Natalya Bilenko

A Decade (1989–1998) of Pediatric Invasive Pneumococcal Disease in 2 Populations Residing in 1 Geographic Location: Implications for Vaccine Choice

During 1 decade (1989-1998), data on invasive pneumococcal disease were collected prospectively to assess the burden of disease among Jewish and Bedouin children in southern Israel and the potential reduction in illness that can be achieved by using conjugate vaccines. Data on 513 children <15 years old with bacteriologically proven invasive pneumococcal disease were obtained. Among Jewish and Bedouin children <5 years old, incidence rates were 45 and 139 cases per 100,000 child-years of observation, respectively. Jewish and Bedouin children differed in clinical manifestations, seasonal patterns of disease, serotype distribution, and antibiotic susceptibility rates. The potential coverage by 7-, 9-, and 11-valent conjugate vaccines is 41%, 67%, and 71%, respectively, for Jewish children and 22%, 63%, and 65%, respectively, for Bedouin children. The 9- and 11-valent pneumococcal conjugate vaccines have the potential to substantially decrease invasive pneumococcal disease in southern Israel.

Giardia lamblia carriage in Israeli Bedouin infants: risk factors and consequences.

Giardiasis is a common protozoan infection, with varying clinical manifestations. We investigated the associations between Giardia lamblia carriage and environmental, family, illness, and growth characteristics. Bedouin infants (n=234) were followed from birth to age 18-23 months. At monthly home visits, stool samples were obtained, history of illness was determined, and an environmental assessment was done. The comparisons presented are between 4 groups defined by length of carriage of G. lamblia. Study children had a mean+/-SD of 4.1+/-2.9 diarrhea episodes. No illness, environmental, or family characteristics were associated with length of carriage. Significant differences were found in weight-for-age and weight-for-height z scores between the never-positive-for-G. lamblia group and all other carriage groups combined. Faltering growth was shown to be subsequent to G. lamblia infection rather than preceding it. Our findings confirm that G. lamblia carriage is not associated with diarrhea. However, the effect on growth deserves further investigation.

Depressive symptoms and risk for malnutrition among hospitalized elderly people

Objectives: To explore the association between depressive symptoms and risk for malnutrition in hospitalized elderly people.Methods: 195 hospitalized medical patients older than 65 years of age were studied in a cross-sectional design. Depression was assessed by 30-item Geriatric Depression Scale (GDS), nutritional status was evaluated by the Mini-Nutritional Assessment (MNA). Eating and digestive problems were assessed using selected items of Nutrition Risk Index (NRI), cognitive and functional status by Folstein and Barthel indices respectively; demographic data, diagnoses and medications were obtained from medical records.Results: The prevalence of depression in the studied population was 28%. MNA scores were significantly lower among depressed patients as compared with non-depressed (22.86 vs. 24.96, p < 0.001), indicating a higher risk for undernutrition among depressed persons. After controlling for age, cognitive status, functional ability, and number of illnesses, undernutrition was significantly associated with depression (OR = 2.23; 95% CI: 1.04–4.8).Conclusions: Nutritional risk is associated with depression in aged inpatients. Close case management of the elderly hospitalized patients that include assessment and treatment for both disorders may be beneficial.

Does Co-Infection with Giardia Lamblia Modulate the Clinical Characteristics of Enteric Infections in Young Children?

Background. Giardia lamblia (G. lamblia) is a prevalent enteric pathogen causing both asymptomatic carriage and diarrheal illness among children worldwide. In this study we examined the hypothesis that G. lamblia may modulate the effect of other enteric pathogens during concurrent infection. Methods. Bedouin (n = 238) infants were followed from birth to ages 18–23 months. Morbidity was ascertained by weekly home interviews and infants stools were collected fortnightly. The risk for and severity of diarrheal disease were compared between episodes caused by enteric pathogens other than G. lambliaalone and G. lamblia-mixed episodes. Results. In 59 of 293(20.1%) diarrhea episodes two or more pathogens were detected. In two thirds of the mixed episodes G. lamblia was involved. Neither the incidence of diarrhea nor the mean diarrheal episode duration differed between follow up months in which G. lambliawas or was not detected, when age specific or age adjusted values were compared. There were no differences in severity of episodes for single or G. lamblia-mixed infections except for rotavirus. Episodes with rotavirus alone were more severe as compared to episodes where co-infection with G. lamblia was found. Conclusions. The results of this study do not confirm the hypothesis that G. lamblia modulates the clinical effect of infection with other enteric agents. However, the findings of the change in severity of infection with rotavirus suggest that this question warrants further investigation.

