisfaction with hospital food services. At about 5 cents per piece, the orange napkin is a low-cost, easily implemented strategy to address malnutrition risk in hospitalized adults.

Knowledge and Attitudes Towards Nutrigenetics: Findings from the 2018 Unified Forces Preventive Nutrition Conference (UFPN)

Background: Nutrigenetics indicates that individual genetic variability results in altered health outcomes necessitating personalized nutrition adaptation. Registered dietitians are recognized as the clinical nutrition experts, but their knowledge and attitudes regarding nutrigenetics has not been delineated. Methods: This cross sectional online survey was conducted in a convenience sample of 169 national nutrition conference attendees. The survey queried demographics, knowledge, and attitudes towards nutrigenetics and information on training in nutrigenetics. Results: The majority of participants were registered dietitians and female, 45% of whom held advanced degrees. Personalized nutrition was perceived by 93.5% of participants as highly important or important; however, 94% of respondents indicated they are not sufficiently knowledgeable in personalized nutrition and only 9.5% had received training in nutrigenetics. The mean nutrigenetics knowledge score was 6.89 ± 1.67 (out of a possible 12). A multivariate regression model of knowledge score identified education as the only independent predictor of this outcome. Conclusion: Personalized nutrition is a rapidly developing field that incorporates genetic data into clinical practice. Dietitians recognize the importance of advanced studies to acquire knowledge in nutrigenetics. Only by acquiring the necessary knowledge can dietitians accurately translate this nutrigenetics into clinical practice.

Outdated allergens are similar to unexpired extracts for the detection of allergen sensitization

Background: Allergen extracts have relatively short shelf lives, which limits their use and increase financial loss and waste on unused extracts. It is thus important to determine if efficacy persists beyond the expiration date. Objective: To determine the in vivo efficacy and bioavailability of outdated allergen extracts for diagnosis of allergic sensitizations. Methods: We enrolled 34 participants with allergic rhinitis and 5 participants with Hymenoptera hypersensitivity. After confirming allergen sensitization with the unexpired extracts, each participant had a second skin test with the matched outdated one (up to 7 years after the expiration date). All pairs of extracts were from the same company, stored under identical conditions, and tested for microbiologic contamination. The results of 356 skin-prick tests between expired and 111 unexpired extracts were compared. Results: None of the extracts had bacterial or fungal contamination. All outdated extracts produced a positive wheal reaction, with an average of 9.4 mm, which was not significantly different than the unexpired allergens. Seven years outdated lyophilized Hymenoptera extracts showed no significant differences in the wheal's size for the intradermal test at 1 μg/mL, between 5 and 9 mm. Conclusion: Outdated allergen extracts were safe and did not seem to differ in potency and bioavailability from unexpired extracts for the detection of allergen sensitization by skin-prick testing. These results supported our hypothesis that allergen extracts have efficacy and bioavailability that extend beyond the expiry date provided by the manufacturer. For the diagnosis of aeroallergens and Hymenoptera sensitization, it seemed that allergens can be used beyond the expiration date.

High-Intensity Statins Are Associated With Increased Incidence of Hypoglycemia During Hospitalization of Individuals Not Critically Ill

BACKGROUND

Serum cholesterol is inversely associated with incident hypoglycemia among patients admitted to internal medicine wards. We examined the association between statin use and incidence of hypoglycemia among patients who were not critically ill.

METHODS

In this retrospective study, we included all patients discharged between January 1, 2010, to December 31, 2013 from internal medicine units at the Wolfson Medical Center. Excluded were patients with hepatocellular or cholestatic liver disease upon admission. Patients were allocated to 4 groups, according to diabetes mellitus status (yes or no) and serum albumin <3.5 g/dL (yes or no) on admission. Regression analysis was used to examine the association of incident hypoglycemia during hospitalization and statin treatment (yes or no), and later, statin intensity.

RESULTS

Included in this analysis were 31,094 patients (mean age 68.9±17.5 years, 48.4% males, 21.7% with diabetes mellitus). Logistic regression models showed that among patients with low admission serum albumin, administration of high-intensity statins was associated with increased incidence of hypoglycemic events compared to patients not treated with statins (odds ratio [OR] 1.303, 95% confidence interval [CI] 1.016-1.671, P = 0.037), whereas treatment with low-intensity statins was associated with less hypoglycemic events (odds ratio 0.590, 95% confidence interval 0.396-0.879, P = 0.010). Among patients with normal serum albumin, no association was found between incident hypoglycemia and statin intensity. These findings were significant regardless of diabetes mellitus status.

CONCLUSION

Statin treatment in general is associated with reduced incidence of hypoglycemia. However, among patients with low serum albumin upon admission, use of high-intensity statins is associated with an increased risk of hypoglycemic events regardless of diabetes mellitus status.

Azithromycin and metronidazole versus metronidazole-based therapy for the induction of remission in mild to moderate paediatric Crohn's disease : a randomised controlled trial

OBJECTIVE

Crohn's disease (CD) pathogenesis associated with dysbiosis and presence of pathobionts in the lumen, intracellular compartments and epithelial biofilms. Azithromycin is active in all three compartments. Our goal was to evaluate if azithromycin-based therapy can improve response and induce remission compared with metronidazole alone in paediatric CD.

