Bariatric Surgery Affects Plasma Levels of Alanine Aminotransferase Independent of Weight Loss: A Registry-Based Study.

Patients that undergo bariatric surgery experience weight loss and a reduction in the plasma levels of the hepatic enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). We used the Israeli national bariatric registry, which includes demographic, clinical, and biochemical data on 19,403 patients, of which 1335 patients had two-year follow-up data on ALT, AST, A1C, and BMI, to test the dependence of the reduction in the levels of ALT and AST on weight loss. The data were analyzed using regression models, retrospective matching, and time course analyses. Changes in liver enzymes did not correlate with change in BMI, and linear regression models did not demonstrate that the change in ALT and AST values were dependent on pre-operative levels of BMI or the extent of weight loss. ALT and AST levels were reduced two years after surgery compared with a cohort of retrospectively matched patients for ethnicity, sex, age, BMI, and A1C. Finally, patients who regained weight displayed a reduction in levels of liver enzymes. Our results suggest that bariatric surgery affects AST and ALT levels via weight loss dependent and independent mechanisms. Mechanistic studies that will identify the nature of this effect and the clinical relevance of ALT and AST levels to the post-bariatric liver function are warranted.

Sleeve Gastrectomy Is Associated with a Greater Reduction in Plasma Liver Enzymes Than Bypass Surgeries-A Registry-Based Two-Year Follow-Up Analysis.

Bariatric surgeries may lead to an improvement in metabolic fatty liver disease, and a reduction in the levels of the hepatic enzyme Alanine Aminotransferase (ALT). We compared the effects of Sleeve Gastrectomy (SG), Roux en Y Gastric Bypass (RYGB) and One Anastomosis Gastric Bypass (OAGB) on the levels of ALT by analysis of two-year follow-up data from 4980 patients in the Israeli Bariatric Registry that included laboratory tests and demographic information. Pre-operative characteristics of patients, and particularly levels of liver enzymes, were similar across surgery types. Regression modeling and retrospective matching showed that SG was superior to RYGB and OAGB in reducing ALT levels, and in reducing the fraction of patients with abnormally high ALT levels. Two-year post-surgery, an increase in ALT levels from normal to abnormal levels was observed in 5% of SG patients, and in 18% and 23% of RYGB and OAGB patients. In conclusion, SG leads to a greater reduction in ALT levels compared with bypass surgeries and a lower incidence of post-surgical elevation of ALT levels. Further studies are required to identify the cause for the rise in liver enzymes, and to determine whether ALT levels correlate with liver pathology especially following bariatric surgery.

Sleeve Gastrectomy Failure-Revision to Laparoscopic One-Anastomosis Gastric Bypass or Roux-n-Y Gastric Bypass: a Multicenter Study.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure performed worldwide. However, many patients undergo secondary surgery due to either weight-related and complication-related reasons or both. Conversional options vary with one-anastomosis gastric bypass (OAGB) and Roux-n-Y gastric bypass (RYGB) being the most common. The aim of the study was to assess the safety and efficacy of converting failed LSG to either OAGB or RYGB, and compare weight-related results and post-conversion complications. METHODS: Retrospective review of hospital records of patients who underwent conversion from LSG to either RYGB or OAGB due to insufficient weight loss or weight regain in 7 bariatric centers between 2013 and 2019. Data retrieved included demographics, anthropometrics, comorbidities, indication for conversion, conversion type, complications, and weight loss. RESULTS: During the study period, 396 patients were included in the study. Eighty-four (21%) patients were lost to follow-up. RYGB and OAGB were performed in 119 and 144 patients, respectively. Mean age and body mass index (BMI) at revision were 44.2 years (range 19-72) and 40.6 ± 5.9 kg/m2 (range 35-71), respectively. Of these, 191 (73%) were female. Percent total body weight loss (%TWL) was 16% ± 1% for the RYGB group vs. 23% ± 12% for the OAGB group (p = 0.0007) at a median follow-up of 29 months (range 7-78 months) following conversion. Gastroesophageal reflux disease (GERD) was significantly higher 1 year following conversion to OAGB vs. RYGB occurring in 25 (17.4%) and 9 (7.6%) patients, respectively (p = 0.018). CONCLUSIONS: Conversion of LSG to OAGB, compared to RYGB, results in increased weight loss but a higher rate of GERD and potential nutritional deficiencies.

Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic Adjustable Gastric Banding-a Comparison Between One- and two-Stage Procedures, an Israeli National Database Study.

PURPOSE: The optimal revisional bariatric surgery procedure following a previous failed gastric band surgery is yet to be determined. The aim of our study was to compare single- and two-stage laparoscopic sleeve gastrectomy (LSG) following laparoscopic adjustable gastric banding (LAGB) in terms of short- and mid-term outcomes. MATERIALS AND METHODS: Patients who underwent LSG after a failed LAGB in Israel during 2014-2017 were included. Data were obtained from the Israeli National Bariatric Surgery Registry. Data analyzed included comorbidities, postoperative complications, and anthropometric outcomes. RESULTS: Of 595 patients included in the data analysis, 381 (64%) underwent one-stage and 214 (36%) had two-stage LSG. No differences were observed between the groups in complication rates (5.0 vs. 5.1%, p=0.93). Percent of total weight loss was lower following one-stage than two-stage procedure at both 6 months (19.3±9.3 vs. 21.5±8.1%; p=0.02) and 1 year postoperative (24.9±10.4 vs. 27.8±9.9%; p=0.02). No difference was observed in the percent excess weight loss (51 vs. 56%; p=0.34 and 66 vs. 72%; p=0.38, at 6 months and 12 months postoperative, respectively). In a regression analysis, percent excess weight loss was greater in the two-stage procedure (p=0.02), with no difference in the complication rates (p=0.98). CONCLUSION: Single-step LSG had a similar safety profile as two-stage LSG following a failed LAGB. Better weight loss was seen following two-stage LSG. Further prospective studies should investigate long-term follow-up after one- and two-stage procedure.

Trends in Bariatric Surgery: a 5-Year Analysis of the Israel National Bariatric Surgery Registry.

BACKGROUND: The worldwide prevalence of obesity nearly tripled between 1975 and 2016. There are limited data quantifying national trends. The aim of this study is to evaluate and summarize current trends in bariatric surgery in Israel. METHODS: Data for all bariatric surgeries (BS) performed between January 2014 and December 2018 was collected from the Israel National Bariatric Surgery Registry (INBSR) and analyzed. RESULTS: During the study period, 42,296 BS were included in the INBSR. Females accounted for 68% and the mean age and body mass index were 41.6 ± 12.6 years and 42.0 ± 5.4 kg/m2, respectively. Most of the patients were Jewish, but there was a significant rise in number of Arabs undergoing BS during the study period. There was a gradual decline in the annual numbers of BS, except for a small rise in 2015. There was a significant rise in the rate of One Anastomosis-Mini Gastric Bypass (OAGB-MGB), from 0.1% in 2014 to 46.1% in 2018, making it the most prevalent BS in that year. Laparoscopic sleeve gastrectomy (SG) surgeries decreased steadily, from 80% in 2014 to 37% in 2018. The annual rate of Roux-en-Y gastric bypass (RYGB) remained essentially constant at 10%. The annual rates of gastric banding decreased sharply and the annual rates of duodenal switch, single anastomosis duodenal switch and biliopancreatic diversion were negligible. Bariatric surgery was distributed evenly between private (50.4%) and public (49.6%) hospitals. CONCLUSIONS: The numbers of BS are decreasing in Israel. There is a gradual but noticeable shift from SG to OAGB-MGB.

Determinants associated with making prenatal screening decisions in a national study.

