Perinatal and neonatal risk factors for retinopathy of prematurity in very low birthweight, very preterm twins: a population-based study

OBJECTIVE

To determine the effect of perinatal and neonatal risk factors on retinopathy of prematurity (ROP) and to examine the association of fertility treatments on the risk for ROP in very low birth weight (VLBW) preterm twins.

METHODS

The population-based observational study consisted of VLBW twins born at 24-29 weeks gestational age (GA). Data from the Israel national database (1995-2020) were applied. Univariate and multivariable logistic regression using the General Estimating Equation were used for assessment of risk factors.

RESULTS

The study population comprised 4092 infants of whom 2374 (58%) were conceived following fertility treatments. ROP was diagnosed in 851 (20.8%) infants. The odds for ROP approximately doubled with each week decrease in GA: at 24 weeks, Odds Ratio (OR) 58.00 (95% confidence interval (CI) 31.83-105.68); 25 weeks, OR 25.88 (95% CI 16.76-39.96); 26 weeks, OR 12.69 (95% CI 8.84-18.22) compared to 29 weeks GA. Each decrease in one birthweight z-score was associated with 1.82-fold increased risk for ROP (OR, 1.82, 95% CI 1.59-2.08). Infertility treatments were not associated with ROP. Neonatal morbidities significantly associated with ROP were surgical necrotizing enterocolitis (NEC) (OR, 2.04, 95% CI 1.31-3.19); surgically treated patent ductus arteriosus (PDA) (OR, 1.63, 95% CI 1.12-2.37); sepsis (OR, 1.43, 95% CI 1.20-1.71) and bronchopulmonary dysplasia (OR, 1.52, 95% CI 1.22-1.90).

CONCLUSION

Among preterm VLBW twins, poor intrauterine growth and surgical interventions for NEC and PDA were associated with high odds for ROP. This study does not support an association of fertility treatments with increased risk for ROP.

The first three years: The association of early postpartum depressive symptoms with infant and toddler development

BACKGROUND

The influence of postpartum depression (PPD) on child development has been a source of professional interest and practical relevance.

OBJECTIVE

This study investigated the association of early PPD symptoms with developmental domains.

DESIGN AND METHOD

This historical cohort study included 574,282 children attending Mother Child Healthcare Centers in Israel from January 1, 2014 to July 31, 2020, who underwent at least one developmental screening examination by public health nurses up to age 36 months, and whose mothers completed the Edinburgh Postnatal Depression Scale (EPDS) postnatally. Developmental milestone tasks included four domains: fine and gross motor, language/communication, and social/behavioral.

RESULTS

The rate of failure to complete age-appropriate tasks was higher among children whose mothers had scored ≥ 10 on the EPDS on the majority of tasks in every domain.

DISCUSSION

This large population-based study has demonstrated the association between early maternal postnatal depressive symptoms and failure to meet developmental milestones across domains, until three years. Recommendations for practice focus on the mother, the child, and health policy.

Late-Onset Sepsis in Very Low Birth Weight Infants

BACKGROUND AND OBJECTIVES

Late-onset sepsis is associated with significant morbidity and mortality among very low birth weight (VLBW) infants. Our objective was to determine risk factors associated with late-onset sepsis and to present temporal trends in overall and pathogen-specific rates.

METHODS

Population-based study by the Israel Neonatal Network on VLBW infants (≤1500 g) born between 1995 and 2019. Late-onset sepsis required clinical symptoms and microbiologic confirmation. Bivariate and multivariable analyses were performed to identify risk factors. The study period was divided into 4 epochs. Overall and pathogen-specific late-onset sepsis rates for each epoch were compared.

RESULTS

The study population comprised 31 612 VLBW infants, of whom 7423 (23.5%) had late-onset sepsis. An increased adjusted risk of late-onset sepsis was associated with gestational age <27 w (odds ratio [OR] 8.90, 95% confidence interval [CI] 7.85-10.09) and delivery room resuscitation (OR 1.43, 95% CI 1.34-1.52) and a decreased adjusted risk among infants born between 2013 and 2019 (OR 0.32, 95% CI 0.29-0.35). Late-onset sepsis rates declined from 29.5% in 1995 to 2000 to 13.0% in 2013 to 2019. Gram-negative and fungal rates decreased in all epochs, whereas gram-positive rates decreased only in the last epoch. The adjusted hazard ratios (95% CI) decreased in the 2013 to 2019 versus 1995 to 2000 epochs and were: all late-onset sepsis, 0.40 (0.37-0.43); gram-positive, 0.47 (0.37-0.59); gram- negative, 0.54 (0.48-0.61); fungal, 0.17 (0.12-0.22).

CONCLUSIONS

The strongest risk factor for late-onset sepsis was gestational age <27 w. Over a 25-year period, the pathogen-specific rates of late-onset sepsis among VLBW infants decreased approximately twofold for gram-positive and gram-negative bacterial infections and sixfold for fungal infections.

Reconsidering the effectiveness of low-dose aspirin in prevention of pre-eclampsia among otherwise low risk twin gestations: A historical cohort study

OBJECTIVE

To investigate the effectiveness of low-dose aspirin (LDA) in the prevention of pre-eclampsia (PE) among otherwise low-risk twin gestations.

METHODS

A historical cohort study consisting of all pregnant individuals with dichorionic diamniotic (DCDA) twin pregnancy who delivered between 2014 and 2020. Patients treated with LDA were matched by a 1:4 ratio to individuals who were not treated with LDA by age, body mass index and parity.

RESULTS

During the study period, 2271 individuals carrying DCDA pregnancies delivered at our center. Of these, 404 were excluded for one or more additional major risk factors. The remaining cohort consisted of 1867 individuals of whom 142 (7.6%) were treated with LDA and were compared with a 1:4 matched group of 568 individuals who were not treated. The rate of preterm PE did not differ significantly between the two groups (18 [12.7%] in the LDA group vs. 55 [9.7%] in the no-LDA group; P = 0.294, adjusted odds ratio 1.36, 95% confidence interval 0.77-2.40). There were no other significant between-group differences.

CONCLUSIONS

Low-dose aspirin treatment in pregnant individuals with DCDA twin gestations without additional major risk factors was not associated with a reduction in the rate of preterm PE.

Risk factors for blood component therapy in parturients-Case-control study

OBJECTIVE

Postpartum hemorrhage is a major cause of maternal morbidity and mortality, so early identification of patients at risk is crucial. In this study, we aim to assess the risk factors for major transfusion in parturients.

METHODS

A case-control study was conducted between 2011 and 2019. The cases included women who were treated with postpartum major transfusion compared with two control groups, one of which was treated with 1-2 packed red blood cells and one of which was not treated with packed red blood cells. Cases were matched with controls based on two variables: multiple pregnancies and previous history of three or more cesarean sections. A multivariable conditional logistic regression model was used to determine the role of the independent risk factors.

RESULTS

Of the 187 424 deliveries included in the present study, 246 (0.3%) women were treated with major transfusions. After applying a multivariate analysis, maternal age (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.996-1.16), antenatal anemia with hemoglobin less than 10 g/dL (OR 12.58, 95% CI 2.86-55.25), retained placenta (OR 5.5, 95% CI 2.15-13.78), and cesarean delivery (OR 10.12, 95% CI 0.93-1.95) remained independent risk factors for major transfusions.

DISCUSSION

Retained placenta and antenatal anemia (hemoglobin < 10 g/dL) are independent risk factors for major transfusion. Of these, anemia was found to be the most significant.

Thrombocytopenia and Bloodstream Infection: Incidence and Implication on Length of Stay in the Pediatric Intensive Care Unit

The incidence and prognosis of thrombocytopenia in critically ill patients with bloodstream infection (BSI) is not well delineated in the pediatric intensive care unit (PICU) setting. We assessed these variables in our PICU and sought to determine whether thrombocytopenia could serve as a prognostic marker for length of stay (LOS). The study was conducted at the medical PICU of a university hospital, on all critically ill pediatric patients consecutively admitted during a 3-year period. Patient surveillance and data collection have been used to identify the risk factors during the study period. The main outcomes were BSI incidence and implication on morbidity and LOS. Data from 2,349 PICU patients was analyzed. The overall incidence of BSI was 3.9% (93/2,349). Overall, 85 of 93 patients (91.4%) with BSI survived and 8 patients died (8.6% mortality rate). The overall incidence of thrombocytopenia among these 93 patients was 54.8% (51/93) and 100% (8/8) for the nonsurvivors. Out of the 85 survivors, 27 thrombocytopenic patients were hospitalized for >14 days versus 14 of nonthrombocytopenic patients (p = 0.007). Thrombocytopenia was associated with borderline significance with an increased LOS (adjusted odds ratio = 3.00, 95% confidence interval: 0.93–9.71, p = 0.066). Thrombocytopenia is common in critically ill pediatric patients with BSI and constitutes a simple and readily available risk marker for PICU LOS.