DESIGN

This blinded randomised controlled trial allocated children 5-18 years with 10<Pediatric Crohn's Disease Activity Index (PCDAI)≤40 to azithromycin 7.5 mg/kg, 5 days/week for 4 weeks and 3 days/week for another 4 weeks with metronidazole 20 mg/kg/day (group 1) or metronidazole alone (group 2), daily for 8 weeks. Failures from group 2 were offered azithromycin as open label. The primary end point was response defined by a decrease in PCDAI>12.5 or remission using intention to treat analysis.

RESULTS

73 patients (mean age 13.8±3.1 years) were enrolled, 35 to group 1 and 38 to group 2. Response and remission rates at week 8 were identical 23/35 (66%) in group 1 and 17/38 (45%) and 15/38 (39%) in group 2 (P=0.07 and P=0.025, respectively). The needed to treat for remission was 3.7. Faecal calprotectin declined significantly in group 1 (P=0.003) but not in group 2 (p=0.33), and was lower at week 8 (P=0.052). Additional therapy was required in 6/35(17%) from group 1 versus 16/38(42%) in group 2 (P=0.027) by week 8. Among 12 failures in group 2, open-label azithromycin led to remission in 10/12 (83%).

CONCLUSIONS

The combination of azithromycin and metronidazole failed to improve response but was superior for induction of remission and reduction in calprotectin.

TRIAL REGISTRATION NUMBER

NCT01596894.

Malnutrition Risk in Hemodialysis Patients in Israel: Results of the Status of Nutrition In Hemodialysis Patients Survey Study

BACKGROUND

Malnutrition is a frequently observed disorder in patients with chronic kidney disease (CKD) receiving hemodialysis (HD). While variously defined, malnutrition is a frequently observed condition among patients on HD. Prevalence estimates of malnutrition among Israeli HD patients have not been reported.

OBJECTIVES

To survey nutrition intake in Israeli HD patients; estimate malnutrition risk prevalence; identify risk factors, and characterize malnutrition risk in HD patients.

METHODS

A representative sample of 378 Israeli HD patients treated in hospital HD centers throughout the country were surveyed. Using the 24-h recall method, dietary intake was estimated and the chronologically corresponding biochemistry, anthropometric, and hemodynamic measures were recorded. Four categories of malnutrition risk were defined: "minimal": body mass index (BMI) > 23 kg/m2 and serum albumin > 3.8 g/dL; "mild": BMI < 23 kg/m2 and albumin > 3.8 g/dL; "moderate": BMI > 23 kg/m2 and albumin < 3.8 g/dL; "severe": BMI < 23 k/m2 and serum albumin < 3.8 g/dL.

RESULTS

Elevated malnutrition risk was identified in 175 (46.3%) study participants, who were more likely to require feeding assistance, have major comorbidities, reduced hemoglobin, and elevated C-reactive protein. Oral nutrition supplementation was prescribed to only 14.3% of patients with elevated malnutrition risk. Intradialytic parenteral nutrition was recorded for 6 patients, all of whom had moderate or severe malnutrition risk. Less than one-third of patients met the guidelines for dietary intake of energy or protein, and this did not differ across malnutrition risk groups.

DISCUSSION

Elevated malnutrition risk is a frequent finding in HD patients treated in hospital settings in Israel. Dietary intake does not meet guidelines but does not differ across malnutrition risk categories. Nutrition supplements are underused in HD patients with high malnutrition risk. There is a need to expand the survey to community HD centers.

Documented hypoglycemia is associated with poor short and long term prognosis among patients admitted to general internal medicine departments

AIM

To study the association of documented hypoglycemia with length of stay, 30-day mortality, and 1-year mortality, among patients with and without diabetes admitted to internal medicine units.

METHODS

The electronic medical records of all patients hospitalized in internal medicine departments at E. Wolfson Medical Center, Holon, Israel, between 1/1/2010 and 31/12/2013, were reviewed. Data extracted included all glucose measurements (performed using an institutional blood glucose monitoring system). Patients were considered hypoglycemic if at least one hypoglycemic event was recorded. Regression analysis was used to assess the association between documented hypoglycemia and length of stay, 30-day and one-year mortality. Age, sex, reason for admission, and the Charlson comorbidity index were entered as covariates, and the most conservative model was developed.

RESULTS

The study population included 45,272 patients (mean age 68.9 ± 17.8 years, 49.4% males, 21.0% had diabetes mellitus). The rate of hypoglycemia in the total study population was 7.5% (16.8% among DM patients, 6.0% among patients without diabetes, p < 0.001). Patients with documented hypoglycemia had a longer length of hospital stay (9.3 ± 18.7 vs. 3.1 ± 6.4 days, p < 0.001), as well as higher risk for both 30-day (23.7% vs. 7.0%, p < 0.001) and 1-year mortality (41.6% vs. 15.3%, p < 0.001). Cox regression analysis showed that hypoglycemia significantly increased risk death at one year (HR 2.436, 95% CI 2.298-2.582, p < 0.001) independent of age, sex, the Charlson comorbidity index, DM status and reason for admission.

CONCLUSION

Documented hypoglycemia is associated with prolonged length of hospital stay and increased risk for both 30-day and 1-year mortality, regardless of diabetes mellitus status.

The effect of a multispecies probiotic on microbiota composition in a clinical trial of patients with diarrhea-predominant irritable bowel syndrome

BACKGROUND

Although probiotics are increasingly used in irritable bowel syndrome (IBS), their mechanism of action has not been elucidated sufficiently. We aimed to evaluate the impact of a multispecies probiotic on enteric microbiota composition in women with diarrhea-predominant-IBS (IBS-D) and to determine whether these effects are associated with changes in IBS symptoms or inflammatory markers.

