Sonographic evaluation of the superior sinus sagittalis.

OBJECTIVE: The aim of this study was to characterize the normal ultrasonographic growth of the fetal superior sinus sagittalis (SSS) throughout gestation. PATIENTS AND METHODS: In a prospective cross-sectional study, measurements of the fetal sinus sagittalis were obtained in patients undergoing elective fetal anatomical surveys or fetal growth scan at between 16.6 and 34.7 weeks of gestation. Special attention was given to the SSS of the fetal brain. On the coronal plane, the SSS may be easily identified immediately below the frontal bone, and anterior to the fetal head parenchyma. RESULTS: 206 fetuses were scanned. A regression line of the SSS was created throughout gestation and a first-degree correlation was found between gestational age (GA) and the SSS height (r = 0.418; p < 0.0001; SSS = -0.015 + 0.0178 × GA). Normal values were established for different gestational weeks. CONCLUSION: We provide ultrasonographic dimensions of the fetal SSS across pregnancy. This data potentially allows for prenatal diagnosis of abnormal appearance of the SSS.

Corpus callosum growth in normal and growth-restricted fetuses.

OBJECTIVE: The aim of this study was to characterize the normal ultrasonographic growth of the corpus callosum (CC) in normal and in growth-restricted fetuses throughout gestation. METHODS: This was a prospective cross-sectional study. Consecutive routine biometric measurements and fetal organ scans were obtained in patients undergoing elective fetal anatomical surveys or evaluation of the fetal growth between 16 to 33 weeks. Special attention was given to the CC of the fetal brain. In addition, we evaluated the growth of the CC in growth-restricted fetuses throughout pregnancy. RESULTS: Two hundred and fifty two normal fetuses were scanned between 16 and 36 weeks of gestation. A regression line of the CC was established through gestation and a second-degree correlation was found between gestational age and CC outer margin. Twenty four growth-restricted fetuses were also evaluated in which the growth of the CC was significantly below both the 25(th) and 50(th) percentiles in 77.3% and 95.5%, respectively, for the same gestational age. CONCLUSIONS: We provide nomograms for the ultrasonographic dimensions of the fetal CC that allows for prenatal diagnosis of abnormal dimensions of CC. The significance of abnormal CC growth in growth-restricted fetuses should be further evaluated.

A functional dynamic scoring model to elucidate the significance of post-induction interim fluorine-18-fluorodeoxyglucose positron emission tomography findings in patients with Hodgkin's lymphoma.

BACKGROUND: The findings of interim fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) predict progression-free survival of patients with Hodgkin's lymphoma. Historically, the assessment was based on a static all-or-none scoring system. However, the clinical significance of any positivity in interim FDG-PET/CT has not been defined. DESIGN AND METHODS: Ninety-six patients with Hodgkin's lymphoma who underwent interim FDG-PET/CT were evaluated using dynamic and visual scores, employing mediastinal or liver blood pool uptake as a comparator. FDG-PET/CT was prospectively defined as positive if any abnormal F(18)FDG uptake was present. In a retrospective analysis dynamic score 0 indicated resolution of all disease sites; score 1 defined a single residual focus; score 2 denoted a reduction in the number of foci; score 3 defined a reduction in intensity with no reduction in number; and score 4 indicated no change in the number and intensity of foci or appearance of new foci. RESULTS: The dynamic visual score review reduced the number of positive interim studies from 24 to 6 if a score of 2 or less was considered negative, with significantly better specificity (96%) as compared to static visual scores (78%-86%). The 5-year progression-free survival and overall survival rates in patients who had a negative dynamic score were 92% and 97%, respectively; the corresponding figures for patients with positive results were 50% and 67%. CONCLUSIONS: A dynamic visual score may be a better indicator for tailoring therapy than static visual scoring.

Arterial and plethysmographic waveform analysis in anesthetized patients with hypovolemia.

