Routine testing for IgG antibodies against hepatitis A virus in Israel

BACKGROUND: Viral hepatitis is highly endemic in Israel, with the hepatitis A virus (HAV) responsible for most cases. Improved socioeconomic factors, as well as the universal vaccination of infants (introduced in 1999) has resulted in a decline in infection rates in Israel. This study examines the benefits of routine testing for anti-HAV IgG in high-risk population. METHODS: A retrospective examination of the files of teenage and adult patients (aged 16–99 years; mean 33.9) in two primary care clinics found 1,017 patients who had been tested for anti-HAV IgG antibodies for either general healthcare screening or ongoing follow-up for chronic illness. Seropositive patients were then asked regarding recall of past hepatitis (i.e. jaundice, regardless of viral etiology); post-exposure prophylaxis with immune serum immunoglobulin (ISG); and active immunization with inactivated virus. Seronegative patients were subsequently sent for active immunization. RESULTS: Of the1,017 patient records studied (503 male, 514 female), a total of 692 were seropositive (354 males, 338 females; P = 0.113). Seropositivity rates increased with age (p < 0.005), and were highest among those born in Middle Eastern countries other than Israel (91.3%) and lowest among immigrants from South America (44.1%; P < 0.005). 456 of the seropositive patients were interviewed, of whom only 91 recalled past illness while 103 remembered receiving post-exposure prophylaxis (ISG) and 8 active vaccination. Those who were unaware of past infection were more likely to have been vaccinated with ISG than those who were aware (26.3% vs. 7.7%; p < 0.005). CONCLUSION: The relatively high prevalence rate of anti-HAV seropositivity in our study may me due to the fact that the study was conducted in a primary care clinic or that it took place in Jerusalem, a relatively poor and densely populated Israeli city. Most of the seropostive patients had no recollection of prior infection, which can be explained by the fact that most hepatitis A infections occur during childhood and are asymptomatic. Routine testing for anti-HAV IgG in societies endemic for HAV would help prevent seropositive patients from receiving either post-exposure or preventive immunization and target seronegative patients for preventive vaccination

Influence of maternal and perinatal factors on subsequent hospitalisation for asthma in children: evidence from the Oxford record linkage study

Background: There is much interest in the possibility that perinatal factors may influence the risk of disease in later life. We investigated the influence of maternal and perinatal factors on subsequent hospital admission for asthma in children. Methods: Analysis of data from the Oxford record linkage study (ORLS) to generate a retrospective cohort of 248 612 records of births between 1970 and 1989, with follow-up to records of subsequent hospital admission for 4 017 children with asthma up to 1999. Results: Univariate analysis showed significant associations between an increased risk of admission for asthma and later years of birth (reflecting the increase in asthma in the 1970s and 1980s), low social class, asthma in the mother, unmarried mothers, maternal smoking in pregnancy, subsequent births compared with first-born, male sex, low birth weight, short gestational age, caesarean delivery, forceps delivery and not being breastfed. Multivariate analysis, identifying each risk factor that had a significant effect independently of other risk factors, confirmed associations with maternal asthma (odds ratio (OR) 3.1, 95% confidence interval 2.7-3.6), male sex (versus female, 1.8, 1.7-2.0), low birth weight (1000-2999 g versus 3000-3999 g, 1.2, 1.1-1.3), maternal smoking (1.1, 1.0-1.3) and delivery by caesarean section (1.2; 1.0-1.3). In those first admitted with asthma under two years old, there were associations with having siblings (e.g. second child compared with first-born, OR 1.3, 1.0-1.7) and short gestational age (24-37 weeks versus 38-41 weeks, 1.6, 1.2-2.2). Multivariate analysis confined to those admitted with asthma aged six years or more, showed associations with maternal asthma (OR 3.8, 3.1-4.7), age of mother (under 25 versus 25-34 at birth, OR 1.16, 1.03-1.31; over 35 versus 25-34, OR 1.4, 1.1-1.7); high social class was protective (1 and 2, compared with 3, 0.72; 0.63-0.82). Hospital admission for asthma in people aged over six was more common in males than females (1.4; 1.2-1.5); but, by the teenage years, the sex ratio reversed and admission was more common in females than males. Conclusion: Several maternal characteristics and perinatal factors are associated with an elevated risk of hospital admission for asthma in the child in later life. </p

The integrated care pathway reduced the number of hospital days by half: a prospective comparative study of patients with acute hip fracture

BACKGROUND: The incidence of hip fracture is expected to increase during the coming years, demanding greater resources and improved effectiveness on this group of patients. The aim of the present study was to evaluate the effectiveness of an integrated care pathway (ICP) in patients with an acute fracture of the hip. METHODS: A nonrandomized prospective study comparing a consecutive series of patients treated by the conventional pathway to a newer intervention. 112 independently living patients aged 65 years or older admitted to the hospital with a hip fracture were consecutively selected. Exclusion criteria were pathological fracture and severe cognitive impairment. An ICP was developed with the intention of creating a care path with rapid pre-operative attention, increased continuity and an accelerated training programme based on the individual patient's prerequisites and was used as a guidance for each patient's tailored care in the intervention group (N = 56) The main outcome measure was the length of hospital stay. Secondary outcomes were the amount of time from the emergency room to the ward, to surgery and to first ambulation, as well as in-hospital complications and 30-day readmission rate. RESULTS: The intervention group had a significantly shorter length of hospital stay (12.2 vs. 26.3 days; p < 0.000), a shorter time to first ambulation (41 vs. 49 h; p = 0.01), fewer pressure wounds (8 vs. 19; p = 0.02) and medical complications (5 vs. 14; p = 0.003) than the comparison group. No readmissions occurred within 30 days post-intervention in either group. CONCLUSION: Implementing an ICP for patients with a hip fracture was found to significantly reduce the length of hospital stay and improve the quality of care