Nutritional risk and health care use before and after an acute hospitalization among the elderly.

OBJECTIVE Our objective was to assess the nutritional status and health care use of community-dwelling elderly before hospitalization and determine risk factors for longer hospitalizations during 3 mo of follow-up. METHODS During a 1-y period, we recruited patients 65 y and older admitted to an internal medicine ward at Soroka Medical Center (Beer-Sheva, Israel). Data were obtained regarding health and nutritional status and demographic and social characteristics. We assessed the utilization of health care services during a follow-up period of 3 mo. RESULTS Seventy-nine of 204 patients (38.7%) were at nutritional risk. Patients at nutritional risk were older (P < 0.001) and less educated (P = 0.03) than the well-nourished group. Nutritional risk was associated with more diagnosed diseases, days of hospital stay, and physician visits before admission. Participants hospitalized for more than 6 d were significantly less educated, with lower cognitive, functional, Mini Nutritional Assessment, and Nutritional Risk Index scores and a significantly higher depressive symptoms score. Functional status and sum of nutritional problems were significant predictors of length of hospitalization in the following 3 mo. CONCLUSION Nutritional risk is a source of concern for health care providers and services, because it significantly increases risk of hospital admission and length of stay. It is important to increase the awareness of primary care providers to the impact of nutrition on health care use and provide appropriate tools to screen and treat nutritional problems.

Fetal exposure to nonsteroidal anti-inflammatory drugs and spontaneous abortions

Background: Spontaneous abortion is the most common complication of pregnancy. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used during pregnancy. Published data are inconsistent regarding the risk of spontaneous abortion following exposure to NSAIDs. Methods: We performed a historical cohort study involving all women who conceived between January 2003 and December 2009 and who were admitted for delivery or spontaneous abortion at Soroka Medical Center, Clalit Health Services, Israel. A computerized database of medication dispensation was linked with 2 computerized databases containing information on births and spontaneous abortions. We constructed time-varying Cox regression models and adjusted for maternal age, diabetes mellitus, hypothyroidism, obesity, hypercoagulation or inflammatory conditions, recurrent miscarriage, in vitro fertilization of the current pregnancy, intrauterine contraceptive device, ethnic background, tobacco use and year of admission. Results: The cohort included 65 457 women who conceived during the study period; of these, 58 949 (90.1%) were admitted for a birth and 6508 (9.9%) for spontaneous abortion. A total of 4495 (6.9%) pregnant women were exposed to NSAIDs during the study period. Exposure to NSAIDs was not an independent risk factor for spontaneous abortion (nonselective cyclooxygenase [COX] inhibitors: adjusted hazard ratio [HR] 1.10, 95% confidence interval [CI] 0.99–1.22; selective COX-2 inhibitors: adjusted HR 1.43, 95% CI 0.79–2.59). There was no increased risk for specific NSAID drugs, except for a significantly increased risk with exposure to indomethacin (adjusted HR 2.8, 95% CI 1.70–4.69). We found no dose–response effect. Interpretation: We found no increased risk of spontaneous abortion following exposure to NSAIDs. Further research is needed to assess the risk following exposure to selective COX-2 inhibitors.