BACKGROUND: Respiratory-induced arterial and plethysmographic (pulse oximetry) waveform changes were shown to be good predictors of cardiac output response to increased preload. The aim of this study was to evaluate the reliability of arterial and plethysmographic waveform variables in patients with mild hypovolemia. METHODS: Patients undergoing autologous hemodilution were studied. After anesthesia induction, hemodilution was performed by withdrawing blood in steps of 2% of estimated circulating blood volume (ECBV), up to 20%. The patients who did not develop hypotension (systolic blood pressure < 80 mmHg) were studied. Arterial and plethysmographic waveforms were recorded and analyzed off-line at baseline and after each withdrawal of blood. Variations in arterial systolic and pulse pressure were analyzed using standard methods. Plethysmographic waveform variation and delta pulse oximetry plethysmography were determined by using pulse oximetry recordings. RESULTS: There were 33 study participants. Systolic blood pressure decreased by 11%, and heart rate increased from 73 to 76 beats/min after a 20% reduction of ECBV. Systolic pressure and pulse pressure variations increased (P < 0.005) after a 4% reduction of ECBV. The values of arterial pressure and pulse oximetry waveform variables almost doubled in value after a 20% reduction of ECBV. Systolic pressure variation was the most reliable variable during hypovolemia. Plethysmographic waveform variation increased significantly after a 6% reduction of ECBV and delta pulse oximetry plethysmography after an 8% reduction of ECBV. CONCLUSIONS: Arterial and pulse oximetry respiratory-induced changes in waveform variables are reliable indicators of mild hypovolemia in anesthetized patients. The pulse oximetry plethysmographic waveforms accurately reflect arterial waveforms during more progressive hypovolemia.

Disease behavior in children with Crohn's disease: the effect of disease duration, ethnicity, genotype, and phenotype.

BACKGROUND: Disease behavior in Crohn's disease (CD) may be modified by disease location and genotype. Disease behavior may change over time, and thus analysis requires follow-up. To date, there have been few pediatric studies that have evaluated the association between disease behavior and genotype with prolonged follow-up. The aim of our study was to evaluate the effect of genotype, phenotype, and ethnicity on disease behavior in pediatric CD. METHODS: Evaluation of 128 pediatric CD was followed by analysis of 232 pediatric and adult-onset CD patients. Inclusion required at least 2 years of follow-up. Phenotype, ethnicity, and disease duration were recorded. Patients were genotyped for polymorphisms in the NOD2/CARD15 gene. RESULTS: Colonic involvement was more frequent in younger patients. Pediatric disease at end of follow-up was classified as inflammatory (78%), penetrating (7%), and stricturing (17%). Duration of follow-up (mean 4.9 pediatric and 6.4 years mixed) was associated with more stricturing and penetrating disease. There was no association between mean age of onset and NOD2/CARD15, or either of these with disease behavior. These observations were replicated in the mixed cohort. Sephardic Jewish origin was inversely correlated with inflammatory behavior (P = 0.006), independent of NOD2/CARD15 genotype. CONCLUSIONS: Duration of disease and ethnicity, irrespective of NOD2/CARD15 genotype and age of onset, were the only predictors for penetrating or stricturing disease.

The use of exercise stress testing for the management of low-risk patients with chest pain.

OBJECTIVE: This retrospective study assessed the contribution of exercise stress testing (EST) in the evaluation of patients with low risk for coronary heart disease who presented to the emergency department (ED) with chest pain. BASIC PROCEDURES: The study included 175 patients who presented to the ED with chest pain and underwent EST between January 1, 2005, and November 30, 2006. MAIN FINDINGS: After the EST, 113 patients were discharged, and 62 were admitted. Exercise stress testing's positive predictive value for coronary artery disease among admitted patients was 35.7%, and sensitivity was 95.2%. Exercise stress testing's negative predictive value among discharged patients was 99.1%. None of the 113 discharged patients returned to the ED for cardiac reasons during the 30-day follow-up period. PRINCIPAL CONCLUSION: A chest pain unit or a parallel facility for evaluating patients with chest pain and with low risk for active coronary disease is necessary for detecting low-risk patients who eventually need cardiac intervention.

Parental and perinatal factors affecting childhood anthropometry of very-low-birth-weight premature infants: a population-based survey.