Preterm Singleton Birth Rate during the COVID-19 Lockdown: A Population-Based Study

OBJECTIVE

The aim of the study is to evaluate the effect of the coronavirus disease 2019 (COVID-19) pandemic national lockdown period on the rate of singleton preterm births in Israel.

STUDY DESIGN

This is a population-based cohort study of 3,41,291 singleton infants born in the months of January to July 2017 to 2020. Multivariable logistic regression analyses were used to estimate the influence of period and year on the rates of preterm births during the lockdown period (11^th March - 5^th May 2020) compared with rates before (January 1^st 2020 - March 10^th 2020), and after the lockdown (May 6^th 2020-June 30^th 2020) and to the corresponding periods in 2017to 2019.

RESULTS

During the lockdown period the preterm birth rate (primary outcome) decreased by 9.7% from 5.05 to 4.56% in the pre-lockdown period (p = 0.006), an adjusted decrease of -0.52% (95% confidence interval -0.89%; -0.15%), odds ratio 0.898 (95% confidence interval 0.832; 0.970).

CONCLUSION

The rate of singleton preterm births declined by 9.7% during the COVID-19 pandemic national lockdown period in Israel.

KEY POINTS

· A 10% decline in all preterm deliveries was observed during the COVID-19 pandemic national lock-down period.. · The lock-down might influence environmental changes which contribute to the decrease in preterm deliveries.. · Changes in lifestyle, and societal behavior might contribute to the decrease in preterm deliveries..

Missed initial appointments at Israeli child development centres: Rate, reasons, and associated characteristics

INTRODUCTION

Missed appointments (MAs) at child development centres (ChDCs) cause multiple problems: they preclude timely diagnosis and treatment of both the invited child and children whose appointment was delayed due to overbooking, as well as disrupting efficient organisational management. The aim of this study was to assess the rate and describe the reasons for missed appointments at Israeli ChDCs, and to evaluate the association of socio-demographic, clinical, and administrative variables with MA rates.

METHODS

This nested case-control study included all children scheduled for initial appointments (N = 1143) at three centres during 1 year. Parents of children who missed their appointment and a sample of those who attended were interviewed by telephone.

RESULTS

The rate of missed appointments was 26.6%, and the most frequent reasons were unexpected events (26.0%) and lack of insurance coverage (23.4%). Variables associated with lower MA rates were: having had ≥3 types of rehabilitative interventions (odds ratios (OR) = 0.26; 95% confidence interval [CI] 0.16-0.44), detailed referral letter (OR = 0.48; 95%CI 0.30-0.75), telephone reminder (OR = 0.37; 95%CI 0.24-0.57) and health maintenance organisations or private insurance coverage (OR = 0.12; 95%CI 0.06-0.17 and OR = 0.56; 95% CI 0.38-0.89, respectively).

CONCLUSION

Encouraging physician's referral letters and personal-contact reminders can reduce missed appointments. Understanding the family's and the child's personal characteristics, and the organisational/administrative aspects of missed appointments may guide efforts to ensure timely care for every child.

Attention-Deficit/Hyperactivity Disorder and Obesity: A National Study of 1.1 Million Israeli Adolescents

PURPOSE

The incidences of obesity and attention-deficit/hyperactivity disorder (ADHD) have increased in parallel over recent decades. We assessed the association between obesity and ADHD in a national sample of adolescents.

METHOD

In a nationwide population-based study of 1 118 315 adolescents (57% males; mean age 17 years), risks of obesity were compared between individuals with severe and mild ADHD and those without ADHD. Diagnoses of ADHD were confirmed by specialists in either neurology or psychiatry. Adolescents requiring regular and continuous treatment with stimulants with no improvement of symptoms under treatment were classified as having severe ADHD; data were available from 2004 to 2019. During 2015 to 2019, the diagnosis of ADHD was defined, and 65 118 (16.76%) of 388 543 adolescents with mild symptoms who required medications only for learning or who used stimulants irregularly were defined as having mild ADHD.

RESULTS

The prevalence of severe and mild ADHD was 0.3% and 20.1%, respectively. Obesity was more prevalent among adolescents with severe ADHD than among those without ADHD (13.5% vs 7.5%). In the mild ADHD group 12.6% of males and 8.4% of females were diagnosed with obesity compared to 9.7% and 6.4%, respectively, in the non-ADHD group. The adjusted odds of severe ADHD for males and females with obesity were 1.77 (1.56-2.02) and 2.09 (1.63-2.66) times the odds for males and females with low-normal body mass index, respectively, and 1.42 (1.37-1.48) and 1.42 (1.34-1.50) for males and females with mild ADHD, respectively. The elevated risk persisted in several sensitivity analyses.

CONCLUSIONS

Both adolescents with severe and mild ADHD are at increased risk for obesity.

Subfertility, use of fertility treatments and BRCA mutation status and the risk of ovarian cancer

PURPOSE

The objective of the study is to evaluate the possible association between history of subfertility, fertility treatments, BRCA mutations and the risk of ovarian cancer.

METHODS

This Israeli National Case-Control study included 1269 consecutive ovarian cancer cases and 2111 individually matched healthy controls. All participants were interviewed and molecular analysis of BRCA mutations were performed to 896 cases. The main outcome measure was reported history of subfertility and exposure to fertility treatments.

RESULTS

The rate of reported subfertility was 15.1% and 14.3% in ovarian cancer cases and controls, respectively. However, subfertility was more prevalent in cases with borderline ovarian cancer (but not for invasive ovarian cancer cases) than controls. Multivariate conditional logistic regression revealed that the risk of borderline ovarian cancer was elevated in both women treated for subfertility and those that were not treated for subfertility, (OR = 1.74; 95% CI 0.9-3.36 and OR = 1.79; 95% CI 0.98-3.26, respectively). In non-carriers of BRCA1/2 mutations, fertility treatments were associated with a decreased risk of invasive ovarian cancer while a significant increased risk of borderline ovarian cancer was observed (OR = 2.92, 95%CI 1.67-5.10).

CONCLUSIONS

Reported subfertility and exposure to fertility treatments were associated with borderline but not with invasive ovarian tumors. This association was more prominent in women who are non-carriers of a BRCA mutation.

Cesarean delivery on maternal request in Israel: Maternity department policies and obstetricians’ perspectives

Objective:

This study aimed to describe Israeli maternity departments’ policies regarding cesarean delivery on maternal request, and factors associated with obstetricians’ support for cesarean delivery on maternal request in specific scenarios.

Methods:

This multicenter cross-sectional study included 22 maternity department directors and 222 obstetricians from the majority of Israeli hospitals. Directors were interviewed and completed a questionnaire about their department’s cesarean delivery on maternal request policy, and obstetricians responded to a survey presenting case scenarios in which women requested cesarean delivery on maternal request. The scenarios represented profiles referring to the following factors: maternal age, poor obstetric history, pregnancy complications, and psychological problems. The survey also included the obstetricians’ socio-demographic information and questions about other issues associated with cesarean delivery on maternal request. The main outcome measures were department policies regarding cesarean delivery on maternal request and obstetricians’ support for cesarean delivery on maternal request in specific cases.

Results:

Policies were divided between allowing and prohibiting cesarean delivery on maternal request (n = 10 and 12, respectively), and varied regarding issues such as informed consent and pre-surgery consultation. Most of the obstetricians (96.5%) did not support cesarean delivery on maternal request in the “reference scenario” describing a young woman with no obstetric complications. Additional factors increased the rate of support. Support was greater among obstetricians aged > 45 (odds ratio = 2.11; 95% confidence intervals 1.33–3.36) and lower among females (odds ratio = 0.58; 95% confidence intervals 0.39–0.86). Obstetricians whose department policy was less likely to allow cesarean delivery on maternal request reported lower rates of support for cesarean delivery on maternal request in most cases.