Breastfeeding and childhood asthma: a six-year population-based cohort study

<p>Abstract</p> <p>Background</p> <p>The question of the protective effect of breastfeeding on development of asthma has raised substantial interest, but the scientific evidence of the optimal duration of breastfeeding is controversial.</p> <p>Methods</p> <p>The authors elaborated the optimal duration of breastfeeding with respect to the risk of asthma primarily, and secondarily to the risk of persistent wheezing, cough and phlegm in school age in a population-based cohort study with the baseline in 1991 and follow-up in 1997. The study population comprised 1984 children aged 7 to 14 years at the end of the follow-up (follow-up rate 77). Information on breastfeeding was based on the baseline survey and information on the health outcomes at the follow-up.</p> <p>Results</p> <p>There was a U-shaped relation between breastfeeding and the outcomes with the lowest risk with breastfeeding from four to nine months for asthma and seven to nine months for persistent wheezing, cough and phlegm.</p> <p>Conclusion</p> <p>Our results suggest a U shape relation between duration of breastfeeding and risk of asthma with an optimal duration of 4 to 6 months. A true concave relation would explain the inconsistent results from the previous studies.</p

The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures

<p>Abstract</p> <p>Background</p> <p>Whether reducing time-to-surgery for elderly patients suffering from hip fracture results in better outcomes remains subject to controversial debates.</p> <p>Methods</p> <p>As part of a prospective observational study conducted between January 2002 and September 2003 on hip-fracture patients from 268 acute-care hospitals all over Germany, we investigated the relationship of time-to-surgery with frequency of post-operative complications and one-year mortality in elderly patients (age ≥65) with isolated proximal femoral fracture (femoral neck fracture or pertrochanteric femoral fracture). Patients with short (≤12 h), medium (> 12 h to ≤36 h) and long (> 36 h) times-to-surgery, counting from the time of the fracture event, were compared for patient characteristics, operative procedures, post-operative complications and one-year mortality.</p> <p>Results</p> <p>Hospital data were available for 2916 hip-fracture patients (mean age (SD) in years: 82.1 (7.4), median age: 82; 79.7% women). Comparison of groups with short (n = 802), medium (n = 1191) and long (n = 923) time-to-surgery revealed statistically significant differences in a few patient characteristics (age, American Society of Anesthesiologists ratings classification and type of admission) and in operative procedures (total hip endoprosthesis, hemi-endoprosthetic implants, other osteosynthetic procedures). However, comparison of these same groups for frequency of postoperative complications revealed only some non-significant associations with certain complications such as post-operative bleeding requiring treatment (early surgery patients) and urinary tract infections (delayed surgery patients). Both unadjusted rates of one-year all-cause mortality (between 18.1% and 20.5%), and the multivariate-adjusted hazard ratios (HR for time-to-surgery: 1.04; p = 0.55) showed no association between mortality and time-to-surgery.</p> <p>Conclusion</p> <p>Although this study found a trend toward more frequent post-operative complications in the longest time-to-surgery group, there was no effect of time-to-surgery on mortality. Shorter time-to-surgery may be associated with somewhat lower rates of post-operative complications such as decubitus ulcers, urinary tract infections, thromboses, pneumonia and cardiovascular events, and with somewhat higher rates of others such as post-operative bleeding or implant complications.</p

Clinical practice: Breastfeeding and the prevention of allergy

The increase in allergic disease prevalence has led to heightened interest in the factors determining allergy risk, fuelled by the hope that by influencing these factors one could reduce the prevalence of allergic conditions. The most important modifiable risk factors for allergy are maternal smoking behaviour and the type of feeding. A smoke-free environment for the child (to be), exclusive breastfeeding for 4–6 months and the postponement of supplementary feeding (solids) until 4 months of age are the main measures considered effective. There is no place for restricted diets during pregnancy or lactation. Although meta-analyses suggest that hypoallergenic formula after weaning from breastfeeding grants protection against the development of allergic disease, the evidence is limited and weak. Moreover, all current feeding measures aiming at allergy prevention fail to show effects on allergic manifestations later in life, such as asthma. In conclusion, the allergy preventive effect of dietary interventions in infancy is limited. Counselling of future parents on allergy prevention should pay attention to these limitations

Using donor human milk to feed vulnerable term infants: a case series in KwaZulu Natal, South Africa

Background Donor human milk is the World Health Organization’s recommendation for infant feeding when the mother’s own breast milk is unavailable. Breast milk has been shown to reduce morbidity and mortality and in low birthweight infants, donor milk reduces the incidence of necrotising enterocolitis, late onset sepsis and improves outcomes. There is a paucity of literature documenting outcomes of using donor human milk in older children who need additional support for a variety of health issues. Case presentation A series of seven case studies is presented of orphaned and abandoned children, many of whom were either HIV exposed or positive. All children were fed with pasteurised donor human milk at a transition home and their progress reported. Conclusions Although detailed medical records were not always available, the case studies provide anecdotal evidence of the protective effects of donor human milk against failure to thrive, diarrhoea, atopic dermatitis, and opportunistic infections