BACKGROUND: The perinatal-neonatal course of very-low-birth-weight (VLBW) infants might affect their childhood growth. We evaluated the effect of parental anthropometry and perinatal and neonatal morbidity of VLBW neonates on their childhood growth. METHODS: We obtained parental anthropometry, height and weight at age 6-10.5 years of 334 children born as VLBW infants. Parental, perinatal and neonatal data of these children were tested for association with childhood anthropometry. RESULTS: (1) Maternal and paternal weight standard deviation score (SDS) and discharge weight (DW) SDS were associated with childhood weight SDS (R(2)= 0.111, p < 0.00001); (2) Maternal and paternal height SDS, corrected gestational age (GA) at discharge, maternal assisted reproduction and SGA status were associated with childhood height SDS (R(2)= 0.208, p < 0.00001); (3) paternal weight SDS, DW SDS and surfactant therapy were associated with childhood body mass index (BMI) SDS (R(2)= 0.096, p < 0.00001). 31.1% of VLBW infants had DW SDS < -1.88, and are to be considered small for gestational age ('SGA'). One quarter of these infants did not catch up by age 6-10.5 years. CONCLUSION: Childhood anthropometry of VLBW infants depends on parental anthropometry, postnatal respiratory morbidity and growth parameters at birth and at discharge. Almost one-third of VLBW premature infants had growth restriction at discharge from neonatal intensive care unit (NICU), a quarter of whom did not catch up by age 6-10.5 years.

Reliability of vision screening tests for school children.

PURPOSE: Estimate the reliability of the E-chart as used with Israeli school children. DESIGN: Cross-sectional, population-based study conducted among 751 Israeli students of the Northern District, aged 6- and 7-year-olds and 13- and 14-years-old in 30 schools in 2003. METHODS: Each student was screened separately by two public health nurses using the illiterate E-chart. Collected data included the students' vision and demographic characteristics, the nurses' professional background, and whether they referred students for medical testing. The reliabilities of vision testing and of the recommendations were determined using total, positive, and negative percentages of agreement and Kappa coefficients. FINDINGS: Total percentage of agreement on vision (combined findings for both eyes) was 78.2% (Kappa 0.47, 95%CI 0.41-0.53). Logistic regression models to predict agreement on vision abnormality showed a higher percentage of agreement among females and 13- and 14-year-old students than among males and 6- and 7-year old students. Total agreement of 85.8% was found in referral recommendations (Kappa 0.58, 95%CI 0.51-0.65). Significant relationships were noted with student age, ethnicity, subdistrict of residence, nurse seniority, and agreement on vision findings. CONCLUSIONS: Improvement in school vision-screening reliability is needed, especially among 6- and 7-year-old students. To this end, the determinants of fair reliability should be investigated and training programs planned. Reasons for differences in the reliability of nurses' recommendations detected among subdistricts must be further studied, together with careful supervision, to ensure better performance and adherence to PHS guidelines. Implications for nurses and nursing should be considered. CLINICAL RELEVANCE: Demographic characteristics were found to predict reliability, which can guide nurses in selecting students who need more careful attention or closer supervision during vision testing.

Vision screening among northern Israeli Jewish and Arab schoolchildren.

BACKGROUND: Uncorrected refractive error is the leading cause of visual impairment in children. In 2002 a screening project was launched in Israel to provide data on the effectiveness of the illiterate E-chart in identifying Jewish and Arab schoolchildren in need of a comprehensive eye examination. OBJECTIVES: To present the aims, design and initial results of the visual screening project and the prevalence of vision abnormality in the study population. METHODS: A cross-sectional population-based study was conducted during 2002-2003 among first- and eighth-graders in 70 schools in northern Israel. The nurse's test included use of the illiterate E-chart to measure visual acuity. The medical examination included vision history, clinical eye examination, VA and retinoscopy. The ophthalmologist's evaluation as to whether a child needed a referral for, diagnostic procedures, treatment and/or follow-up was recorded and compared with explicit referral criteria formulated after data collection. RESULTS: Of 1975 schoolchildren, 31% had abnormal VA, defined as VA worse than 6/6 in at least one eye, and a quarter had VA equal or worse than 6/12 in both eyes. The prevalence of vision abnormality among the children was 22.4% when based on the evaluation of the field ophthalmologist and 26.1% when based on two sets of explicit severity scores and referral criteria. CONCLUSIONS: Vision abnormality is a significant health problem among northern Israeli schoolchildren. This project is unique in scope and importance, providing evidence to assist policy making with regard to vision screening for schoolchildren (including data on test reliability and validity) and optimal VA cutoff level, and confirming the need for clinical guidelines regarding referral criteria.