Accuracy of acute otitis media diagnosis in community and hospital settings

Aim: To evaluate the accuracy rates of acute otitis media (AOM) diagnosis in the community by analyzing the initial AOM diagnosis (according to information from the referral letters to the Pediatric Emergency Department [PED]) among children with AOM diagnosis confirmed by tympanocentesis at PED. Methods: A descriptive, retrospective study conducted during the year 2000, including 590 children aged 0–48 mo diagnosed with AOM at PED. AOM was confirmed by tympanocentesis. We defined: (1) simple AOM as <3 or <4 episodes during the last 6 or 12 mo, respectively; (2) complicated AOM as 3 or 4 episodes during the last 6 or 12 mo, respectively, and/or not improving with antibiotics. Results: 571 (96.8%) were <24 mo of age; 355 (60%) were Arab Bedouins and 235 (40%) Jews. Seventy‐three pediatricians, 57 general practitioners and 27 family practitioners provided referral letters. Information on disease severity was available in 471/590 (79.8%) patients, of whom 320 (68%) had simple and 151 (32%) complicated AOM. Three hundred and sixty‐five (62%) of 590 patients were accurately diagnosed by referring physicians, more frequently in patients with complicated than simple AOM ( p<0.001). Diagnostic accuracy was similar among physician specialties ( p=0.33) and ethnic groups ( p=0.11). Multivariable logistic regression analysis showed that complicated AOM, adjusted for age, sex, ethnic origin, and physician specialty, was the only predictive factor for accurate AOM diagnosis (odds ratio 4.0, p<0.001).

Utilization of Antenatal Care Services by a Semi-Nomadic Bedouin Arab Population: Evaluation of the Impact of a Local Maternal and Child Health Clinic

Objective. The objective of this study was to evaluate changes in antenatal care (ANC) utilization among semi-nomadic Bedouin Arab women living in the Negev desert of Israel before and after the establishment of a local Maternal and Child Health (MCH) Clinic. Methods. Retrospective record review of ANC utilization by pregnant women in two successive pregnancies, one before and one after the establishment of a local MCH Clinic. The study population was comprised of all 85 women who registered their newborns for care at MCH Clinic A, regardless of whether or not they had registered at the clinic for ANC. Records of their care in previous pregnancies were obtained from other MCH Clinics previously utilized by the family. Results. There was a significant increase in the percent of women receiving ANC from 31.8% to 57.6% with the establishment of the local MCH Clinic (p = 0.004), increase in the percent of pregnant women who had at least one physician examination from 27% to 45% (p = 0.003), in the percent who had at least 3 nursing visits from 25% to 39% (p = 0.011) and in the compliance with screening tests. There was no significant change in birth week and birth weight between pregnancies before and after the establishment of Clinic A. Conclusions. The study demonstrated improvement in utilization of ANC in the study population. However, after the establishment of a local MCH clinic, over 40% of pregnant women still received no ANC. Non-geographic barriers to ANC are important and need to be addressed through community-based intervention programmes.

Continuous decrease of consanguineous marriages among Arabs in Israel.

To describe the trend in the rate of consanguineous marriages among the Israeli Arab population and to identify factors associated with this custom shift in recent years.

Maternal weight misperceptions and smoking are associated with overweight and obesity in low SES preschoolers

Objectives:To identify modifiable risk factors for obesity among low socioeconomic status (LSES) children.Methods:Cross-sectional data were obtained from 238 4–7-year-old children and 224 mothers from LSES preschools. Anthropometric measurements were obtained; mothers were interviewed about sociodemographic characteristics, health behaviors, perceptions and beliefs.Results:The combined prevalence of overweight and obesity (OWOB) among children was 29.8% based on the new World Health Organization (WHO) growth standard. Prevalence of OWOB (body mass index ⩾25) among mothers was 51.8%. Mean age, sleeping hours, gender distribution and poverty level were similar between normal and OWOB children. Over 82% of mothers underestimated their childs weight status. Of the 62 OWOB children, 74.2% were perceived by their mothers as having ‘normal weight’ (NW) and 8% were perceived as ‘thin’. Mothers perceived 67 out of 158 NW children (42.4%) as ‘thin’ (P<0.001). Mediation analysis indicated that 10% of the effect of maternal underestimation on childs OWOB may be mediated through childs daily sedentary hours (P=0.06). In a multivariable logistic-regression analysis controlling for maternal obesity, knowledge regarding breakfasts importance and childs daily sedentary hours, maternal underestimation of the childs weight status (odds ratio=7.33; 95% confidence interval (CI):2.41–22.37; P<0.0001) and parental smoking (odds ratio=3.25; 95% CI: 1.26–8.40; P=0.015) were the only significant factors associated with OWOB in LSES children.Conclusions:Maternal perception of childs weight status and parental smoking are associated with childhood OWOB among LSES children. These parameters can help identify children at risk for obesity. Maternal perception may be amenable to intervention.