This study sought to evaluate the associations between background exposures and psychological determinants, among postpartum Jewish and Arab women, relative to actual prenatal test endorsement. The independent and aggregative effects of contextual features and the subjective opinions and attitudes relative to a prenatal testing were evaluated, using logistic regressions. After accounting for contextual features, Jews with positive vs. negative opinions on screening were significantly more likely to undergo a prenatal screening. Specifically, having more favourable ideas on pregnancy termination, among Jews, was associated with a greater likelihood of triple test, nuchal translucency and ultrasound uptake as compared with those that refused. Similarly, Arabs who were more inclined to abort the pregnancy had a greater chance of using nuchal translucency and ultrasound vs. those that declined testing. As the preferences for prenatal test outcomes are multifaceted and vary according to population group, a better understanding of the factors involved in making testing choices could help ease the decision-making process. Impact Statement What is already known on this subject? The choice to undergo prenatal screening tests is influenced by various determinants, which include: social, demographic and emotional factors that vary by cultural preferences. Indeed, women integrate (subjective) beliefs and values that extend beyond rational (objective) reasoning when estimating whether or not to undergo testing. It may then be that, prenatal test choices might be, influenced less by actual risk status and more so by emotional factors. And while, the latter are more likely to be amendable, and thus influence changes in perception, the effect of psychological exposures on the decision making process in the genetic testing context, especially among Israeli Jews and Arabs, has been understudied. What the results of this study add? The current study extends the focus by addressing the role of evaluative beliefs and emotional factors involved with formulating prenatal screening judgments relative to actual testing among individuals with diverse profiles (Israeli Jews and Arabs). What was clarified was that background factors and psychological perceptions, such as having supportive attitudes on screening and a willingness to undergo abortion were, for the most part, related to prenatal test uptake. Concomitantly, these involve dense decision-making practices that can be difficult to approximate, as cultural settings and individual preferences often have an impact on intention-to-test. What the implications are of these findings for clinical practice and/or further research? Culturally appropriate counselling that would account for personal preferences alongside actual risk appraisals could enable pregnant women to make informed and autonomous prenatal testing choices. The integration of socio-demographics, psychological correlates and other contextual factors into a theoretical framework, studied uniquely by sub-populations, could enrich future research. Such research can, in turn, provide a clearer picture of the social need for genetic counselling, help customise local interventions, and on a broader scale inform national policy.

Correction to: Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study.

In Table 5 the P value for the parameter "More than one chronic disease" is incorrect. The correct value is 0.387, not 0.0387.

Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study.

BACKGROUND: Although bariatric surgery (BS) is considered safe, concern remains regarding severe post-operative adverse events and mortality. Using a national BS registry, the aim of this study was to assess the incidence, etiologies, and risk factors for mortality following BS. METHODS: Prospective data from the National Registry of Bariatric Surgery in Israel (NRBS) including age, gender, BMI, comorbidities, and surgical procedure information were collected for all patients who underwent BS in Israel between June 2013 and June 2016. The primary study outcome was the 3.5-year post-BS mortality rate, obtained by cross-referencing with the Israel population registry. RESULTS: Of the 28,755 patients analyzed (67.3% females, mean age 42.0 ± 12.5 years, and preoperative BMI 42.14 ± 5.21 kg/m2), 76% underwent sleeve gastrectomy (SG), 99.1% of the surgeries were performed laparoscopically, and 50.8% of the surgeries were performed in private medical centers. Overall, 95 deaths occurred during the study period (146.9/100,000 person years). The 30-day rate of post-operative mortality was 0.04% (n = 12). Male gender (HR = 1.94, 95%CI 1.16-3.25), age (HR = 1.06, 95%CI 1.04-1.09), BMI (HR = 1.08, 95%CI 1.05-1.11), and depression (HR = 2.38, 95%CI 1.25-4.52) were independently associated with an increased risk of all-cause 3.5-year mortality, while married status (HR = 0.43, 95%CI 0.26-0.71) was associated with a decreased risk. CONCLUSION: Mortality after BS is low. Nevertheless, a variety of risk factors including male gender, advanced age, unmarried status, higher BMI, and preoperative depressive disorder were associated with higher mortality rates. Special attention should be given to these "at-risk" BS patients.

Differences in quality of life between Jewish and Arab patients on hemodialysis.