FGFR2 is a breast cancer susceptibility gene in Jewish and Arab Israeli populations.

Genetic variation in FGFR2 is a newly described risk factor for breast cancer. We estimated the relative risk and contribution of FGFR2 polymorphisms to breast cancer risk in diverse ethnic groups within Jewish and other Middle Eastern populations. We genotyped four FGFR2 single nucleotide polymorphisms (SNP) and tested for association of these SNPs and haplotypes with breast cancer risk in a population-based case-control study of 1,529 women with breast cancer and 1,528 controls. We found significant associations between breast cancer risk and all four studied SNPs in FGFR2 (P trend for all SNPs < 0.0001). In ethnicity-specific analysis, all four SNPs were significantly associated with breast cancer risk in Ashkenazi and Sephardi Jews, with a similar but not significant trend in Arabs. Haplotype analysis identified five common haplotypes (>1%). The previously described AAGT risk haplotype was significantly associated with breast cancer risk in Ashkenazi [odds ratio (OR), 1.25; 95% confidence interval (95% CI), 1.07-1.45; P = 0.0059] and Sephardi Jews (OR, 1.46; 95% CI, 1.17-1.80; P = 0.0006) compared with the reference GGAC haplotype. The AAAC haplotype was significantly associated with breast cancer risk in Sephardi Jews (OR, 1.97; 95% CI, 1.16-3.35; P = 0.0125) but not in Ashkenazi Jews (OR, 0.83; 95% CI, 0.41-1.62; P = 0.5613) or in Arabs (OR, 1.31; 95% CI, 0.80-2.14; P = 0.2881). Genetic variation in FGFR2, identified by rs1219648, may account for a substantial fraction of breast cancer in Arab (12%), Ashkenazi (15%), and Sephardi Jewish (22%) populations. The identification of population-specific risk haplotypes in FGFR2 is likely to help identify causal variants for breast cancer.

Is visual assessment of jaundice reliable as a screening tool to detect significant neonatal hyperbilirubinemia?

OBJECTIVE: To assess the reliability of visual assessment of bilirubin levels (BiliEye) in newborns as a screening tool to detect significant neonatal hyperbilirubinemia. STUDY DESIGN: 5 neonatologists and 17 nurses estimated 3,532 BiliEye in 1,129 term and late preterm (> or = 35 weeks) infants before discharge from the nursery, at 62 +/- 24 hours. Total serum bilirubin (TSB) levels were measured concomitantly. RESULTS: Mean TSB and BiliEye were 6.7 +/- 2.9 mg/dL (range, 0.4-18.2 mg/dL) and 6.6 +/- 3.2 mg/dL (range, 0.0-17.2 mg/dL), respectively, with good correlation (Pearson's r = 0.752, P < .0001), but other measures of agreement were poor. 61.5% of the 109 babies with TSB levels in high-risk zones were clinically misclassified. The area under curve (AUC) of the receiver-operating characteristics plotted for these high-risk zones was 0.825, but became low for early discharge (< or = 36 hours; AUC = 0.638) and late preterm (35-37 weeks; AUC = 0.613). There was significant interobserver variation (low weighted kappa, 0.363). CONCLUSIONS: Although there was good correlation between BiliEye and actual TSB level, visual assessment was unreliable as a screening tool to detect significant neonatal hyperbilirubinemia before discharge. Babies with TSB levels within high-risk zones may be clinically misdiagnosed as low-risk, resulting in inadequate follow-up.

Peptic ulcers and erosions are common in Israeli children undergoing upper endoscopy.