METHODS

In a double-blind, placebo-controlled study, Rome III IBS-D women completed a two-week run-in period and eligible women were assigned at random to a probiotic capsule (BIO-25) or an indistinguishable placebo, twice daily for 8 weeks. IBS symptoms and stool consistency were rated daily by visual analogue scales and the Bristol stool scale. High sensitivity C-reactive protein, fecal calprotectin and microbial composition were tested at baseline and at 4 and 8 weeks. Microbial sequencing of the 16S rRNA was performed and data were analyzed to compare patients who responded to treatment with those who did not.

KEY RESULTS

172 IBS-D patients were recruited and 107 eligible patients were allocated to the intervention (n = 54) or placebo (n = 53) group. Compared to placebo, BIO-25 did not result in changes in microbial diversity or taxa proportions, except for higher relative proportions of Lactobacillus in the BIO-25 group (P = 0.002). Symptomatic responders to BIO-25 showed a reduction in the proportion of Bilophila(P = 0.003) posttreatment. Patients with beneficial inflammatory-marker changes had higher baseline proportions of Faecalibacterium(P = 0.03), Leuconostoc (P = 0.03), and Odoribacter (P = 0.05) compared to corresponding non-responders.

CONCLUSIONS & INFERENCES

Identifying patients with a more amenable microbiome at treatment initiation may result in better treatment response.

Association of albumin and cholesterol levels with incidence of hypoglycaemia in people admitted to general internal medicine units

AIM

To study the association between serum albumin and cholesterol levels at hospital admission and incident hypoglycaemia among people admitted to internal medicine units.

METHODS

In this cross-sectional analysis, we examined the electronic medical records of people hospitalized in internal medicine departments. Data extracted included all glucose measurements as well as serum albumin and cholesterol, which were measured upon admission. A hypoglycaemia event was recorded for a given person if at least one glucose measurement of ≤ 3.9 mmol/l was recorded during the hospital stay. Regression analysis was used to determine which clinical measures predict hypoglycaemia.

RESULTS

During the acquisition period, 45 224 people (mean age 68.9 ± 17.8 years, 49.4% male, 21.1% diabetes mellitus) were discharged from internal medicine units. Hypoglycaemia was documented in 7.5% of these individuals (15.4% of people with diabetes vs. 5.5% of those without; P < 0.001). Logistic regression showed that both serum albumin [odds ratio (OR) 0.908, 95% confidence interval (CI) 0.896-0.919; P < 0.001) and cholesterol (OR 0.938, 95% CI 0.896-0.981; P = 0.005] were significantly associated with incident hypoglycaemia. Results remained significant even after controlling for age, sex, average glucose during hospitalization, length of hospital stay, acute infection upon admission, diabetes status, haemoglobin, white blood cell count and C-reactive levels. A combination of hypoalbuminaemia (< 35 g/l) and hypocholesterolaemia (< 3.37 mmol/l) upon admission greatly increased the risk of incident hypoglycaemia (OR 2.544, 95% CI 2.096-3.088; P < 0.001).

CONCLUSION

Hypoalbuminaemia and hypocholesterolaemia predict incident hypoglycaemia in the hospital setting among people with and without diabetes mellitus.

The Effects of an External Nasal Dilator on Labor

Background

The aim of this study was to assess the effect of an external nasal dilator on several variables characterizing labor in both mother and fetus.

Methods

One hundred and fifty primigravida women in active labor were randomized to wear, throughout labor, either a dilator spring-loaded nasal strip or a placebo device. Data were obtained during labor and compared between the groups. After delivery, the satisfaction rate was assessed.

Results

No differences were found between the study and the control group regarding rate of induction or augmentation of labor as well as Montevideo units reached, frequency of rupture of membranes, duration of the active phase and second stage of labor, usage of epidural analgesia, normal fetal heart pattern, meconium-stained amniotic fluid, and neonatal well being. Length of maternal and neonatal hospitalization also did not differ between the groups. Satisfaction rate was significantly higher in parturient women wearing nasal strips with a dilator spring than in parturient women wearing a placebo spring (P < 0.0001).

Conclusion

Nasal strips do not change the course but ameliorate the quality of labor by improving the ease of breathing. Nasal dilators sustain the respiratory effort associated with the long process of labor and may control the switch from nasal to oronasal breathing during delivery.

Asthma, Family History of Drug Allergy, and Age Predict Amoxicillin Allergy in Children

BACKGROUND

Suspected adverse reactions to amoxicillin are common, but there are no known factors that can predict amoxicillin allergy in children. In addition, methods used for the diagnosis of amoxicillin allergy are not standardized and their role in diagnosis is not clear.

OBJECTIVE

To identify predictive factors and to assess the role of skin test in the diagnosis of amoxicillin allergy in children.

METHODS

Children with a history of immediate (excluding anaphylaxis) or nonimmediate reactions to amoxicillin were tested by skin prick test, followed by oral graded challenge with amoxicillin. Clinical characteristics of the reaction before and after the challenge were recorded, and data of personal and relatives' drug allergies and atopy were collected for statistical analysis.

