Cytokine fingerprint differences following infection and vaccination - what can we learn from COVID-19?

COVID-19 vaccination and acute infection result in cellular and humoral immune responses with various degrees of protection. While most studies have addressed the difference in humoral response between vaccination and acute infection, studies on the cellular response are scarce. We aimed to evaluate differences in immune response among vaccinated patients versus those who had recovered from COVID-19. This was a prospective study in a tertiary medical centre. The vaccinated group included health care workers, who had received a second dose of the BNT162b2 vaccine 30 days ago. The recovered group included adults who had recovered from severe COVID-19 infection (<94% saturation in room air) after 3-6 weeks. Serum anti-spike IgG and cytokine levels were taken at entry to the study. Multivariate linear regression models were applied to assess differences in cytokines, controlling for age, sex, BMI, and smoking status. In total, 39 participants were included in each group. The mean age was 53 ±14 years, and 53% of participants were males. Baseline characteristics were similar between the groups. Based on multivariate analysis, serum levels of IL-6 (ß=-0.4, p<0.01), TNFα (ß=-0.3, p=0.03), IL-8 (ß=-0.3, p=0.01), VCAM-1 (ß=-0.2, p<0.144), and MMP-7 (ß=-0.6, p<0.01) were lower in the vaccinated group compared to the recovered group. Conversely, serum anti-spike IgG levels were lower among the recovered group (124 vs. 208 pg/mL, p<0.001). No correlation was identified between antibody level and any of the cytokines mentioned above. Recovered COVID-19 patients had higher cytokine levels but lower antibody levels compared to vaccinated participants. Given the differences, these cytokines might be of value for future research in this field.

Are Higher Body Mass Index and Worse Metabolic Parameters Associated with More Aggressive Differentiated Thyroid Cancer? A Retrospective Cohort Study.

Obesity is a risk factor for differentiated thyroid cancer (DTC), but the association with DTC aggressiveness is controversial. To evaluate the association between preoperative body mass index (BMI)/other metabolic parameters and DTC aggressiveness in our surgical cohort, we retrospectively evaluated patients following thyroid surgery who were diagnosed with DTC between December 2013 and January 2021. Baseline characteristics, histopathological features, treatment modalities, and follow-up data were studied. We conducted logistic regression to analyze the association between BMI/other metabolic parameters and adverse DTC features. The final study cohort included 211 patients (79.6% women; mean age± standard deviation 48.7 ± 15.9 years): 66 (31.3%) with normal weight, 81 (38.4%) with overweight, and 64 (30.3%) with obesity. The median follow-up was 51 months (range 7-93). Complete versus partial thyroidectomy was more common among patients living with overweight or obesity than in normal weight patients (79.7% versus 61.7%, p = 0.017, respectively). Logistic regression demonstrated that higher BMI was associated with mildly increased risk for lymph nodes metastases (odds ratio [OR] 1.077, 95% CI: 1.013-1.145), and higher triglycerides/high-density lipoprotein-cholesterol (TG/HDL-C) ratio was associated with aggressive histological variants of DTC (OR 1.269, 95% CI 1.001-1.61). To conclude, specific adverse clinical and histopathological DTC features were indeed associated with higher BMI and higher TG/HDL-C ratio.

The humoral response to COVID-19 vaccinations can predict the booster effect on health care workers-toward personalized vaccinations?

BACKGROUND: Waning immunity after the coronavirus disease 2019 (COVID-19) vaccinations creates the constant need of boosters. Predicting individual responses to booster vaccines can help in its timely administration. We hypothesized that the humoral response to the first two doses of the BNT162b2 vaccine can predict the response to the booster vaccine. METHODS: A prospective cohort of hospital health care workers (HCW) that received three doses of the BNT162b2 vaccine. Participants completed serological tests at 1 and 6 months after the second vaccine dose and 1 month after the third. We analyzed predictive factors of antibody levels after the booster using multivariate regression analyses. RESULTS: From 289 eligible HCW, 89 (31%) completed the follow-up. Mean age was 48 (±10) and 46 (52%) had daily interaction with patients. The mean (±standard deviation) antibody level 1 month after the second vaccine was 223 (±59) AU/ml, and 31 (35%) had a rapid antibody decline (>50%) in 6 months. Low antibody levels 1 month after the second vaccine and a rapid antibody decline were independent predictors of low antibody levels after the booster vaccine. CONCLUSIONS: The characteristics of the humoral response to COVID-19 vaccinations show promise in predicting the humoral response to the booster vaccines.

Assessment of a close respiratory follow-up schedule at 3 and 6 months after acute COVID-19 and its related investigations.