Conclusion:

Policies and obstetricians’ support for cesarean delivery on maternal request vary broadly depending on clinical profiles and physician characteristics. Department policy has an impact on obstetricians’ support for cesarean delivery on maternal request. Health policy will benefit from a framework in which the organizations, physicians, and patients are consulted.

Antepartum Hemorrhage and Outcome of Very Low Birth Weight, Very Preterm Infants: A Population-Based Study

OBJECTIVE

We aimed to determine the independent effect of maternal antepartum hemorrhage (APH) on mortality and major neonatal morbidities among very low birth weight (VLBW), very preterm infants.

STUDY DESIGN

A population-based cohort study of VLBW singleton infants born at 24 to 31 weeks of gestation between 1995 and 2016 was performed. Infants born with the following pregnancy associated complications were excluded: maternal hypertensive disorders, prolonged rupture of membranes, amnionitis, maternal diabetes, and small for gestational age. APH included hemorrhage due to either placenta previa or placental abruption. Univariate and multivariable logistic regression analyses were performed to assess the effect of maternal APH on mortality and major neonatal morbidities.

RESULTS

The initial cohort included 33,627 VLBW infants. Following exclusions, the final study population comprised 6,235 infants of whom 2,006 (32.2%) were born following APH and 4,229 (67.8%) without APH. In the APH versus no APH group, there were higher rates of extreme prematurity (24-27 weeks of gestation; 51.6% vs. 45.3%, p < 0.0001), mortality (20.2 vs. 18.5%, p = 0.011), bronchopulmonary dysplasia (BPD, 16.1 vs. 13.0%, p = 0.004) and death or adverse neurologic outcome (37.4 vs. 34.5%, p = 0.03). In the multivariable analyses, APH was associated with significantly increased odds ratio (OR) for BPD in the extremely preterm infants (OR: 1.31, 95% confidence interval: 1.05-1.65). The OR's for mortality, adverse neurological outcomes, and death or adverse neurological outcome were not significantly increased in the APH group.

CONCLUSION

Among singleton, very preterm VLBW infants, maternal APH was associated with increased odds for BPD only in extremely premature infants, but was not associated with excess mortality or adverse neonatal neurological outcomes.

KEY POINTS

· Outcome of very low birth weight infants born after antepartum hemorrhage (APH) was assessed.. · APH was not associated with higher infant mortality.. · APH was not associated with adverse neurological outcome.. · APH was associated with increased bronchopulmonary dysplasia in extremely preterm infants..

How Are They Doing? Neurodevelopmental Outcomes at School Age of Children Born Following Assisted Reproductive Treatments

OBJECTIVE

The purpose of this study was to assess major neurodevelopmental aspects of children conceived by assisted reproductive treatments compared to spontaneously conceived children during the early school years.

MATERIAL & METHODS

In this follow-up study, mothers of 358 children born following assisted reproductive treatments and 401 spontaneously-conceived children were interviewed by telephone regarding their children's health and development, when the children were 7-8 years old. The main outcomes were maternal responses to 4 questionnaires: Developmental Coordination Disorder Questionnaire, Short Sensory Profile, Autism Spectrum Screening Questionnaire, and the Attention-deficit hyperactive disorder (ADHD) Child Symptom Inventory-4 subscale. Mothers reported diagnoses of ADHD and autism spectrum disorder.

RESULTS

No significant differences were found between the groups in Developmental Coordination Disorder Questionnaire or Short Sensory Profile scores upon univariate or multivariable analyses. There was a slightly higher but nonsignificant rate of diagnosed ADHD among children in the assisted reproductive treatment group (9.6% vs 5.5%; P = .18); on multivariable analysis, a nonsignificant increase in ADHD was also found for assisted reproductive treatment children (hazard ratio 1.45, 95% confidence interval 0.81-2.61). Regarding the Child Symptom Inventory-4 criteria for ADHD among the children who had never been diagnosed, there was also a slightly higher but nonsignificant rate among the assisted reproductive treatments compared to spontaneously-conceived children on univariate (2.4% vs 1.8%; P = .50) and multivariable analysis (odds ratio 0.88, 95% confidence interval 0.27-2.86). Autism spectrum disorder diagnosis or Autism Spectrum Screening Questionnaire scores were not significantly different; however, 5 of the 6 children with autism spectrum disorder diagnoses were in the assisted reproductive treatment group.

CONCLUSIONS

Neurodevelopmental measures were similar in both groups, although nonconclusive regarding ADHD and autism spectrum disorder risk. These findings contribute to the knowledge regarding long-term assisted reproductive treatment outcomes.

Abstract PR05: Utilizing electronic fertility clinic records and registry linkage to establish a retrospective population-based cohort study to evaluate the association between in vitro fertilization (IVF) and subsequent cancer risk in women

Background: Since the introduction of in vitro fertilization (IVF) in 1978, the use of assisted reproduction technology (ART) has increased annually with an estimated 240,000 ART-conceived children born each year worldwide. Despite its widespread use, the impact on subsequent maternal and child health is not well understood. Specifically, cancer risk in women receiving IVF treatment has not been adequately evaluated, in part due to the complex nature of the research question and the need for large numbers of exposed women with long follow-up to evaluate rare cancer outcomes.

Methods: To address this research question, we designed a country-wide retrospective medical record linkage study that utilizes electronic records from all IVF units in operation in Israel between 1997 and 2014. Linkage to cancer registry is facilitated via unique national identification numbers. We selected Israel for this study because it has the highest rate of ART/IVF exposure in the world, with 24 IVF units in the country that perform more than 45,000 ART cycles annually. Fertility treatment is fully covered by national health insurance with no restriction on the number of cycles or type of procedure, thus reducing potential selection issues related to access to care that may exist in other populations. We are currently collecting medically documented and detailed exposure information from the IVF units, including causes of infertility, hormonal treatments, procedures (e.g., IVF), and important covariates (e.g., parity, body mass index, etc.). To date we have collected exposure and covariate information from 18,470 women receiving treatment at 9 IVF clinics and conducted an interim linkage with the cancer registry through December 2014, providing on average 15 years of follow-up. We calculated standardized incidence ratios (SIRs) for all cancers combined and separately for breast cancer and further evaluated breast cancer risk with number of treatment cycles using Cox proportional hazards regression.

Results: Based on interim registry linkage we identified 611 invasive cancers including 272 breast cancers among 18,470 women with more than 236,000 woman-years of follow-up. The incidence of cancer [SIR (95% confidence interval (CI)): 0.96 (0.88-1.04)] or breast cancer [0.98 (0.87-1.11)] was not elevated compared to the general population. Further, breast cancer risk was not associated with increased number of IVF treatment cycles [adjusted hazard rate ratio (RR) (95% CI) per IVF cycle: 1.01 (0.96-1.09)].

Conclusions: With this data we have demonstrated the feasibility of linking IVF clinic data with the nationwide cancer registry to evaluate cancer risk. In our preliminary analyses, IVF treatment was not associated with risk of incident invasive cancer or breast cancer. Given that continued linkage with the cancer registry is feasible, we will be able to monitor long-term cancer risks associated with IVF treatment using the enumerated data.

This abstract is also being presented as Poster A15.

Citation Format: Britton Trabert, Galit Hirsh-Yechezkel, Adel Farhi, Inna Zaslavsky, Shai E. Elizur, Arik Kahana, Raoul Orvieto, Hananel Holzer, Ilan Calderon, Shevach Friedler, Einat Shalom-Paz, Raphael Ron-El, Arie Raziel, Louise A. Brinton, Liat Lerner-Geva. Utilizing electronic fertility clinic records and registry linkage to establish a retrospective population-based cohort study to evaluate the association between in vitro fertilization (IVF) and subsequent cancer risk in women [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr PR05.

Postnatal steroid therapy is associated with autism spectrum disorder in children and adolescents of very low birth weight infants

BACKGROUND

This study evaluates the association between major neonatal morbidities and autism spectrum disorder (ASD) in children and adolescents born of very low birth weight (VLBW).

METHODS

Historical cohort study using the Israel national VLBW infant database linked with the Maccabi Healthcare Services (MHS) medical records. The study cohort comprised 4963 VLBW subjects born from 1999 to 2012, >1 year of age. Multivariable logistic regression analyses were used to assess factors associated with ASD.