RESULTS

Skin prick tests followed by an oral graded challenge with amoxicillin were performed on 133 children. The skin test result was not of clinical value because it was negative in all children. Three children (2%) had an immediate reaction and 7 children (5%) had a nonimmediate reaction. Asthma (odds ratio [OR], 0.12; 95% CI, 0.017-0.869; P = .03), family history of drug allergy (OR, 0.12; 95% CI, 0.026-0.613; P = .01), older age at reaction (OR, 0.837; 95% CI, 0.699-1; P = .05), and angioedema (OR, 0.22; 95% CI, 0.043-1.12; marginally significant at P = .069) were associated with reduced chance to pass the oral challenge.

CONCLUSIONS

Skin prick test did not contribute to the diagnosis of amoxicillin allergy. The presence of asthma, family history of drug allergy, and older age at reaction can be used as predictive factors for true amoxicillin allergy in children.

Does Body Mass Index Reduction by Bariatric Surgery Affect Laryngoscopy Difficulty During Subsequent Anesthesia?

BACKGROUND

The effect of body mass index (BMI) reduction following bariatric surgery on subsequent airway management has not been investigated. This study aimed to investigate the association between BMI reduction and airway assessment and management measured by Mallampati class (MC) and laryngoscopy grade (LG).

METHODS

We conducted a retrospective study over 6 years to compare the BMI changes, MC and LG in patients having weight reduction bariatric surgery followed by subsequent surgery. Data was extracted from the anesthesia records of patients undergoing laparoscopic band insertion (LBI) and laparoscopic sleeve gastrectomy (LSG). Difficult airway was defined as Malampati class 3 and 4 on a 1-4 difficulty scale or laryngoscopy grade >2 on a 1-4 difficulty scale and need for unplanned fiberoptic intubation. Changes in these variables were correlated with weight reduction. Statistical analysis included t test, univariante, and multivariant logistic regression.

RESULTS

Five hundred forty-six patients underwent LSG and 83 patients had LBI during the study period. Of those patients, 65 patients had subsequent surgical procedures after the bariatric procedure. Of the 65 patients identified, 62 were eligible. BMI decreased by approximately13 kg/m² (p = 0.000) which roughly represents a 30 % reduction between the two surgical procedures. Mallampati class decreased significantly (p = 0.000) while laryngoscopy grade did not (p = 0.419).

CONCLUSION

Our study revealed that a significant reduction in BMI was associated with a significant decrease in Mallampati class. There was no significant decrease in laryngoscopy grade, and there was no case of unplanned fiberoptic intubation.

Dietary Therapy With the Crohn's Disease Exclusion Diet is a Successful Strategy for Induction of Remission in Children and Adults Failing Biological Therapy

BACKGROUND

Loss of response [LoR] to biologics in Crohn's disease [CD] is a significant clinical problem. Dietary therapy as a treatment strategy in this setting has not been previously reported. We report the use of dietary strategies using enteral nutrition coupled with the Crohn's Disease Exclusion Diet [CDED] for LoR to infliximab or adalimumab as a single-centre experience.

METHODS

Patients with LoR to a biologic despite dose escalation or combination therapy were treated with partial enteral nutrition [PEN] by a polymeric formula and the CDED for 12 weeks. Paediatric patients with severe flares received 14 days of exclusive enteral nutrition followed by PEN + CDED as above. All patients were seen at weeks 6 and 12 for follow up. Current and prior treatment, Harvey Bradshaw Index [HBI], C-reactive protein [CRP] and albumin were recorded. Remission was defined as HBI <5 at week 6.

RESULTS

Twenty-one patients, mean age 22.1 ± 8.9 years [11 adults and ten children] met study criteria. Seventeen patients [81%] had used combination therapy, and 10/21 [47.6%] had failed a second biologic. Seven patients had a prior intestinal resection. Dose escalation had failed in 13/21 [62%] patients. Clinical remission by physician's global assessment and HBI after 6 weeks was obtained in 13/21 [61.9%]. Mean HBI decreased from 9.4 ± 4.2 to 2.6 ± 3.8 [p < 0.001], mean CRP decreased from 2.8 ± 3.4 to 0.7 ± 0.5 [p = 0.005] and mean albumin increased from 3.5 ± 0.6 to 3.8 ± 0.5 [p = 0.06].

CONCLUSION

Dietary treatment combining PEN with the CDED may be a useful salvage regimen for patients failing biological therapy despite dose escalation.

Functional Foods in fad diets: A review

Background: Fad diets can be defined as any diet making claims that are unrealistic and not supported by evidence-based data. Having been developed since the early 19th century, fad diets promise drastic weight loss and/or other unsubstantiated health claims, often omitting entire food groups. Their popularity with the public makes them an important topic for nutritionists and clinicians, especially in the framework of the obesity epidemic. Additionally, it is conceivable that components of fad diets can indeed facilitate weight loss, even if the diet overall is without merit. The grapefruit diet, the cabbage soup diet, and the human chorionic gonadotropin (hCG) diet are among the most popular fad diets and are reviewed within this study not only in terms of the diet plan itself, but also in terms of possible and known weight loss and health benefits provided by the foods on which the diets are based. Bioflavonoids in grapefruit, including naringin, hesperidin, and bergamottin, may benefit glucose homeostasis. Cabbage contains lutein, zeaxanthin, kaempferol, quercetin, and apigenin, which have anti-inflammatory properties and improve both glucose homeostasis and fat metabolism. The hCG diet is frequently supplemented with non-hCG preparations, which often  contains African mango, which has been shown to enhance weight loss by an unspecified mechanism; astragalus root, which has antioxidant, anti-inflammatory, and peroxisome proliferator-activated receptor-gamma receptor agonistic properties; arginine, which stimulates lipolysis; glutamine, which has been shown to enhance weight loss, perhaps by altering the gut microbiome; carnitine, which appears to facilitate weight loss; B12, which improves insulin resistance; and niacin, which improves the dyslipidemia associated with overweight/obesity. Presently, high quality clinical trials suggest that fad diets reduce weight in the short term due to drastic caloric restriction rather than functional food properties. However, the proof of principle has been demonstrated, and clinical trials of the functional foods utilized in fad diets are much needed.Keywords: functional foods, Fad diet, weight loss, naringin, hesperidin, and bergamottin