BACKGROUND: Peptic ulcers and erosions (PU&E) are thought to be uncommon in children. Patients with early exposure to Helicobacter pylori may be at a higher risk for early onset PU&E. Children in Israel have a high prevalence and early acquisition of Helicobacter pylori (H. pylori) and have easy access to pediatric gastroenterologists and endoscopy. Our aim was to describe the prevalence and characteristics of PU&E in this population referred by Pediatric Gastroenterologists for an upper endoscopy. METHODS: We conducted a retrospective study over the years January 2003-May 2006. Over these years we had information on 751 diagnostic upper endoscopies. PU&E was regarded as erosive gastritis/duodenitis or ulcer in either the stomach or duodenum. H. pylori status was assessed using rapid urease test and gastric biopsies. RESULTS: PU&E was detected in 169 (22.5%) patients (ulcers 51 (6.8%), erosions 118 (15.7%)). One hundred twenty-four had gastric PU&E and 58 had duodenal PU&E. H. pylori was positive in 112 (66.3%). H. pylori-associated PU&E becomes common after age 10 years, with gastric PU&E presenting much earlier than duodenal disease. Most of the H. pylori-negative PU&E were idiopathic and improved symptomatically on PPI treatment. Interestingly, 43% of patients with PU&E in our cohort were either immigrants from the former Soviet Union or of Israeli Arab origin. CONCLUSIONS: PU&E appears to be common in this selected population with a relatively high incidence of gastric PU&E. H. pylori associated PU&E becomes common after age 10 years with gastric PU&E presenting much earlier than duodenal disease. Non H. pylori PU&E in children comprises approximately a third of all PU&E, are mostly idiopathic and appear earlier than H. pylori associated PU&E.

Performance measures of the illiterate E-chart vision-screening test used in Northern District Israeli school children.

OBJECTIVES: To evaluate the screening performance of 6/6 and 6/12 vision cut-offs with an illiterate E-chart implemented by a public health nurse to test children for ocular abnormalities and uncorrected refractive error. The gold standard diagnosis is an eye examination performed by an ophthalmologist. SETTING: A cross-sectional population-based study was conducted among 2113 students' ages 6-7 and 13-14 years old in 70 Northern District Israeli schools. METHODS: Students were tested by nurses and ophthalmologists. A nurse examination was carried out using the illiterate E-chart for vision measurement. The medical examination included vision history, clinical eye examination, vision and retinoscopy testing. The Physician's evaluation of whether students needed a referral for diagnostic procedures, treatment and/or follow-up was recorded. Screening test's performance was determined using ophthalmologist's decision regarding referral as the gold standard. Detection rate (DR), false-positive rate (FPR), odds affected positive result (OAPR), positive predictive value (PPV) and negative predictive value (NPV) were estimated overall and by students' demographic characteristics. RESULTS: For vision >6/6 cut-off in at least one eye (eyes tested separately): DR - 71.9% (95% CI 65.8-78.7%), FPR - 22.8% (95% CI 17.9-28.9%), OAPR - 0.98:1 (95% CI 0.84:1-1.15:1), PPV - 52.7% (95% CI 45.4-61.2%), NPV - 90.9% (95% CI 88.7-93.1%). For 6/12 vision cut-off, namely vision 6/12 or worse in both eyes (tested separately): DR - 58.6 (95% CI 51.8-66.4%), FPR - 15.2% (95% CI 10.9-21.1%), OAPR - 1.13:1 (95% CI 0.94:1-1.35:1), PPV - 61.1% (95% CI 52.9-70.6%), NPV - 87.6% (95% CI 84.9-90.4%). CONCLUSIONS: Vision-screening test performance measures are mild. It is suggested to change vision cut-off level that denotes vision abnormality from current policy of vision not equal 6/6 in both eyes (tested separately) to vision 6/12 or worse in both eyes (tested separately). This change will result in reduction of FPR from 22% to 15%, concomitant with an increase in false-negative rate from 28% to 41%. Students may be equally screened by either a senior or a less experienced nurse.

Quality control in a National Program for the Early Detection of Breast Cancer: women's satisfaction with the mammography process.

INTRODUCTION: The experience of the mammography testing process and related satisfaction influence women's willingness to undergo the test again. The study goal was to assess women's overall satisfaction with the mammography examination service provided by participating units in the National Program for the Early Detection of Breast Cancer in Israel. METHODS: Between August 2003 and March 2004, a random sample of 3,295 women from 38 mammography units nationwide was drawn. Women were interviewed within 48 hours of their mammography, regarding their assessment of the examination process: discomfort, overall satisfaction, and intention to rescreen. Overall satisfaction and process items were measured on an ordinal scale ranging from 1 (lowest) to 6 (highest). Multivariate binomial regression was performed to identify significant predictors of being less satisfied and to estimate the associated relative risks with 95% confidence interval (CI). RESULTS: A response of "very satisfied" (score 6), indicating overall satisfaction with the mammography process, was reported by 77% (95% CI, 73%-80%) of the women, 19% (95% CI, 17%-21%) said they were satisfied. Willingness to rescreen was reported by 95%. Negative assessment of staff attitude was the most influential predictor of being less satisfied. Twenty-six percent of women reported experiencing very discomforting pain. This response was associated with a diagnostic test indication, and with process items directly related to the test (technician's attitude toward the patient; information provided by her; privacy during the test). CONCLUSIONS: Women's satisfaction was high, as was intention to rescreen. The gap between intention and rescreening begs further investigations as to other types of barriers preventing women from adherence to rescreening.