RESULTS

The diagnosis of ASD was confirmed in 113 children (2.3%). Infants with major neonatal morbidities had higher rates of ASD; however, in the multivariable analyses these were not significantly associated with ASD: severe intraventricular hemorrhage (OR 1.21 [95% CI 0.60-2.45]), post-hemorrhagic hydrocephalus (OR 1.77 [0.73-4.29]), periventricular leukomalacia (OR 1.02 [0.42-2.51]), severe retinopathy of prematurity (OR 1.91 [0.995-3.67]), and bronchopulmonary dysplasia (OR 1.44 [0.84-2.45]). Postnatal steroid therapy when included separately was associated with an OR of 1.97 [1.18-3.29] for ASD. This association remained significant when postnatal steroid therapy was included with each of the neonatal morbidities (ORs ranging from 1.91 to 2.11).

CONCLUSIONS

This study suggests a significant association between postnatal steroid therapy and ASD in VLBW infants. This possible association should be considered in future studies evaluating potential risk factors for ASD in preterm infants.

Cancer in IVF patients treated at age 40 years and older: long term follow-up

RESEARCH QUESTION

Current knowledge of cancer risk among women who undergo IVF is based mainly on studies of women treated in their thirties, frequently with short follow-up periods. Therefore, information about cancer risk among infertile menopausal women is limited. We aimed to evaluate the risk of cancer among IVF patients treated at age 40 years and older, followed up for an extended period.

DESIGN

Historical cohort study of all IVF patients treated at the age of 40 years or older at two university-affiliated IVF units in Jerusalem, Israel, between 1994 and 2002. Data were cross-linked with the Israel National Cancer Registry to 2016. Standardized incidence ratios (SIR) and 95% confidence intervals were computed by comparing the observed number of cancer cases with the expected cancer rate in the general Israeli population adjusted for age and year of birth. In addition, Kaplan-Meier analysis was conducted to account for the length of follow-up.

RESULTS

A total of 501 patients were included in the analysis, with mean follow-up of 16.7 ± 3.7 years (range 2-22 years). Mean age at first IVF cycle was 42.3 years (±2.1). Mean number of IVF cycles was 3.2 ± 2.6 (range 1-15). Thirty-six women (7.2%) developed invasive cancer, compared with 47.2 expected cases; SIR 0.76 (95% CI 0.53 to 1.06); 22 women were diagnosed with invasive breast cancer, compared with 19.84 expected; SIR 1.11 (95% CI 0.69 to 1.68).

CONCLUSIONS

Older women undergoing IVF treatment were not significantly associated with an excess risk of cancer at long-term follow up. Further studies, however, are needed to confirm these findings.

Mode of delivery and necrotizing enterocolitis in very preterm very-low-birth-weight infants

Objective: To investigate the association between delivery mode and necrotizing enterocolitis (NEC) in very preterm (24-31 weeks' gestational age (GA)) very-low-birth-weight (VLBW) (≤1500 g) infants.Design: Population-based observational study using univariate and multivariable logistic regression analyses.Setting: The Israel National VLBW infant database 1995-2015.Patients: 20,223 VLBW infants, 11,832 singletons and 8391 multiples.Main outcome measures: The association of NEC occurrence to delivery by cesarean section (CS) in singletons and multiples VLBW very preterm infants.Results: NEC occurred in 7.6% of singletons and 6.4% of multiples. 71.5% were delivered by CS (64.7% of singletons, 80.9% of multiples). CS delivery was not significantly associated with NEC stages 2-3 in singletons; but multiple births CS were associated with significantly higher odds for NEC (OR 1.31, 95% CI 1.01-1.69). Odds for NEC were greater with lower GA, small for GA (SGA) and patent ductus arteriosus (PDA) in both singletons and multiples, and lower in multiples with antenatal corticosteroids.Conclusions: We demonstrated association between deliveries by CS and increased risk for NEC only in multiple pregnancies.

Assessing and monitoring the impact of the national newborn hearing screening program in Israel

BACKGROUND

The Israeli Newborn Hearing Screening Program (NHSP) began operating nationally in January 2010. The program includes the Otoacoustic Emissions (OAE) test for all newborns and Automated Auditory Brainstem Response (A-ABR) test for failed OAE and infants at risk for auditory neuropathy spectrum disorders. NHSP targets are diagnosis of hearing impairment by age three months and initiation of habilitation by six months.

OBJECTIVES

(1) Review NHSP coverage; (2) Assess NHSP impact on age at diagnosis for hearing impairment and age at initiation of habilitation; (3) Identify contributing factors and barriers to NHSP success.

METHODS

(1) Analysis of screening coverage and referral rates for the NHSP; (2) Analysis of demographic data, results of coverage, age at diagnosis and initiation of habilitation for hearing impaired infants pre-implementation and post-implementation of NHSP from 10 habilitation centers; (3) Telephone interviews with parents whose infants failed the screening and were referred for further testing.

RESULTS

The NHSP coverage was 98.7% (95.1 to 100%) for approximately 179,000 live births per year for 2014-2016 and average referral rates were under 3%. After three years of program implementation, median age at diagnosis was 3.7 months compared to 9.5 months prior to NHSP. The median age at initiation of habilitation after three years of NHSP was 9.4 months compared to 19.0 prior to NHSP. Parents (84% of 483 sampled) with infants aged 4-6 months participated in the telephone survey. While 84% of parents reported receiving a verbal explanation of the screening results, more than half of the parents reported not receiving written material. Parental report of understanding the test results and a heightened level of concern over the failed screen were associated with timely follow-up.

CONCLUSIONS

The findings indicate high screening coverage. The program reduced ages at diagnosis and initiation of habilitation for hearing impaired infants. Further steps needed to streamline the NHSP are improving communication among caregivers to parents to reduce anxiety; increasing efficiency in transferring information between service providers using advanced technology while ensuring continuum of care; reducing wait time for follow-up testing in order to meet program objectives. Establishment of a routine monitoring system is underway.

Type of Re-Hospitalization and Association with Neonatal Morbidities in Infants of Very Low Birth Weight

BACKGROUND

Preterm infants are at high risk for long-term morbidities and an increased rate of re-hospitalization.

OBJECTIVE

The aim of this study was to evaluate the type of re-hospitalization of very low birth weight (VLBW) infants, from infancy through adolescence, and to assess the association of neonatal morbidities with specific types of re-hospitalization.

STUDY DESIGN

The study cohort comprised 6,385 VLBW infants who were registered with the Maccabi Healthcare Services (MHS) from their birth hospitalization. Data were collected for up to 18 years (median 10.7 years) following neonatal intensive care unit discharge. Hospitalization types were determined from the MHS coding. Neonatal morbidities included necrotizing enterocolitis (NEC), grades 3-4 intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using the Cox proportional hazards model.

RESULTS

Overall, 3,956 infants were re-hospitalized at least once and a total of 11,595 hospitalization types were identified. NEC, IVH, PVL, and BPD were associated with significantly higher aHRs for general pediatric (aHR 1.28-1.55), general surgical (aHR 1.18-1.46), and pediatric intensive care unit (aHR 1.57-2.04) hospitalizations. IVH and PVL were associated with significantly higher aHRs for orthopedic (aHR 2.12 and 4.88, respectively) and ophthalmology (1.76 and 4.02, respectively) hospitalizations. IVH was associated with a 14.2-fold higher aHR for neurosurgical admissions, and ROP with a 1.62-fold higher aHR for ophthalmology hospitalizations.

CONCLUSION

Among VLBW infants, specific patterns of re-hospitalization types associated with major neonatal morbidities were identified as particularly high risks for orthopedic and ophthalmology hospitalizations in infants with IVH and PVL, and for intensive care admissions in infants with NEC and BPD.

Bariatric surgery in patients with type 1 diabetes: special considerations are warranted

OBJECTIVE

We examined short and long-term outcomes of bariatric surgery in patients with obesity and type 1 diabetes mellitus (T1DM).

METHODS

We reviewed the records of all adults insured by Maccabi Healthcare Services during 2010 -2015, with body mass index (BMI) ⩾30 kg/m2 and T1DM; and compared weight reduction and glucose control according to the performance of bariatric surgery. BMI and glycated hemoglobin (HbA1c) levels were extracted for baseline and every 6 months, for a mean 3.5 years.