PURPOSE: Higher health-related quality of life (HRQOL) in dialysis patients has been associated with fewer hospitalizations and lower mortality. Since Arab patients on dialysis have better survival rates than Jewish patients, we hypothesized that they would have higher HRQOL. We also studied the impact of several risk factors on HRQOL in each population. METHODS: Based on a national dialysis registry, patients from 64 hemodialysis units were recruited to participate. Patients who consented were interviewed face-to-face, using the Kidney Disease Quality of Life Short Form (KDQOL-SF36) questionnaire. RESULTS: Five hundred and fifty-eight (50.6%) Jewish and 544 (49.4%) Arab patients participated in the study. For Arab patients mean crude scores for the "mental component summary" and KDQOL scores were significantly lower than for Jewish patients [31.6 (95% Cl 30.0-33.3) vs. 38.0 (95% Cl 36.1-39.9), p < 0.0001 and 55.6 (95% Cl 54.5-56.7) vs. 59.8 (95% Cl 58.6-60.9), p < 0.0001, respectively]. Much lower scores were observed for Arabs in the "emotional role" and "work status" subscales. The two populations had similar general health assessments and albumin level. For both, HRQOL was positively associated with higher educational level, higher albumin level, and dialysis connection by fistula or graft; and negatively associated with low income and diabetes. HRQOL was negatively associated with previous cerebrovascular accident among Arabs and with female gender among Jews. CONCLUSIONS: Differences between Jews and Arabs in subscales related to psychosocial factors suggest that cultural differences in the perceptions of sickness and health may be relevant here. Future studies should explore such possibility and focus on the large gap in the "work status" subscale.

Adolescent versus parent reports on asthma and asthma symptoms.

PURPOSE: Epidemiological studies of asthma in adolescence commonly rely on self-reports. This study aimed to compare adolescent and parent reports regarding the presence of asthma and asthma symptoms in two ethnic groups, Jews and Arabs, living in the same country. METHODS: Eighth-grade pupils attending five schools in Tel Aviv and four schools in two Arab cities in Israel were asked to complete the self-report International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire in the classroom. Their parents were interviewed by telephone using the parental ISAAC questionnaire. We assessed prevalence rates of asthma and asthma symptoms according to adolescent and parent responses. Agreement between adolescents and parents was assessed by Cohen's kappa coefficient. RESULTS: Adolescents reported more asthma and asthma symptoms than their parents in both the Jewish (327 adolescent-parent pairs) and the Arab (335 adolescent-parent pairs) groups. Both groups showed moderate adolescent-parent chance-corrected agreement for current asthma (kappa 0.59 in Jews, 0.52 in Arabs, P = 0.60) and lifetime asthma (kappa 0.53 Jews, 0.44 in Arabs, P = 0.33); and slight to fair chance-corrected agreement for asthma symptoms. There were no statistically significant differences between the Jewish and Arab populations in chance-corrected agreement for any of the parameters assessed. CONCLUSIONS: Jewish and Arab adolescents more often report asthma and asthma symptoms than do their parents. This seems to be a cross-cultural phenomenon. Therefore, particular attention should be paid to the source of information when comparing prevalence of asthma and asthma symptoms across studies. Pediatr Pulmonol. 2017;52:154-159. © 2016 Wiley Periodicals, Inc.

Continuous decrease of consanguineous marriages among Arabs in Israel.

OBJECTIVES: 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. METHODS: The study was conducted between November 2009 and January 2010 in Family Health Centers. A questionnaire was presented to parents during routine visits to the center with their children. RESULTS: Information on 6,437 couples was collected. The rate of consanguineous marriages decreased from 35.8% among those married before 2000, to 28.2% among those married in 2000-2004, and to 24.0% among those married in 2005-2009 (P for trend <0.001). First cousin marriages were the most common type of consanguineous marriages in all the time periods. Consanguineous marriages were associated with consanguinity between the couples' parents (both husband and wife), a high consanguinity rate in the place of residence and younger age at marriage (wife). CONCLUSIONS: The rates of consanguineous marriages among Israeli Arabs are decreasing but still high. Because consanguineous marriages are widely acceptable, the role of public health professionals and primary care personnel is to provide comprehensive information about the potential genetic risks of consanguinity on offspring health and to increase the accessibility of premarital and preconception counseling services.

Increasing rates of prenatal testing among Jewish and Arab women in Israel over one decade.