BACKGROUND: Respiratory sequela after acute COVID-19 is common and requires medical follow-up. Considering its vast economic impact, there is still no consensus regarding the mid-term follow-up plan after recovery. OBJECTIVE: To evaluate the necessity of a close pulmonary follow-up schedule after acute COVID-19 and its related investigations. METHODS: A prospective cohort study including adult patients after acute COVID-19 pneumonia. Patients were invited or referred to a 3- and 6-month follow-up visits at a large pulmonary institute in a tertiary center. Before each visit, patients completed demographic and clinical questionnaires, pulmonary function tests (PFTs), and chest CT scans. RESULTS: 168 patients were included after completing both visits (medians of 80 and 177 days). Their mean age was 58 ± 15 and 52% recovered from severe or critical COVID-19. Between the two visits, there was no change in DLCOc (mean 73 ± 18 %predicted in both visits) and FVC (mean 90 ± 16 vs. 89 ± 16 %predicted). The COPD assessment tool and modified Medical Research Council scale had inverse correlations with the DLCOc, and similarly did not change between the visits. Occupational exposures were the only factor associated with a change in DLCOc during follow-up (3% decrease, p = 0.04). An improvement in chest CT findings at the second visit was not associated with a change in PFTs. CONCLUSIONS: Most clinical variables did not change during a close follow-up schedule in the first six months after acute COVID-19. Such a follow-up plan does not appear necessary and should be personalized to limit excessive costs and resources.

Interactions and clinical implications of serological and respiratory variables 3 months after acute COVID-19.

Medical follow-up of symptomatic patients after acute Coronavirus Disease 2019 (COVID-19) results in major burdens on patients and healthcare systems. The value of serological markers as part of this follow-up remains undetermined. We aimed to evaluate the clinical implications of serological markers for follow-up of acute COVID-19. For this purpose, we conducted an observational cohort study of patients 3 months after acute COVID-19. Participants visited a respiratory-clinic between October 2020 and March 2021, and completed pulmonary function tests (PFTs), serological tests, symptom-related questionnaires, and chest CT scans. Overall, 275 patients were included at a median of 82 days (IQR 64-111) post infection. 162 (59%) patients had diffusing capacity for carbon monoxide corrected for hemoglobin (DLCOc) below 80%, and 69 (25%) had bilateral chest abnormalities on CT scan. In multivariate analysis, anti-S levels were an independent predictor for DLCOc (ß = - 0.14, p = 0.036). Anti-S levels were also associated with severe COVID-19 and older age, and correlated with anti-nucleocapsid (r = 0.30, p < 0.001) and antibodies to receptor binding domain (RBD, r = 0.37, p < 0.001). Other serological variables were not associated with clinical outcomes. In conclusion, symptomatic patients 3-months after COVID-19 had high respiratory symptomatic burden, in which anti-S levels were significantly associated with previous severe COVID-19 and DLCOc.

Effectiveness of a bivalent mRNA vaccine booster dose to prevent severe COVID-19 outcomes: a retrospective cohort study.

BACKGROUND: In late 2022, the SARS-CoV-2 omicron (B.1.1.529) BA.5 sublineage accounted for most of the sequenced viral genomes worldwide. Bivalent mRNA vaccines contain an ancestral SARS-CoV-2 strain component plus an updated component of the omicron BA.4 and BA.5 sublineages. Since September, 2022, a single bivalent mRNA vaccine booster dose has been recommended for adults who have completed a primary SARS-CoV-2 vaccination series and are at high risk of severe COVID-19. We aimed to evaluate the effectiveness of a bivalent mRNA vaccine booster dose to reduce hospitalisations and deaths due to COVID-19. METHODS: We did a retrospective, population-based, cohort study in Israel, using data from electronic medical records in Clalit Health Services (CHS). We included all members of CHS who were aged 65 years or older and eligible for a bivalent mRNA COVID-19 booster vaccination. We used hospital records to identify COVID-19-related hospitalisations and deaths. The primary endpoint was hospitalisation due to COVID-19, which we compared between participants who received a bivalent mRNA booster vaccination and those who did not. A Cox proportional hazards regression model with time-dependent covariates was used to estimate the association between the bivalent vaccine and hospitalisation due to COVID-19 while adjusting for demographic factors and coexisting illnesses. FINDINGS: Between Sept 27, 2022, and Jan 25, 2023, 569 519 eligible participants were identified. Of those, 134 215 (24%) participants received a bivalent mRNA booster vaccination during the study period. Hospitalisation due to COVID-19 occurred in 32 participants who received a bivalent mRNA booster vaccination and 541 who did not receive a bivalent booster vaccination (adjusted hazard ratio 0·28, 95% CI 0·19-0·40). The absolute risk reduction for hospitalisations due to COVID-19 in bivalent mRNA booster recipients versus non-recipients was 0·089% (95% CI 0·075-0·101), and the number needed to vaccinate to prevent one hospitalisation due to COVID-19 was 1118 people (95% CI 993-1341). INTERPRETATION: Participants who received a bivalent mRNA booster vaccine dose had lower rates of hospitalisation due to COVID-19 than participants who did not receive a bivalent booster vaccination, for up to 120 days after vaccination. These findings highlight the importance of bivalent mRNA booster vaccination in populations at high risk of severe COVID-19. Further studies with longer observation times are warranted. FUNDING: None.

One-year dynamics of antibody titers after three doses of SARS-CoV-2 BNT162b2 vaccine.