Nutritional supplementation with polymeric diet enriched with transforming growth factor-beta 2 for children with Crohn's disease.

BACKGROUND: A polymeric diet rich in transforming growth factor-beta 2 used as a single nutrient has been shown to induce remission in 79% of children with Crohn's disease. OBJECTIVES: To summarize the experience of several pediatric gastroenterology units in Israel using a TGFbeta2-enriched polymeric diet (Modulen IBD) supplementation in children and adolescents with Crohn's disease. METHODS: In a retrospective study we reviewed the charts of 28 children with Crohn's disease (10 girls, 18 boys) who received, in addition to conventional treatment, Modulen IBD as a supplement to their regular nutrition. These children were compared with 18 children supplemented with standard polymeric formula (Ensure Plus) and 18 children without formula supplementation. We recorded clinical manifestations, growth, and the Pediatric Crohn's Disease Activity Index before and after initiation of the polymeric diet. RESULTS: The Modulen-treated children showed a significant decrease in PCDAI from 34.3 to 15.7 (P< 0.0001). A significant decrease in PCDAI was recorded also in the Ensure Plus group, from 35 to 22 (P= 0.02) but not in the non-supplemented group. Significant improvements in body mass index (P = 0.01) and erythrocyte sedimentation rate (P= 0.03) were recorded at follow-up (median 3.4 months) only in the Modulen IBD group. CONCLUSIONS: In this cohort of children with Crohn's disease, supplementation of the diet with Modulen IBD as well as supplementation with Ensure Plus was associated with a decrease in PCDAI. The children supplemented with Modulen IBD also showed improvement in BMI, suggesting an additional advantage of nutritional therapy in children with this disease.

Approach to term neonates born after maternal intrapartum fever and unknown maternal group B Streptococcus status: value of serum C-reactive protein and 16S rRNA gene PCR amplification.

Thirty-six term neonates born after maternal intrapartum fever, with premature rupture of membranes <18 hours and unknown maternal group B Streptococcus status had blood samples for complete blood count, C-reactive protein, culture, and 16S rRNA gene polymerase chain reaction amplification. Only 2 neonates were symptomatic and none had leukopenia, C-reactive protein >1.0 mg/dL, bacteremia, or positive polymerase chain reaction.

Pain catastrophizing, response to experimental heat stimuli, and post-cesarean section pain.

UNLABELLED: This prospective study assessed the relation between pain catastrophizing, response to experimental pain stimuli, and pain perceived by women after elective cesarean sections. Forty-seven women who were scheduled for elective cesarean section were enrolled in the study. Magnitude estimation to suprathreshold phasic and tonic heat pain stimuli was assessed 1 or 2 days before surgery. Women completed the Pain Catastrophizing Scale after the heat stimuli and again on the first postoperative day. During the first and second postoperative days, perception of pain intensity was assessed by visual analog scale at each analgesia request. A multiple regression analysis revealed that pain on the first postoperative day was predicted by patient response to preoperative tonic heat stimuli (r(2) = .167, P = .008). Pain on the second postoperative day was predicted by preoperative pain catastrophizing (r(2) = .139, P = .021). No significant association was observed between preoperative response to heat stimuli or pain catastrophizing and the patient's analgesic consumption in the obstetrical ward. It is concluded that pain catastrophizing and response to experimental tonic heat pain correlate with post-cesarean section pain. PERSPECTIVE: This article presents psychological and psychophysical measures that may be of help in the prediction of post-cesarean section pain. It may therefore contribute to the treatment of the sequelae of the most common major surgical procedure performed in women in their reproductive years.