UNLABELLED: BACKGROUND/AIMS/OBJECTIVE: This study compared data on the use of prenatal tests offered to pregnant women in Israel as reported in a national survey conducted by the Israel Center for Disease Control in 2001 to data from 2010. METHODS: Mothers of newborns were interviewed 8-72 h after delivery in 29 maternity wards in Israel on May 31, 2010. RESULTS: A total of 768 women were interviewed, 569 (72.3%) were Jewish and 197 (25.7%) were Arabs. Nuchal translucency screening and early ultrasound level 2 were significantly more frequently done in both Jewish and Arab women in 2010 than in 2001. The use of the biochemical triple marker test and amniocentesis did not change. The increased rate of nuchal translucency screening and early ultrasound level 2 was significantly higher among the Jewish women compared to the Arabs (21.5 and 28.0% vs. 2.9 and 13.7% in 2001; 62.0 and 65.6% vs. 30.1 and 30.9% in 2010, respectively). The rates of amniocentesis in the Jewish women aged ≥35 years were 47.6 and 47.5% in 2001 and 2010, respectively; they are significantly higher than among the Arabs (18.5 and 28.5%, respectively). The factors associated with making more use of different prenatal tests were: secularity, a higher income, and supplementary medical insurance for the Jewish women, and supplementary medical insurance and printed information on prenatal testing for the Arabs. CONCLUSIONS: The prenatal testing rates have risen over the last decade in both population groups, but there are still significant gaps. We suggest that public funding of additional prenatal tests may increase their use in both population groups.

Prevalence of consanguineous marriages and associated factors among Israeli Bedouins.

The Bedouin population in Israel is a semi-nomadic traditional patriarchal society. Consanguineous marriages are very common, contributing to high rates of congenital malformations and genetic diseases, resulting in high infant mortality. Data on consanguineous marriages among Bedouins in Israel are limited. This study examined the current prevalence of consanguineous marriages and their determinants among Israeli Bedouins. One thousand two hundred ninety Bedouin women who delivered in the maternity wards of the only hospital serving the Bedouin population were interviewed between November 2009 and January 2010. The prevalence of consanguineous marriages was 44.8 %. The most common type of spousal relationship was first cousins (65.7 % of all consanguineous marriages). The mean inbreeding coefficient was 0.0238. Factors significantly associated with consanguinity were less years of schooling (OR 0.94, 95 % CI (0.88-0.99), p = 0.02) and younger age at marriage of the wife (OR 0.90, 95 % CI (0.80-0.96), p = 0.0002). In conclusion, the rate of consanguineous marriages among Bedouins is very high, making this population at risk for congenital malformations and genetic diseases. Efforts should be directed at better education and provision of premarital and prenatal counseling on the health consequences of consanguineous marriages and the possibilities to lower those risks.

Validity of self-reported weight and height among 13-14 year old schoolchildren in Israel.

BACKGROUND: Data regarding the validity of self-reported weight and height in adolescents are conflicting. OBJECTIVES: To evaluate the validity of self-reported weight and height among 13-14 year olslddren. METHODS: We conducted a cross-sectional study of 517 schoolchildren aged 13-14 years and compared self-reported and measured weight and height by gender, population group, parental education and crowdedness. RESULTS: Females under-reported their weight on average by 0.79 +/- 5.46 kg (P = 0.03), resulting in underestimation of the body mass index with borderline significance (mean difference 0.28 +/- 2.26 kg/m2, P = 0.06). Males over-reported their height on average by 0.75 +/- 5.81 cm (P = 0.03). Children from less crowded homes (< or = 1 person per room) overestimated their height more than children from more crowded homes, resulting in a significant underestimation of BMI (mean difference between reported BMI and measured values was 0.30 +/- 2.36 kg/m2, P = 0.04). Measured BMI was a significant predictor of the difference between self-reported and measured BMI, adjusted for gender, population group, parents' education, and crowdedness (beta = -0.3, P < 0.0001). As a result of this reporting bias, only 54.9% of children with overweight and obesity (BMI > or = 85th percentile) were classified correctly, while 6.3% of children were wrongly classified as overweight and obese. The largest difference in BMI was observed in obese females (4.40 +/- 4.34) followed by overweight females (218 +/- 1.95) and underweight females (-1.38 +/- 13.75). Similar findings were observed for males, where the largest difference was found among obese males (2.83 +/- 3.44). CONCLUSIONS: Studies based on self-reported weight and height in adolescents may be biased. Attempts should be made to correct this bias, based on the available data for each population.

Increased rate and greater severity of allergic reactions to insect sting among schoolchildren with atopic diseases.