RESULTS

Of 52 patients, 26(50%) underwent bariatric surgery. Those who underwent surgery were more often female and with a longer duration of diabetes. Immediately postoperative, 4(15%) developed diabetic ketoacidosis, while 6(23%) experienced severe hypoglycemic episodes. The mean BMI decreased among surgery patients: from 39.5±4.4 to 30.1±5.0 kg/m2 (p < 0.0001); and increased among those who did not undergo surgery: from 33.6±3.9 to 35.1±4.4 kg/m2 (p = 0.49). The mean HbA1c level decreased during the first 6 months postoperative: from 8.5±0.9% to 7.9±0.9%; however, at the end of follow-up, was similar to baseline, 8.6±2.0% (p = 0.87). For patients who did not undergo surgery, the mean HbA1c increased from 7.9±1.9% to 8.6±1.5% (p = 0.09).

CONCLUSIONS

Among individuals with obesity and T1DM, weight loss was successful after bariatric surgery, but glucose control did not improve. The postoperative risks of diabetic ketoacidosis and severe hypoglycemic episodes should be considering when performing bariatric surgery in this population.

Risk factors and epidemiology of pediatric ventriculoperitoneal shunt infection

BACKGROUND

The aim of this study was to identify independent risk factors for cerebrospinal fluid shunt infection.

METHODS

The medical records of all patients aged 0-18 years who underwent shunt-related surgery for the treatment of hydrocephalus at the present institution between January 1996 and December 2015 were reviewed. For each case, two randomly selected controls with no shunt infection, matched for year of surgery, were chosen. Demographic clinical and microbiological data were abstracted.

RESULTS

A total of 1,570 shunt-related procedures met the inclusion criteria, yielding 68 infections (in 63 patients). The control group consisted of 132 infection-free patients. The average annual infection rate was 4.2% cases per year. The median time between shunt procedures to infection was 19 days (range, 1-2,181). On multivariate analysis, risk factors associated with increased risk for developing an infection included a history of two or more previous revisions (OR, 4.8; 95%CI: 1.5-15.9); and age <5 years (OR, 4.5; 95%CI 1.5-13.4). A neoplastic etiology for hydrocephalus was found to be a protective factor for shunt infection (P = 0.001).

CONCLUSIONS

A history of shunt revision was the most significant risk factor in the development of subsequent shunt infection. Age >5 years was a protective factor. Future efforts should focus on modalities to optimize revision procedures and reduce the risk of subsequent infection.

Deliveries following fertility preservation by ovarian tissue cryopreservation without autotransplantation-what should be expected?

OBJECTIVE

To evaluate the delivery rate and to characterize patients following ovarian tissue cryopreservation (OTCP) who did not undergo auto-transplantation.

METHODS AND MATERIALS

All consecutive cancer patients admitted to our IVF unit, from January 2004 to December 2015, who underwent OTCP for the purpose of fertility preservation without autotransplantation were analyzed. The cohort included 338 patients and was linked to the National Live Birth registry of the Israel Ministry of Health in order to determine whether the women delivered following the cancer diagnosis.

MAIN OUTCOME MEASURES

Delivery rate following OTCP without autotransplantation.

RESULTS

During 6.4 years of follow-up, 30% of the patients delivered, with no differences in gravity, age at first diagnosis of cancer, type of malignancy, or the prevalence of relapse of malignancy between those who delivered and those who did not. Moreover, in multivariate analysis, those undergoing OTCP before the age of 30 and those suffering from breast cancer had significantly higher odds to conceive and deliver following cancer treatment without the need of autotransplantation.

CONCLUSIONS

Further studies are required to elucidate the appropriate subgroup of patients with breast cancer under the age of 30 years, who will need OTCP. This information might aid both fertility specialists' counseling and their oncological patients in pursuing the appropriate fertility preservation strategy.

Focus on fathers: paternal depression in the perinatal period

Aims:

This report aims to present a concise overview and synthesis of current research findings regarding paternal depression in the perinatal period.

Methods:

A literature search was conducted, primarily via PubMed and PsychNET, for English-language research studies and meta-analyses using combinations of the terms ‘perinatal’, ‘pregnancy’, ‘postpartum’, ‘depression’ AND ‘fathers’ OR ‘paternal’. Peer-reviewed articles were considered, and a representative sample of literature, with an emphasis on recent publications from a broad range of populations was summarized for each of the following sub-sections: prevalence, risk factors, impact on the infant/child, and healthcare costs.

Results:

Reported prevalence has ranged from 2.3% to 8.4%, with a significant degree of heterogeneity in rates, due to differences in multiple aspects of the methodology (timing, instruments, etc.). Nevertheless, rates of maternal depression remain higher than paternal depression, and higher rates of one are associated with higher rates of the other. The primary risk factors for paternal depression are maternal depression and the father’s history of severe depression, or symptoms of depression or anxiety prenatally. Biological mechanisms may underlie paternal depression, with changes reported in testosterone, cortisol and prolactin levels during this period. Paternal depression has been related to children’s behavioral, emotional and social function at 36 months and psychiatric disorders at 7 years, adjusting for maternal depression. Healthcare costs may also be impacted by paternal postpartum depression, with higher father–child dyad costs found after controlling for potential confounders.

Conclusions:

Focusing on fathers’ emotional well-being in the perinatal period is important in itself, as well as for their wives and children. Programs recommending screening for maternal perinatal mood and anxiety disorders should include inquiry regarding the father’s emotional state, and if his distress is reported it should be clarified and followed-up by support and intervention as necessary.

Knowledge of risk factors and prevention of osteoporosis: the Israeli women's health at midlife study

Wide disparities in knowledge of risk factors and prevention of osteoporosis were demonstrated among midlife Israeli minority women (Arabs and immigrants from the former USSR) compared to Jewish long-time residents. Women who believed osteoporosis to be a serious disease and those who felt susceptible to it reported better knowledge.

PURPOSE

The main goals of this study were to assess knowledge of risk factors and preventive measures for osteoporosis in middle-aged women and to evaluate the relationship of knowledge to personal risk factors and personal perceptions about osteoporosis.

METHODS

Face-to-face interviews with women aged 45-64 years were conducted during 2004-2006 within three population groups: long-term Jewish residents (LTJRs), immigrants from the former Soviet Union, and Arab women. The survey instrument included five knowledge statements related to the risk after menopause, the risk of smoking, family history of fractures, decreased risk by physical activity, and by use of medications.

RESULTS

The findings indicated wide disparities in knowledge about risk factors and preventive behavior of osteoporosis between the two minority groups (immigrants from the former Soviet Union and Arab women) and the majority group of midlife Israeli women. Knowledge of osteoporosis was related to perceived severity of the disease and partly to perceived susceptibility to osteoporosis. Past diagnosis of osteoporosis, current or past smoking status, and BMI were unrelated to knowledge in multivariate analyses.

CONCLUSIONS

There is a need to improve knowledge of osteoporosis especially among less educated and minority women. Subjective perception of risk was more strongly related to knowledge than actual risk factors and should be targeted in public campaigns. The efforts should be aimed at strengthening women's perception of their own susceptibility to osteoporosis and of the severity of this disease.

Increased prevalence of disordered eating in the dual diagnosis of type 1 diabetes mellitus and celiac disease

BACKGROUND

Disordered eating behaviors (DEBs) may lead to full blown eating disorders. Both type 1 diabetes mellitus (T1DM) and celiac disease (CD) have been linked to DEBs.

OBJECTIVE

To compare the presence of DEBs between adolescents and young adults with a dual diagnosis of T1DM and CD, and individuals with only one of the diagnoses.

METHODS

Individuals with a dual diagnosis of T1DM and CD ("T1DM + CD group" n = 39), with a diagnosis of T1DM only ("T1DM group" n = 97) and with a diagnosis of CD only ("CD group" n = 267) filled the Eating Attitude Test-26 (EAT-26) questionnaire. Those with T1DM completed in addition to the Diabetes Eating Problem Survey-Revised (DEPS-R).