Infant feeding patterns in the first 6 months: an assessment in full-term infants.

BACKGROUND: The infant formula market has grown significantly and offers a wide range of products for the different stages of healthy infant growth. Healthy infants often go through a series of unnecessary changes of formulas. The present study aimed to identify the factors leading to switches to alternative formulas. We studied the feeding patterns in the first 6 months of babies born at term, particularly changes in infant formulas. We also investigated the reasons for choosing the first formula, infant formula changes, the addition of formulas to supplement breast-feeding, and various aspects related to formula thickening. PATIENTS AND METHODS: Two hundred parents of babies ages 6 to 18 months were interviewed. The interviews included a detailed questionnaire and were conducted in child and maternal health care centers. RESULTS: Forty-seven percent of these infants underwent changes in their formula in the first 6 months of life, most of which (67%) were to another cow's milk-based formula. The main reasons for switching a formula were regurgitation or vomiting (24%) followed by restlessness (18%). Lower z scores at birth and a higher Deltaz2 (z score at the time of the questionnaire minus z score at birth) were associated with significantly more formula changes. The impact of pediatricians and other health care professionals on the choice of infant nutrition was surprisingly negligible. CONCLUSIONS: The most common reason for switching a formula was concern regarding common infantile symptoms or behavior patterns perceived by parents to be related to formula intolerance. The decision to switch formula was usually made by the parents without consulting a health professional.

The LBP patient perception scale: a new predictor of LBP episode outcomes among primary care patients.

OBJECTIVE: To describe a new tool designed to capture patients' perception of their low back pain (LBP) episodes-the patient perception scale (PPS) and test its ability to predict episode outcomes. METHODS: Thirty-two family physicians recruited 526 low back pain patients during an office visit. Physicians completed a short questionnaire at the index visit, which included both their assessments of patients' patient perception scale (PPS-doc) and contact information. Patients were then interviewed by telephone within 2 weeks after the index visit, with follow-up telephone contacts at 2, 4, 8 and 12 months. The patient perception scale as reported by the physician (PPS-doc) and patient (PPS-pt), each constituent question, and different combinations were analyzed for their ability to predict patient outcomes. RESULTS: Patients' responses (PPS-pt) proved predictive for all outcome items. PPS-doc was much less predictive. Measures of patient centeredness did not perform well in this study. CONCLUSION: By using a short scale based on the patient's perception of pain (PPS-pt), it is possible to predict adverse outcomes of a low back pain episode. The patient perception scale should be evaluated further and perhaps combined with other instruments for targeting care and chronicity prevention efforts in low back pain. PRACTICE IMPLICATIONS: The PPS-pt could potentially be used as part of the standard initial patient evaluation of new LBP patients, as a proxy for "yellow flags" (markers of psychosocial risk) where a positive score might be the equivalent to high-risk identification. The apparent advantage of this scale is its brevity and simplicity of administration. The separation, through this scale of pain episodes into simple and complex LBP might be a useful tool for helping direct resources and avoiding chronicity.

Intravenous cyclosporine for inflammatory bowel disease--safe and effective.

BACKGROUND/AIMS: Intravenous cyclosporine has been used in the treatment of active inflammatory bowel disease. However, there are serious concerns regarding its toxicity. Cyclosporine's exact place in the treatment of Crohn's disease is yet to be defined. The aims of this study are to assess the safety and efficacy of intravenous cyclosporine in treatment of patients with inflammatory bowel disease. METHODOLOGY: We reviewed the hospital files of all patients who received intravenous cyclosporine in Rambam Medical Center during the period of December 2000 to November 2003. The patients' charts, focusing on clinical outcomes and toxicity were recorded and analyzed. RESULTS: Twenty patients, 10 males, seven with Crohn's disease and 13 ulcerative colitis. Seven patients underwent surgery within one year after cyclosporine therapy. Clinical response was achieved in 77.8% of Crohn's patients' treatment courses and 85.7% of ulcerative colitis patients' treatment courses. Clinical response included significant reduction in bowel movements, amount of blood and improvement in consistency of stool. No major or life-threatening adverse effects of cyclosporine were observed. CONCLUSIONS: Cyclosporine as given was as effective and safe for Crohn's disease patients as for ulcerative colitis patients.