The question of whether atopic diseases are a risk factor for allergic reactions to insect sting is still unresolved. The aim of this study was to evaluate the association between atopic diseases (asthma, allergic rhinitis, atopic eczema) and allergic reactions to insect stings among schoolchildren in Israel. A self-report questionnaire of the International Study of Asthma and Allergies in Childhood was administered to a national sample of 13-14-yr-old schoolchildren. Questions regarding reactions to insect stings were added. A total of 10,021 questionnaires were available for analysis. Among the children who reported insect stings (56.3%), the prevalence of current asthma was 6.0%, of allergic rhinitis, 10.5%, and of atopic eczema, 8.7%, with no significant differences from the whole study population. Among children with any of the atopic diseases, 36.9% reported an allergic reaction to insect sting compared to 24.8% of the non-atopic children (p < 0.0001). On multivariate analysis, asthma, allergic rhinitis, and atopic eczema were found to be significant risk factors for allergic reactions of any severity. Children in the atopic group had a significantly higher rate of severe allergic reactions than the non-atopic children, and relatively higher rates of milder ones (p < 0.0001). Asthmatic patients with severe allergic reactions had more parameters of severe asthma than asthmatic patients with mild or no reactions. In conclusions, allergic diseases are associated with a higher rate and greater severity of allergic reactions to insect sting in children. The severity of the allergic reaction is related to the severity of the asthma symptoms.

Trends in the prevalence of asthma symptoms and allergic diseases in Israeli adolescents: results from a national survey 2003 and comparison with 1997.

PURPOSE: To investigate the temporal trends in the prevalence of asthma symptoms and allergies in Israeli adolescents. METHODS: A modified version of the International Study of Asthma and Allergies in Childhood questionnaire was administered to a national sample of Jewish and Arab schoolchildren in Israel. The results were compared to a similar survey conducted in 1997. RESULTS: Asthma prevalence was 7.0% in 1997 and 6.4% 2003 respectively (p = 0.1). Wheezing in the past 12 months decreased significantly from 17.9% in 1997 to 13.8% in 2003 (p < 0.001). Allergic rhinitis and atopic dermatitis increased from 9.4% to 10.5%, and from 5.9% to 8.7% respectively. The prevalence of allergic disease remained higher in Jewish compared with Arabs. CONCLUSIONS: The prevalence of asthma symptoms decreased in Israel from 1997 to 2003 while there was an increase in allergic rhinitis and atopic dermatitis.

Allergic reactions to insect stings: results from a national survey of 10,000 junior high school children in Israel.

BACKGROUND: Insect sting allergy is a medical condition the magnitude of which has not been fully estimated in children. OBJECTIVES: We sought to evaluate the prevalence of insect stings among schoolchildren in Israel, the rate of allergic reactions, and hospital attendance. METHODS: A self-report questionnaire of the International Study of Asthma and Allergies in Childhood was administered to a national sample of schoolchildren aged 13 to 14 years across Israel. Questions regarding insect stings, allergic reactions, and hospital attendance were added. RESULTS: Ten thousand twenty-one questionnaires were available for analysis. Most (56.3%) had been stung at least once in their lifetime. Of these, 20.5% had a large local reaction (LLR), 11.6% had a mild (cutaneous) systemic reaction (MSR), and 4.4% had a moderate-to-severe systemic reaction (SSR); 11.5%, 6.5%, and 2.5% of the study group, respectively. Arabs had significantly more allergic reactions of all 3 types than Jews (P < .0001). On multivariate analysis, LLR was associated with SSR (odds ratio, 6.25; 95% CI, 4.66-8.41) and MSR (odds ratio, 5.15; 95% CI, 4.24-6.25). More than 10% of the children with an LLR only attended a hospital compared with 7.5% of those with an MSR only and 14.5% with an SSR only. CONCLUSIONS: The frequency of reported allergic sting reactions in children might be higher than previously estimated. Arab children reported significantly more allergic reactions than Jews. Hospital attendance does not correlate with the severity of the allergic reaction, and only a minority of children with SSRs are treated in hospital. CLINICAL IMPLICATIONS: The improper care of severe reactions highlights the need for better public and physician education.

Widespread use of soy-based formula without clinical indications.