RESULTS

The study population comprised of 403 individuals, of whom 65% were females. There were no statistically significant differences among the groups in distribution of sex, age, hemoglobin A1c (HbA1c) levels, age of disease diagnosis and duration. The prevalence of DEBs in the T1DM + CD group was 3-fold higher (26.0%) than in the T1DM (8.2%) and CD (8.2%) groups (P = .003). This trend was observed for both females and males. Multivariate analysis demonstrated that the T1DM + CD group had an increased risk for DEBs (odds ratio, OR: 4.7, 95% confidence interval, CI: 1.9-11.2, P = .001) after adjustment for age, sex, and body mass index. Additionally, being female, older and overweight increased the risk for DEBs. HbA1c values were not associated with an increased DEBs rate.

CONCLUSIONS

Individuals with the dual diagnoses of T1DM and CD have an increased likelihood to develop DEBs compared to those with only one of these diagnoses.

When the Ideal Meets the Feasible: Constructing a Protocol for Developmental Assessment at Early School-Age

Objective: To describe development of a methodology for an outcome study of children born following in-vitro fertilization or spontaneously-conceived, as a model for defining normal and below-normal development of school-age children for research purposes. Study Design: The main issues addressed were defining the major health and developmental domains to be investigated, selection of age-appropriate validated instruments, considering time constraints to maximize compliance, and budgetary limitations. The final protocol included a half-hour structured telephone interview with mothers of all 759 children and a 2-h developmental assessment of 294 of them. Each of the instruments and recruiting methods are described in terms of the abovementioned considerations. Results: Almost all of the mothers who agreed to be interviewed completed it within the half-hour allotted; however only about half of those who agreed to bring the child for the developmental assessment actually did so. The entire examination battery, assessing cognitive ability, executive functions, attention, and learning skills, was completed by almost all 294 children. There was a significant degree of agreement between the maternal report of the child's reading, writing and arithmetic skills and the in-person examination, as well as regarding the child's weight and height measurements. Conclusion: The findings lend support for a low-budget study, relying on telephone interviews. However, limitations such as the validity of maternal report and recall bias must be taken into consideration.

Rehospitalization Through Childhood and Adolescence: Association with Neonatal Morbidities in Infants of Very Low Birth Weight

OBJECTIVE

To evaluate the impact of major neonatal morbidities on the risks for rehospitalization in children and adolescents born of very low birth weight.

STUDY DESIGN

An observational study was performed on data of the Israel Neonatal Network linked together with the Maccabi Healthcare Services medical records. After discharge from the neonatal intensive care unit, 6385 infants of very low birth weight born from 1995 to 2012 were registered with Maccabi Healthcare Services and formed the study cohort. Multivariable negative binomial regression models were calculated to estimate the adjusted relative risk (aRR) and 95% CI for hospitalization.

RESULTS

Up to 18 years following discharge, 3956 infants were hospitalized at least once. The median age of follow-up was 10.7 years with total of follow-up of 67 454 patient years and 10 895 hospitalizations. The risks for rehospitalization were increased significantly for each of the neonatal morbidities: surgical necrotizing enterocolitis (NEC), aRR 2.71 (95% CI 2.08-3.53), intraventricular hemorrhage grades 3-4, 2.13 (1.85-2.46), periventricular leukomalacia (PVL), 1.83 (1.58-2.13), bronchopulmonary dysplasia, 1.94 (1.72-2.17), and retinopathy of prematurity stages 3-4, 1.59 (1.36-1.85). During the first 4 years, children with surgically treated NEC, intraventricular hemorrhage, PVL, or bronchopulmonary dysplasia had 1.5- to 2.5-fold greater risks for hospitalization compared with those without the specific morbidity. In the 11th-14th and 15th-18th years, respectively, surgically treated NEC was associated with a 3.05 (1.32-7.04) and 3.26 (0.99-10.7) aRR for hospitalization, and PVL was associated with a 2.67 (1.79-3.97) and 3.47 (2.03-5.92) aRR for hospitalization.

CONCLUSIONS

Specific major neonatal morbidities as well as the number of morbidities were associated with excess risks of rehospitalization through childhood and adolescence.

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.

Possible risk for cancer among children born following assisted reproductive technology in Israel

BACKGROUND

Among children conceived by assisted reproductive technology (ART), increased risk of adverse birth outcomes has been observed, including multiple births, preterm births, and congenital malformations. Regarding cancer among ART-conceived children, findings are discrepant.

METHODS

This is a historical cohort of 9,042 ART-conceived children and 211,763 spontaneously conceived (SC) children born from 1997 through 2004. The median duration of follow-up was 10.6 years (interquartile range 9.0-12.3) in the ART group and 9.3 years (interquartile range 8.0-10.6) in the SC group. The cohort database was linked with the Israel National Cancer Registry updated until December 31, 2011 using each child's personal identification number.

RESULTS

Twenty-one cases of cancer were identified in the ART group (2.2 per 10,000 person-years), as compared to 361 cancer cases in the SC group (1.8 per 10,000 person-years). The relative risk (RR) for overall cancer in the ART group compared to the SC group adjusted for maternal characteristics was 1.18 (95% confidence interval [CI] 0.80-1.75). ART children had a significantly increased risk for specific cancers, although based on small number of cases, including two cases of retinoblastoma (RR 6.18, 95% CI 1.22-31.2), as well as four cases of renal tumors (RR 3.25, 95% CI 1.67-6.32).

CONCLUSION

A statistically significant increased risk for two pediatric cancers was found. However, for overall types of cancer the risk estimate was elevated but not statistically significant. Further studies with larger sample size and longer follow-up time are warranted in order to either confirm or refute these findings.

Sexual lifestyle among young adults with type 1 diabetes

BACKGROUND

Sexual lifestyles including sexual activity, problems, satisfaction, and the formation and maintenance of relationships are greatly affected by physical health. Data are limited regarding the sexual lifestyle of adolescents and young adults with type 1 diabetes mellitus (T1DM). Fear of hypoglycemic episodes during sexual intercourse and intimacy issues can impact individuals with T1DM. The aim of this study was to assess sexual lifestyles of individuals with T1DM.

METHODS

Fifty-three patients with T1DM, 27 (51%) males, mean ± SD age 27.9 ± 8.3 years completed the Hypoglycemia Fear Survey-II and the Sex Practices and Concerns questionnaire.

RESULTS

Thirty-seven (70%) reported they never or almost never had concerns in their sexual lifestyles that were related to their diabetes. None experienced severe hypoglycemia during sex, but 21 (40%) reported occasional mild hypoglycemic events. More than two-thirds do not take any measures to prevent hypoglycemia before sex (decreasing insulin dose, snacks, and measuring blood glucose levels). Fear of hypoglycemia during sex was reported by 18 (35%); those who reported increased fear experienced mild hypoglycemic events during sex (61.1% vs 26.5%, P = .01), were singles (94.4% vs 64.7%, P = .02), and had higher scores on the Worries subscale of the Hypoglycemia Fear Survey-II (42.8 ± 12.8 vs 34.9 ± 10.5, P = .04) compared with those who did not.

CONCLUSIONS

Among young people with T1DM, most do not have concerns regarding sex that are related to their diabetes, and most do not take specific measures before or after sex. One-third, however, fear of hypoglycemia during sex, mostly singles and those who experienced hypoglycemia in the past. Caregivers should be aware and address these concerns. Copyright © 2016 John Wiley & Sons, Ltd.

Health and functioning of adolescents conceived by assisted reproductive technology

OBJECTIVE

To evaluate the general health, mental health, and cognitive ability of assisted reproductive technology (ART)-conceived adolescents.

DESIGN

A nested case-control study within a historic cohort.

SETTING

Not applicable.

PATIENT(S)

A total of 253 ART-conceived adolescents born between 1982 and 1993 and 253 matched references according to birth year, gender, and the high-school they attended.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Medical and psychiatric diagnoses, and cognitive ability recorded at the military preinduction screening (ages 16-17 years) and doctor's appointments throughout the military service.

RESULT(S)

No differences were detected in general and mental health of ART adolescents or cognitive ability, compared with the reference group. Similar results were obtained after stratification for gender and singleton births. The ART adolescents had fewer cases of discharge from military service due to health reasons (4% vs. 8.3%). Follow-up during the military service revealed that male ART adolescents had significantly more doctor's appointments compared with the reference group (23.80 ± 15.59 vs. 19.95 ± 13.79).