Lifestyle intervention program benefits children with overweigh compared to children with obesity

BACKGROUND

Lifestyle weight loss interventions represent the mainstay of treating children with obesity. Long-term follow-up studies of intervention programs are scarce. This study assessed the long-term effects and identified factors associated with significant weight loss.

METHODS

This prospective, observational study involved 165 children with body mass index (BMI) z-score ≥1.5 who participated in after-school intervention program.

MAIN OUTCOME MEASURE

change in BMI z-scores; decreased BMI z-score ≥0.5 units was defined as clinically significant.

RESULTS

At baseline, 55/165 (33.3%) had BMI z-score 1.5-2 and 98 (59.4%) had BMI z-score >2. At follow-up (mean 5.4±1.4 years), 80 (48.5%) had a clinically significant reduction in BMI z-score, while 56 (33.9%) reported a mildly decrease in BMI z-score of 0-0.5 and 29 (17.6%) reported increased BMI z-score. Lower BMI z-score at baseline and participation in sport activity at follow-up were associated with long-term decrease in BMI z-score. Participation in additional post-intervention weight control programs was correlated with weight gain.

CONCLUSIONS

Intervention program was associated with long-term improvement in weight control, especially in children with mild obesity. Physical activity was related to long-term success. Participation in an additional intervention program was associated with failure of weight control.

Random blood glucose screening at a public health station encouraged high risk subjects to make lifestyle changes

BACKGROUND

Screening and early diagnosis of prediabetes and diabetes can prevent or delay disease onset and complications. To that end, a free public health station was established in a large, government medical centre. This study evaluated the long-term outcomes of abnormal random blood glucose results among patients with no history of diabetes or prediabetes.

METHODS

The Diabetes Unit supervised a public dysglycaemia and hypertension screening station. Participants with blood glucose >140 mg/dL and no history of diabetes or prediabetes were contacted by telephone for follow-up.

RESULTS

Among screened subjects, 868 (average age 57.5±12 years) had a random blood glucose level >140 mg/dL and 341 (39.3%) responded to the telephone survey. Of these, 313 (91.8%) subsequently had fasting blood glucose measured at their health maintenance organisation (HMO), of which 101 (32.3%) were abnormal. A total of 173 (51%) respondents initiated interventions: 59 (17.3%) antidiabetic treatment; 145 (42.5%) sugar-restricted diet; and 96 (28.2%) a physical activity programme. Of patients with abnormal fasting blood glucose, 17 (14.5%) reported having had this result previously compared with 9 (4.2%) with normal fasting glucose (P=.001). Among respondents, 216 (63.3%) stated the screening was effective and 273 (80.1%) would recommend it.

CONCLUSION

The station was effective in promoting additional screening among high-risk age groups and encourages subjects to make lifestyle changes. Operating the screening station is simple and effective; therefore it may serve as a complementary step in promoting community healthcare.

Mesalamine Enemas for Induction of Remission in Oral Mesalamine-refractory Pediatric Ulcerative Colitis: A Prospective Cohort Study

BACKGROUND

Paediatric ulcerative colitis [UC] is more extensive than adult disease, and more often refractory to mesalamine. However, no prospective trials have evaluated mesalamine enemas for inducing remission in children. Our goal was to evaluate the ability of mesalamine enemas to induce remission in mild to moderate paediatric UC refractory to oral mesalamine.

METHODS

This was an open-label arm of a previously reported randomised controlled trial of once-daily mesalamine in active paediatric UC [MUPPIT trial]. Children aged 4-18 years, with a Paediatric Ulcerative Colitis Activity Index [PUCAI] score of 10-55, were enrolled after failing at least 3 weeks of full-dose oral mesalamine. Patients treated with steroids or enemas in the previous month and those with isolated proctitis were excluded. Children received Pentasa® enemas 25 mg/kg [up to 1g] daily for 3 weeks with the previous oral dose. The primary endpoint was clinical remission by Week 3.

RESULTS

A total of 38 children were enrolled (mean age 14.6 ± 2.3 years; 17/38 [45%] with extensive colitis). Clinical remission was obtained in 16 [42%] and response was obtained in 27 [71%] at Week 3. Eight children deteriorated and required steroids. There were no differences in baseline parameters between those who entered or failed to enter remission, including disease extent [43% in left-sided and 41% in extensive colitis] and disease activity [44% in mild and 41% in moderate activity].

CONCLUSION

Clinical remission can be markedly increased in children who are refractory to oral mesalamaine by adding mesalamine enemas for 3 weeks, before commencing steroids.