OBJECTIVES: In view of reports of the growing popularity of soy-based formula for infants, we examined soy consumption and its possible overuse during early infancy in central Israel. METHODS: Mothers of 1,803 infants aged 2, 4, 6 and 12 months attending well-baby clinics participated in a telephone survey covering background data, rate, duration, and pattern of soy-based formula use and the reasons for its initiation. The reasons were grouped into those based on the recommendations of the medical personnel and those based on mothers' initiative, and evaluated according to infants' age at soy-based formula initiation (0 to 1, 2 to 4 and 5 to 12 months). The symptoms that prompted soy-based formula use were assessed quantitatively. RESULTS: The rate of soy-based formula use was 10.4% at 2 months and 31.5% at 12 months (P<0.001); 70.6%+/- 2.7% of the infants were given soy for>6 months. Regardless of infants' age, the role of the mothers in the decision to use soy-based formula was greater than that of the medical personnel, and increased significantly with age (chi for trend=0.018). A suspicion of cow's milk allergy was responsible for only 10.9% (7/64) of all soy initiations in infants aged 5 to 12 months. In all ages, occasional symptoms, mainly diarrhea (33.3%) and colic (19.8%), were the leading cause for recommending soy-based formula by medical personnel, whereas the personal preference without clinical justification was the leading cause among mothers. CONCLUSIONS: The use of soy-based formula in central Israel is extensive and continues for long periods, with rates far beyond clinical indications. Mothers play a greater role than medical personnel in the decision to initiate soy-based formula.

Should fetal weight growth curves be population specific?

BACKGROUND AND OBJECTIVES: The use of ultrasound to estimate fetal weight has become very common. Several studies have examined which fetal parameters predict best fetal weight, and based on those parameters fetal growth curves have been established. It is possible however, that fetal growth patterns differ across population groups, and therefore should be population specific. To establish fetal weight growth curve for the Israeli population and to compare it to the one currently used, suggested by Hadlock et al. METHODS: A cross-sectional study of singleton pregnancies was conducted. For each fetus the estimated weight was calculated using sonographic measurements of bi-parietal diameter, femur length, abdominal circumference, and head circumference. A regression analysis was used to evaluate the relationship between weight and fetal age. RESULTS: A growth curve was established based on measurements of 857 fetuses. There was a gradual increase in fetal weight from 99 grams at 14 weeks to 3505 grams at 40 weeks. There was a slight difference between the new curve and the one currently used. Comparing 3rd percentile curve of the one in use with ours, we found that the first curve fell outside our 95% confidence limits for weeks 14 to 23 (when it was too low) and for weeks 27 to 35 (when it was too high). Comparing the 97th percentile curves, we found that the current curve fell outside our 95% confidence limits for weeks 14 to 22 (when it was too low), and for weeks 25 to 37 (when it was too high). CONCLUSIONS: We recommend that the physicians in Israel use the new Israeli fetal weight curve. This curve may be useful, especially in situations where fetal weight is close to or below the 3rd percentile of Hadlock's curve in weeks 27-35, and when fetal weight is close to or above the 97th percentile of Hadlock's curve in weeks 14-22.

Factors affecting performance of prenatal genetic testing by Israeli Jewish women.

The number of prenatal genetic tests that are being offered to women is constantly increasing. However, there is little national data as to who is performing the tests and the reasons for doing or not doing so. This study evaluated the proportion of Jewish women in Israel who perform the various prenatal genetic tests and the factors affecting the performance of these tests. It was found that 60.9% of the women performed the triple test, 50.8% of women older than 35 years performed amniocentesis, while 63.3 and 24.3% of women performed Tay-Sachs and fragile-X carrier testing respectively. Ninety-six percent of the secular women compared to only 6.7% of the ultrareligious women performed the triple test. It was also found that94.4% of the secular women, 36.4% of the religious, and none of the ultrareligious women older than 35 years performed amniocentesis. In the stepwise regression analysis, being secular, having a higher income, fewer children, and being of Ashkenazi origin remained significant factors in determining performance of Tay-Sachs carrier testing. As regards fragile-X carrier testing, being secular, having fewer than four children, and having a higher income and a supplementary medical insurance remained significant factors. The main reason reported by the women for not performing amniocentesis or the triple test was for religious or moral grounds (53.3 and 67% respectively). The main reason given for not performing Tay-Sachs or fragile-X testing was that they were not referred for the tests (76 and 82% respectively). Consideration should be given to providing first trimester prenatal diagnosis to the ultrareligious group, including state subsidized fragile-X testing and educating the primary care givers about the importance of prenatal genetic testing. The information from the present study is vital for the planning of an equitable prenatal genetic service and provides guidelines for the implementation of such services in other countries.