CONCLUSION(S)

Our preliminary results provide reassurance that in the long-run health and functioning of ART-conceived adolescents is not compromised. Further studies with larger cohorts are needed to confirm these results.

Knowledge and recommendation regarding routine childhood vaccinations among pediatric healthcare providers in Israel

BACKGROUND

A recommendation by pediatric healthcare providers (HCPs) is a major factor influencing parents' decision to vaccinate their children. Consequently, it is important to understand the motives behind the HCPs' recommendations to vaccinate children according to the routine immunization program.

OBJECTIVES

To study the association of pediatric HCPs' knowledge about and attitudes towards childhood vaccinations and of their professional and demographic characteristics, with two variables: 1. Their recommendations to parents regarding adherence to the routine immunization program. 2. Their choices concerning routine immunization of their own children.

STUDY DESIGN AND SETTINGS

We conducted a cross-sectional study of pediatric nurses and physicians working at Mother-Child Health Clinics (MCHCs) in Haifa and Tel-Aviv districts and at a hospital in Hadera City, Israel.

METHODS

A structured, anonymous self-administered questionnaire was used.

RESULTS

The overall response rate was 60%, totaling 218 participants. 92% of whom were nurses. Misconceptions related to vaccine safety were found among a high percentage of the participants. The HCPs knowledge level was associated with the HCPs vaccinating their own children according to the recommended immunization program (OR=1.32; CI95% 1.06-1.64), but not with their recommendation to parents to adhere to the program. No association was found between attitudes and these variables. Workplace (MCHCs versus hospital) correlated with the above mentioned two dependent variables (OR=1.89; CI95% 1.21-2.97 and OR=2.42; CI95% 1.73-3.4, respectively).

CONCLUSIONS

Amplifying the knowledge of HCPs and addressing their concern about vaccinations can improve their adherence to the routine immunization program regarding their own children. This may lead to better adherence of other parents who are frequently interested in the HCPs' behavior and consider them as a role model. In general, there is a need to emphasize the HCP's responsibility for the successful implementation of the immunization program in the community and at hospitals.

Association between neonatal morbidities and head growth from birth until discharge in very-low-birthweight infants born preterm: a population-based study

AIM

To evaluate the possible association between major neonatal morbidities and poor head growth from birth to discharge home in very-low-birthweight (VLBW) infants born preterm.

METHOD

Population-based observational study comprising 12 992 infants (6340 male, 6652 female) of 24 to 32 weeks' gestation, and birthweight ≤1500g. Severe head growth failure (HGF) was defined as a decrease in head circumference z-score >2 z-scores, and moderate HGF as a decrease of 1 to 2 z-scores. Multinomial logistic regression analysis was applied to determine morbidities associated with HGF.

RESULTS

Severe HGF occurred in 4.5% and moderate HGF in 20.9% of infants. Each unit increase in head circumference z-score at birth was associated with increased odds for severe and moderate HGF (odds ratios [OR] 5.29, 95% confidence intervals [CI] 4.67-6.00, and OR 2.38, 95% CI 2.23-2.54 respectively). Both severe and moderate HGF were associated with respiratory distress syndrome (OR 2.03, 95% CI 1.58-2.62, and OR 1.66, 95% CI 1.48-1.85 respectively); bronchopulmonary dysplasia (OR 3.38, 95% CI 2.33-4.91, and OR 1.87, 95% CI 1.52-2.30 respectively); necrotizing enterocolitis (OR 2.89, 95% CI 2.04-4.09, and OR 1.72, 95% CI 1.38-2.16 respectively), and sepsis (OR 2.06, 95% CI 1.69-2.50, and OR 1.38, 95% CI 1.24-1.53 respectively).

INTERPRETATION

Major neonatal morbidities were associated with HGF in VLBW infants born preterm. Identification of whether this is a direct effect of these morbidities or mediated through nutritional or growth factors may enable interventions to improve postnatal head growth of infants born preterm.

Cultural Disparities in the Use of Prescription and Nonprescription Medications Among Midlife Women in Israel

The study aimed to examine differences in medication use among midlife women from different cultural origins and to identify socio-demographic, health, and lifestyle characteristics associated with prescribed and non-prescribed medication use. Face-to-face interviews with women aged 45-64 years were conducted during 2004-2006 within three population groups: long-term Jewish residents (LTJR), immigrants from the former Soviet Union after 1989, and Arab women. The survey instrument included current use of medications and way of purchasing (with/without prescription). The level of prescribed and non-prescribed medication use was categorized as taking none, taking 1-2, and taking 3 or more medications. The rates of medication use were 59.5% for prescribed medication and 47% for non-prescribed medications. Differences between the minority groups and LTJR were observed mainly for cardiovascular, vitamins, supplements, and hormonal medications. The analyses showed significantly lower use of prescribed medications among immigrants and of non-prescribed medications among Arab women after taking into account health and socioeconomic indicators. Increased use of prescribed and non-prescribed medications was associated with worse health status and older age. Education was associated with increased use of non-prescribed medications. The disparities in pharmaceutical care may be linked to barriers in access to health care and to cultural preferences among minorities.

Advanced bone age and hyperinsulinemia in overweight and obese children

OBJECTIVE

In obese children, bone age (BA) tends to significantly exceed chronological age (CA). In vitro studies in mice suggest that insulin may directly modulate skeletal growth. We investigated whether there is an association between fasting insulin and BA maturation in obese children.

METHODS

The study cohort comprised 74 overweight and obese children ages 4 to 13 years. BA divided by CA was used as an index for bone advancement. Participants were classified into tertiles based on their BA:CA ratio. Advanced BA maturation was defined as the third tertile, with BA:CA > 1.21. Components of the metabolic syndrome, including fasting insulin, fasting glucose, triglycerides, and high-density lipoprotein (HDL) levels, were measured.

RESULTS

Children with advanced BA were significantly younger, had a higher body mass index (BMI)-Z score (BMI-Z), and were taller than children with bone advancement in the lower tertiles. Females had a 4.7-fold increased risk for advanced BA compared with males (95% confidence interval [CI], 1.29-17.1; P = .02). Children with a BMI-Z ≥ 1.96 and fasting insulin ≤ 30 μU/L had a 3.6-fold increased risk of advanced BA (95% CI, 1.00-12.8; P = 0.05). Moreover, hyperinsulinemia (fasting insulin > 30 μU/L) was associated with a 6.8-fold increased risk for advanced BA, independent of the degree of obesity (95% CI, 1.45-32.1; P = .01).

CONCLUSION

Marked hyperinsulinemia is associated with advanced BA in obese children. Insulin appears to modulate skeletal growth in humans.

Psychometric properties of the Hebrew version of the Oswestry Disability Index

BACKGROUND

Low back pain (LBP) is one of the most common health complaints, with lifetime prevalence rates as high as 84%. The Oswestry Disability Index (ODI) is often the measure of choice for LBP in both research and clinical settings and, as such, has been translated into 29 languages and dialects. Currently, however, there is no validated version of Hebrew-translated ODI (ODI-H).

OBJECTIVE

To examine the psychometric properties of the ODI-H.

METHODS

Cross-culturally appropriate translation into Hebrew was conducted. A convenience sample of 115 participants (Case Group) with LBP and 68 without LBP (Control Group) completed the ODI-H, SF-36 Health Survey, and two Visual Analog Scales (VAS).

RESULTS

Internal consistency was α = 0.94 and test-retest reliability for 18 participants repeating the ODI-H was 0.97. No floor or ceiling effects were noted for Cases, although there was a floor effect for the Control Group. Scores were significantly different for the two groups, indicating discriminant validity. Concurrent validity was reflected by significant correlations with SF-36 scores, particularly the Physical Functioning and Bodily Pain subscales (-0.83 and -0.79, respectively) and with the VAS (0.84 and 0.79).

CONCLUSIONS

The ODI-H is a valid and reliable measure of low back pain-related disability for the Hebrew-speaking public.