A double-blind, placebo-controlled study to assess the effect of a probiotic mixture on symptoms and inflammatory markers in women with diarrhea-predominant IBS

BACKGROUND

Micro-inflammation is considered an element in the pathogenesis of irritable bowel syndrome (IBS). High-sensitivity C reactive protein (hs-CRP) was previously shown to be higher in IBS compared to healthy controls, albeit within the normal range. Since probiotics may suppress micro-inflammation in the gut, we tested if they reduce symptoms and inflammatory markers (hs-CRP and fecal calprotectin (FC) in diarrhea-predominant IBS (IBS-D). The aim of this study was to assess the clinical and laboratory effects of BIO-25, a multispecies probiotic, in women with IBS-D.

METHODS

A double-blind, placebo-controlled study. Following a 2-week run-in, eligible women were assigned at random to a probiotic capsule or an indistinguishable placebo, twice daily for 8 weeks. IBS symptoms and stool consistency were rated daily by Visual Analogue Scales (VAS) and the Bristol Stool Scale (BSS). High-sensitivity C reactive protein was tested at baseline, 4 and 8 weeks. FC was tested at baseline and 8 weeks.

KEY RESULTS

One hundred and seventy-two IBS-D patients were recruited and 107 eligible patients were allocated to the intervention (n=54) or placebo (n=53) group. All symptoms improved in both groups with no significant difference between them in symptom improvement, hs-CRP or FC levels.

CONCLUSIONS & INFERENCES

An 8-week treatment with BIO-25 improved symptoms in women with IBS-D, but was not superior to placebo. This rigorously designed and executed study supports the findings of other studies that did not demonstrate superiority of probiotics over placebo in IBS. High quality clinical studies are necessary to examine the efficacy of other specific probiotics in IBS-D patients since data are still conflicting.

A randomized, controlled clinical trial to evaluate the immunogenicity of a PreS/S hepatitis B vaccine Sci-B-Vac™, as compared to Engerix B®, among vaccine naïve and vaccine non-responder dialysis patients

BACKGROUND

Dialysis patients have a suboptimal response to hepatitis B (HBV) vaccination. This study aimed to compare the immunogenicity of two vaccines: the third-generation Sci-B-Vac™ vs. the second-generation Engerix B^®. The cohort included two groups of dialysis patients: naïve and previously vaccinated non-responders. Primary endpoints were antibody titers ≥10 IU/L at 3 and 7 month post-vaccination. Secondary objectives were seroprotection rates in vaccine-naïve patients and in previously vaccinated non-responders.

METHODS

Eighty-six patients were assigned to vaccine (Sci-B-Vac™ or Engerix B^®) using computer-generated randomization, stratified by age, gender, diabetes, and previous HBV vaccination. Sci-B-Vac™ was administered in three doses, 10 μg, at 0, 1, and 6 months in naïve patients; or 20 μg in previously vaccinated non-responders. Engerix B^® included four doses, 40 μg at 0, 1, 2, and 6 months.

RESULTS

Each group had 43 patients. Seroconversion was 69.8% with Engerix B^® vs. 73.2% with Sci-B-Vac™. Antibody titers at 7 months were higher with Sci-B-Vac™ (266.4 ± 383.9, median 53.4) than with Engerix^® (193.2 ± 328.9, median 19). However, these differences were not significant, perhaps due to a suboptimal sample size.

CONCLUSIONS

This study suggests comparable immunogenicity for both vaccines. Thus, we cannot reject the null hypothesis that there is no difference in seroconversion by vaccine type. It is noteworthy that naïve patients were vaccinated with a standard dose of Sci-B-Vac™, while Engerix B^® was administered at a double dose. Similarly, although mean antibody titer levels in the Sci-B-Vac™ group were higher than in the Engerix^® group, this difference did not reach significance. Consequently, a future clinical trial should recruit a larger cohort of patients, using a standard double-dose protocol in both groups.

Serum asymmetric dimethylarginine and arginine levels predict microvascular and macrovascular complications in type 2 diabetes mellitus

BACKGROUND

Increased oxidative stress in diabetes increases nitric oxide (NO) oxidation and low l-arginine (Arg) could further reduce NO and impair vascular function, thereby accelerating, in the long run, vascular complications. We therefore measured Arg and asymmetric dimethylarginine (ADMA) levels in patients with type 2 diabetes mellitus (T2DM) and healthy controls. Additionally, we observed the diabetic individuals over time to see if Arg and asymmetric dimethylarginine predicted T2DM complications.

METHODS

We examined baseline serum Arg and ADMA levels in a cohort of 105 participants with type 2 diabetes and compared them with an age- and weight-matched nondiabetic group of 137 individuals who served as a reference population. Additionally, we assessed whether Arg and/or ADMA predicted macrovascular and microvascular complications over 6 years of follow-up.

RESULTS

Serum Arg was lower in individuals with T2DM than in controls (64 ± 28 vs 75 ± 31 μmol/L; P = .009) and inversely related to hemoglobin A1c (r = -0.2; P = .002). Over follow-up, we observed that participants with T2DM in the lowest quartile of Arg had increased risk for the subsequent evolution of nephropathy, peripheral neuropathy, and composite microvascular complications (odds ratio [OR] = 5.5; 95% confidence interval [CI] -1.9 to 16; P = .002). The highest ADMA quartile was associated with increased risk for both microvascular (OR = 4.5; 95% CI -1.4 to 14.1; P = .009) and 6.5-year incident macrovascular complications (OR = 8.3; 95% CI 1.9-35.5; P = .004).