Patients' Evaluation of Intervention by a Medical Clown Visit or by Viewing a Humorous Film Following In Vitro Fertilization and Embryo Transfer

This study compared responses to an in-person clown visit and a humorous film following in vitro fertilization and embryo transfer. Intervention was a 10-minute clown visit (n = 101) or 10-minute humorous video clip (n = 99). Demographic and fertility-related data and preintervention anxiety scores were collected. Participants completed an Evaluation of Intervention form postintervention. There were no group differences on demographic or fertility-related data or anxiety scores. Findings indicate while participants viewed the intervention positively, the clown visit offered a higher degree of satisfaction in more patients than did the film. Median evaluation scores were significantly higher for the clown visit, specifically reducing anxiety level and being more distracting. Both groups reported that the exposure made the clinic experience more pleasant and did not bother them, and most would recommend incorporating the intervention in routine treatment. However, free-text comments clearly expressed greater enthusiasm to the in-person clown intervention than to the film.

Glycemic control and clinic attendance of emerging adults with type 1 diabetes at a transition care clinic

BACKGROUND

Emerging adulthood is a challenging period for diabetes management. Our aim was to determine whether a dedicated transition clinic for emerging adults with type 1 diabetes can improve glycemic control and visit attendance.

METHODS

An observational study of 53 emerging adults (30 males) treated during 2010-2014 in a newly established transition clinic. The clinic was operated jointly by pediatric and adult endocrinologists and included a transition coordinator. Data collected included the source of referral, HbA1c levels, frequency of visit attendance, and acute complications. For 27 patients who had attended the pediatric clinic at the same medical center, data from up to 2 years preceding the transition were also collected. Patients filled the Diabetes Quality of Life-Youth questionnaire at the transition and 1 year later.

RESULTS

Mean ± SD age at the transfer to the transition clinic was 22.1 ± 2.7 years; mean disease duration was 8.4 ± 5.0 years. Follow-up duration at the transition clinic was 1.2 ± 1.1 years. Mean HbA1c levels decreased from 67 mmol/mol (95 % CI 63-72) [8.3 % (95 % CI 7.9-8.7)] at transfer to 57 mmol/mol (95 % CI 52-63) [7.4 % (95 % CI 6.9-7.9)] after 1 year (p < 0.001). Thirty-six patients (68 %) attended three or more visits during their first year in the transition clinic. The impact of diabetes on quality of life, disease-related worries, and life satisfaction did not change significantly during 1-year attendance in the transition clinic.

CONCLUSIONS

A dedicated transition clinic for emerging adults, with tailored support according to the developmental needs of emerging adulthood, showed improved glycemic control and visit attendance.

[THE ISRAEL NATIONAL VERY LOW BIRTH WEIGHT INFANT DATABASE]

BACKGROUND

Very low birth weight (VLBW ≤ 1,500g] infants represent approximately 1% of all live births in Israel but are responsible for about 45% of all infant deaths and account for 45% of all hospitalization days in the neonatal special and intensive care units (NICU's).

AIM

To identify perinatal and neonatal factors associated with mortality, morbidity and handicap among VLBW infants.

METHODS

Since 1995 data for > 99% of VLBW infants were received from all 27 NICU's in Israel. The data includes maternal obstetric history, infant's status at birth, deaths, major neonatal morbidities and treatments during the infant's hospitalization. The data are analyzed, collated and annual national and departmental reports prepared.

RESULTS

The database comprises information on 25,800 VLBW infants born from 1995-2011. Approximately 20% of VLBW infants were conceived by in-vitro fertilization, one-third of the births were multiple births and 60% of multiple births were the result of infertility treatments. Mortality declined significantly from 23.7% in 1995-1997 to 16.8% in 2010-2011. During this period significant decreases in major neonatal morbidities were documented: Late onset sepsis (> 3 days) decreased from 29.9% to 23.2% in 2010-2011; severe retinopathy of prematurity from 7.6% to 3.8% and periventricular leukomalacia from 8.3% to 5.0%. The rate of bronchopulmonary dysplasia increased from 9.5% in 1995-1997 to 13% in the period 2001-2006, subsequently declining to 10.8% in the last years.

CONCLUSION

Since 1995 the Israel national VLBW infant database has provided information at both national and hospital levels, documenting the improving care and outcomes for VLBW infants. The significant decline in VLBW infant mortality has been associated with a parallel decrease in major neonatal morbidities.

A case-control study of caesarean delivery on maternal request: who and why?

OBJECTIVE

The current study aimed to evaluate the profile of women who are most likely to undergo caesarean delivery on maternal request (CDMR) and clarify their reasons for this decision.

METHODS

For this multicentre case-control study, data were collected from 429 women who underwent CDMR and 429 matched controls who delivered vaginally from June, 2008 through February, 2009. Participants were interviewed by telephone regarding sociodemographic variables, health and lifestyle.

RESULTS

CDMR predictors were as follows: increasing age (OR = 1.09/year; 95%CI: 1.05-1.14), family status (unmarried without a steady partner versus married - OR = 3.60; 95%CI: 1.08-11.97), decreasing level of religiosity (secular versus ultra-orthodox - OR = 11.82; 95%CI: 3.75-37.21), and never having engaged, or ceasing sports activity during pregnancy (OR = 1.79; 95%CI: 1.09-2.91 and 2.38; 95%CI: 1.28-4.43, respectively). Above average income reduced the probability of CDMR (OR = 0.56; 95%CI: 0.33-0.94). The most frequent reasons for choosing CDMR were concern for pain (21.9%), concern for their own or baby's health (20.4% and 16.5%, respectively) and emotional aspects (10.0%).

CONCLUSIONS

Older, unmarried and/or secular women had increased probability of CDMR. Addressing specific concerns regarding vaginal delivery may provide the basis for a patient-oriented intervention for preventing unnecessary surgery.

Overweight and obese midlife women in Israel: cultural differences in perceived weight status

OBJECTIVES

To examine cultural differences in Weight status misperception (WSMP) and identify associations between weight perception and weight control efforts among overweight/obese midlife women in Israel.

METHODS

Data from the nationally representative Women's-Health-in-Midlife-National-Study were used. Participants included overweight (25 ≤ BMI < 30) and obese (BMI ≥ 30) midlife women (45-64 years) from three cultural groups: Long-Term Jewish Residents (LTJR), Immigrants from the former USSR, and Arabs. Interviews included measures of BMI, weight perception, lifestyle, and socio-demographics.

RESULTS

Most overweight/obese women (88 %) perceived their weight status correctly. No significant differences were found in overall WSMP rates across cultural groups. Overweight women of Arab origin were significantly more likely (p < 0.001) to perceive their weight as "about right" relative to LTJR and Immigrants. WSMP was associated with several unhealthy eating patterns [eating red meat (OR = 2.1, 95 % CI = 1.13-3.97), white bread (OR = 2.4, 95 % CI = 1.26-4.58)] and with more perceived barriers to exercising (OR = 1.8, 95 % CI = 1.00-3.42).

CONCLUSIONS

Health care providers are encouraged to pay attention to overweight/obese women who misperceive their weight status. These women are more likely to consume unhealthy foods and to be at higher risks of suffering from medical complications associated with obesity.

Biological monitoring of Persistent Organic Pollutants in human milk in Israel

BACKGROUND

The Stockholm Convention on Persistent Organic Pollutants (POPs) aims to eliminate or restrict the production and use of POPs around the globe. The Ministry of Health, collaborating with the Ministry of Environmental Protection, measured the exposure of the population to POPs as part of the WHO-coordinated exposure study. Human milk, with a relatively high fat content is a preferred matrix for the monitoring of exposure.

METHODS

Donors of breast milk were recruited from three hospitals after signing informed consent forms. Breast milk was collected from 52 primipara women, aged 23-35, living in Israel for the last 10 years who gave birth to singleton full term healthy infants. Samples, collected at 3-17 weeks postpartum, were stored at -20 °C until sent to the WHO Reference Laboratory, State Laboratory for Chemical and Veterinary Analysis of Food (CVUA), in Frieburg, Germany for a single pooled analysis. Mothers were provided with the pooled analysis results.

RESULTS

Out of over 50 Persistent Organic Pollutants listed in the analysis, 16, including aldrin, endrin, parlar and mirex were not found at detectable levels in the Israeli pooled sample. For the indicator compounds found at detectable levels, most were lower than those reported in European countries.

DISCUSSION

Since 1982, levels of POPs contamination as measured in breast milk have declined significantly. This is likely due to restrictions on agricultural, industrial, and other uses of many POPs in Israel. Ongoing biomonitoring in Israel and inter-ministerial collaboration supports the elimination of POPs in the environment and human milk.