CONCLUSION

l-Arginine levels are lower in individuals with T2DM than in matched controls. Both low Arg and high ADMA, independent of each other and adjusted for classical risk factors, predict the incidence of microvascular complications.

Purslane Extract and Glucose Homeostasis in Adults with Type 2 Diabetes: A Double-Blind, Placebo-Controlled Clinical Trial of Efficacy and Safety

Purslane extract (PE) is derived from Portulaca oleracea L., a medicinal plant used in traditional medicine for its antidiabetic properties. This randomized, placebo-controlled clinical trial was designed to evaluate the efficacy and safety of PE in improving glucose control, blood pressure, and lipid profile in adults with type 2 diabetes mellitus (T2DM) treated with a single oral hypoglycemic agent at baseline. Subjects were randomized to treatment with three capsules of PE/day or a matched placebo. Change from baseline to the week 12 end-of-follow-up visit measures of glucose homeostasis, hemodynamics, and lipid profile was compared by treatment assignment. In addition, these measures were evaluated in a subgroup of "responders," defined as patients whose week 12 HbA1c was lower than baseline values, regardless of treatment assignment. This group was further assessed in subgroups of baseline oral hypoglycemic treatment. A total of 63 participants were treated with either PE (n = 31, 11 females, mean age 52.4 ± 7.9 years) or matched placebo (n = 32, 11 females, mean age 58.3 ± 10.8 years). In the total cohort, systolic blood pressure declined significantly more in the PE group than the placebo group: -7.5 ± 5.0 versus -0.01 ± 0.3 mmHg, P < .0001. In the responders' subgroup, HbA1c declined significantly more in the PE group than the placebo group: -0.8% ± 0.4% versus -0.6% ± 0.5%, P = .03. Few adverse events were reported. These were mild and did not differ by treatment assignment. PE appears to be a safe, adjunct treatment for T2DM, significantly reducing systolic blood pressure in the total cohort and HbA1c in the subgroup of responders.

Using a public health station for screening of undiagnosed dysglycemia and hypertension

AIM

Dysglycemia, diabetes and abnormal blood pressure screening can be conducted by trained volunteers and may identify unknown cases. The aim of the study was to examine the feasibility and effectiveness of operating a screening station in pubic setting supervised by diabetes unit.

METHODS

A cross-sectional analysis of a program offering free screening services to non-hospitalized subjects. From 1.1.2011 through 31.12.2013 trained volunteers measured height, weight, blood glucose and blood pressure at the main entrance of the hospital. Subjects were asked whether they had diabetes or hypertension. Dysglycemia was defined as blood glucose 141-199mg/dL and probable newly-identified diabetes as ≥200mg/dL.

RESULTS

13,112 adults underwent screening. Among the screened individuals (age 55.3±14.9 years) 2215 (16.9%) reported diabetes and 3037 (23.2%) hypertension. Among subjects without known hypertension, 9.6% had blood pressure ≥140/90. Among the subjects without known diabetes, 5012 (46%) had glucose ≤110mg/dL, 2873 (26.4%) ≥126mg/dL, 1553 (14.3%) >140mg/dL and 170 (1.6%) ≥200mg/dL. Compared to subjects with blood glucose ≤140mg/dL, those with dysglycemia or diabetes were older (58.9±13.4 vs. 52.7±15.2 years, P<0.001), had elevated BMI (27.5±4.6kg/m(2) vs. 26.6±4.6kg/m(2), P<0.001), higher systolic (137.5±22.2mmHg vs. 132.2±21.3mmHg, P<0.001) and diastolic blood pressure (80.3±15.6mmHg vs. 78.6±13.7mmHg, P<0.001). Compared to subjects with blood glucose<200mg/dL, those with probable newly-identified diabetes were older (58.6±10.9 vs. 53.5±15.2, P<0.001), had elevated BMI (28.4±4.8kg/m(2) vs. 26.7±4.6kg/m(2), P<0.001), higher systolic (139.4±24.0mmHg vs. 132.8±21.4mmHg, P<0.001) and diastolic blood pressure (85.4±20.7mmHg vs. 78.8±13.9mmHg, P<0.001).

CONCLUSIONS

Screening supervised by healthcare center can identify individuals at high-risk for dysglycemia and abnormal blood pressure, who are referred for further diagnosis and treatment and may serve as a complementary step in primary health care setting.

Prevalence of undiagnosed hyperglycaemia in patients presenting to the Department of Emergency Medicine with no known history of diabetes

BACKGROUND

Diabetes is considered a major epidemic of the 21st century. Usually, diabetes begins asymptomatically and the diagnosis takes place an average of 8-12 years after the onset of dysglycaemia. Blood check for glucose is taken at different medical setting, whether at the fasting condition or randomly. Previous studies had shown that abnormal blood glucose predicts future diabetes. Hence, medical staff should consider taking reasonable actions in patients with abnormal blood glucose.

OBJECTIVE

To assess the prevalence of hyperglycaemia in patients presenting to the Department of Emergency Medicine (DEM) with no known history of diabetes, and to evaluate how often were they recommended following this up as an outpatient by the medical staff.

DESIGN

A cross-sectional study examined the medical records of adult patients referred to the DEM during 1 November 2011-31 January 2012.

PARTICIPANTS

Patients with random blood glucose ≥140 mg/dL and no known history of diabetes were included in the study. The discharge letter was examined for the presence of instructions to conduct further follow up.

KEY RESULTS

A total of 16 784 patients presented to the DEM. Of these, 402 patients (2.4%) without known diabetes were hyperglycaemic, 346 patients had blood glucose levels ≥140 mg/dL and 56 patients had blood glucose levels above 200 mg/dL. Only 35 of the 402 included patient files (8.7%) contained instructions for further investigation. There was no statistically significant difference between those who received a letter for further follow up compared with those who did not receive it with respect to age, sex or blood glucose levels.

CONCLUSION

Over 2% of patients who presented to the DEM were hyperglycaemic, without a prior diagnosis of diabetes. A small per cent was recommended to have outpatient follow-up. This represents a missed opportunity for earlier diagnosis of diabetes and emphasised the need for raising medical staff awareness concerning abnormal blood glucose and its implication.

Memory Performance in Late Pregnancy and Erythrocyte Indices

OBJECTIVE

A previous study in elderly people observed an association between chronologically younger erythrocyte population and memory impairment. The aim of this study was to assess whether a similar shift in erythrocyte population in pregnant women in late pregnancy is associated with changes in memory performance in healthy pregnant women.

METHODS

Thirty healthy pregnant women were included in a prospective cross-sectional study. Explicit memory and autobiographic memory tests were performed in the late third trimester and 4 months postpartum. Mean corpuscular volume (MCV) was considered the primary predictor variable.

RESULTS

The mean explicit memory recall scores were significantly higher at post-delivery compared to pre-delivery: 8.3 +/- 1.7 and 7.4 +/- 1.4, respectively (P = .015). The difference in mean autobiographic memory test score pre- and post-delivery did not reach statistical significance. A positive correlation between post-delivery explicit memory recall scores and the difference between pre- and post-delivery MCV was detected (r = 0.458, P = .01). The correlation between delta MCV and delta explicit memory recall scores was r = 0.2, P =.311. Pre-delivery autobiographic memory test scores were positively correlated with MCV (r = 0.50, P = .006), mean corpuscular hemoglobin (r = 0.57, P = .001), and mean corpuscular hemoglobin concentration (r = 0.46, P = .013).

CONCLUSION

The change in erythrocyte population that is present in late pregnancy predicted explicit memory performance after delivery, when it was improved. The younger erythrocyte population that exists in late pregnancy is associated with a better autobiographic memory.

Sugammadex: An Update

The purpose of this update is to provide recent knowledge and debates regarding the use of sugammadex in the fields of anesthesia and critical care. The review is not intended to provide a comprehensive description of sugammadex and its clinical use.

The Role of Helminth Infection and Environment in the Development of Allergy: A Prospective Study of Newly-Arrived Ethiopian Immigrants in Israel

Helminth infection may be protective against allergy and account for the low prevalence of allergy in developing countries. We studied prospectively the prevalence of allergy in Ethiopian immigrants with heavy helminth infection on arrival in Israel, and again after a year of adjustment to an urban industrialized setting, to explore the roles of helminth infection, changed environment and background immunity on the manifestations of allergy. 126 newly arrived Ethiopian immigrants were studied at baseline and 115 after a year of follow up in Israel. Allergic symptoms, Skin prick tests (SPT), Tuberculin (PPD) skin tests, stool and blood samples were obtained for determining parasites, blood IgE and eosinophil levels, respectively. Anti-helminthic therapy was offered to the entire infected individuals, but only 50/108 (46.3%) took the medication. At baseline, there was a significant negative association between helminth infection and allergy, 4/18 (22.2%) of uninfected participants were allergic compared to 7/108 (6.5%) of helminth-infected participants (p = 0.028), as well as between helminth infection and SPT reactivity, 12/18 (66.6%) of uninfected participants compared to 43/108 (39.8%) of helminth-infected participants (p = 0.033). After one year, a significant general increase in allergy and SPT was observed. While only 11/126 (8.7%) were allergic at baseline, 30/115 (26.1%) became allergic at follow-up (p<0.0001), and while 55/126 (43.7%) were SPT+ at baseline, 79/115 (68.7%) became SPT+ at follow-up (p<0.001). A twofold increase in allergen sensitization was also observed after one year in Israel, particularly for dust mites, grasses and olive tree (p<0.001). These results show that: a) Helminth infection is significantly associated with low allergy and low SPT reactivity; b) One year after immigration to Israel, allergy and SPT reactivity increased significantly in all immigrants; c) Higher increases in positive SPT and allergy were observed after a year in the group that remained infected with helminths, even though they had a lowered helminth load; d) The reasons for the increased allergy one year after immigration needs further investigation but probably reflects the combined influence of the decreased helminth load and novel environmental factors.

The role of intestinal parasitic infections in allergy is of great interest since it has been suggested that they suppress the development of allergy. Urbanization has also been claimed to cause allergy because of air pollution and higher exposure to allergens. The present study took advantage of the special opportunity presented by the recent Ethiopian immigration to Israel in order to study this question. A cohort of newly arrived Ethiopian immigrants to Israel, highly infected with parasites, was studied prospectively for the presence of allergy and response to allergens on arrival and after a year of follow up in Israel. The results showed clearly a significant inverse association between the presence of parasitic infections and allergy on arrival, while after a year of living in Israel, accompanied by a lowered parasitic infection load, a general increase of allergy was observed in all immigrant groups, and not only in those that had parasitic infections on arrival. These results lend support to the suppressive effect of intestinal parasites on allergy, but suggest that additional factors, most probably environmental, also play a role in the generation of allergy.