BACKGROUND: A third dose of the BNT162b2 SARS-CoV-2 vaccine leads to a significant increase in antibody levels, however, concerns regarding the long-term persistence of this response exist. We assessed the humoral response for one year following vaccination. METHODS: A prospective study among immunocompetent healthcare workers (HCW) who received three doses of BNT162b2. anti-spike antibody titers were measured at six predefined timepoints, from before the second vaccine dose, and up to one year afterwards, which is 4-6 months after the third dose. HCW with a history of SARS-CoV-2 infection were excluded. RESULTS: Seventy-six HCW had all the six serological measurements. Antibody titers significantly increased shortly following the third vaccine dose, and while declining, remained higher from all previous measurements for up to six months. CONCLUSIONS: A third dose of BNT162b2 leads to a profound humoral response, which remains significantly higher than previous measurements, even after 6 months.

Impact of Group vs. Individual Prenatal Care Provision on Women's Knowledge of Pregnancy-Related Topics: An Open, Controlled, Semi-Randomized Community Trial.

The importance of acquiring knowledge of pregnant women on prenatal care lies in its leading to confidence and ability in decision-making. There is a growing need for a model of prenatal care that will allow nurses to provide the most efficient pregnancy-related guidance with minimum need for additional staff. This study compares the level of knowledge on subjects pertaining to pregnancy and birth in low-risk pregnancies when delivered in group versus individual settings. The study is an open, controlled, semi-randomized community trial. The intervention arm received prenatal care services in a group setting led by a nurse. The control arm received prenatal care services in routine individual meetings with a nurse. Knowledge of prenatal subjects was evaluated by questionnaires. The level of knowledge of the women in the group setting for the pre-service questionnaire was lower than that of the women in the individual group, but higher for the final questionnaire. After accounting for a starting point difference (the women in the individual care arm started with a higher knowledge score), the women in the group setting had a three-fold improvement in score compared to the women in the individual setting (p = 0.043). Prenatal care provided in a group setting may lead to better knowledge acquisition, leading to better awareness of pregnancy-related medical conditions and to enhanced adherence to recommended pregnancy tests and healthy lifestyle.

Assessment of Predictors for SARS-CoV-2 Antibodies Decline Rate in Health Care Workers after BNT162b2 Vaccination-Results from a Serological Survey.

Background: SARS-CoV-2 is a novel human pathogen causing Coronavirus Disease 2019 that has caused widespread global mortality and morbidity. Since health workers in Israel were among the first to be vaccinated, we had a unique opportunity to investigate the post-vaccination level of IgG anti-S levels antibodies (Abs) and their dynamics by demographic and professional factors. Methods: Prospective Serological Survey during December 2020−August 2021 at Barzilai Medical Center among 458 health care workers (HCW) followed for 6 months after the second BNT162b2 vaccine dose. Results: Antibody levels before the second dose, and 30, 90 and 180 days after were 57.1 ± 29.2, 223 ± 70.2, 172.8 ± 73.3 and 166.4 ± 100.7 AU/mL, respectively. From GEE analysis, females had higher Abs levels (ß = 26.37 AU/mL, p = 0.002). Age was negatively associated with Abs, with a 1.17 AU/mL decrease for each additional year (p < 0.001). Direct contact with patients was associated with lower Abs by 25.02 AU/mL (p = 0.009) compared to working with no such contact. The average decline rate overall for the study period was 3.0 ± 2.9 AU/mL per week without differences by demographic parameters and was faster during the first 3 months after vaccination than in the subsequent 3 months. Conclusions: All demographic groups experienced a decline in Abs over time, faster during the first 3 months. Findings of overall Abs lower in males, workers with direct contact with patients, and older workers, should be considered for policy-making about choosing priority populations for additional vaccine doses in hospital settings.

Traffic Noise and Ambient Air Pollution Are Risk Factorsfor Preeclampsia.

Purpose: We aimed to evaluate the effect of traffic-related noise (TRN), environmental noise (EN) and traffic-related air pollution (TRAP) on preeclampsia. Methods: We followed 285 pregnant women from Maternal and Child Health Clinics who reported exposure to TRN on a scale from 0 (absence of EN) to 10 (high level of EN). EN was measured using a portable dosimeter, and NOx was calculated using the AERMOD pollutant dispersion model. Results: Using a multiple logistic regression model, adjusted for maternal age, BMI, number of births, fetal sex and maternal chronic illness, TRN (score ≥ 6 vs. score < 6) and TRAP (NOx ≥ 300 µ/m3 vs. NOx < 300 µ/m3) were noted as independent risk factors for preeclampsia, with OR = 3.07 (95% CI 0.97; 9.70, p = 0.056) and OR = 3.43 (95% CI 1.20; 9.87, p = 0.022), respectively. Joint exposure to TRN and TRAP was associated with a significant and independent risk for preeclampsia (OR of 4.11 (95% CI 1.31; 12.94, p = 0.016). Conclusions: In our population, traffic-related noise and ambient TRAP were risk factors for preeclampsia.

Epidemiologic, microbiologic and imaging characteristics of urinary tract infections in hospitalized children < 2 years of age diagnosed with anatomic abnormalities of the urinary tract.

BACKGROUND: To compare the epidemiologic, microbiologic and imaging characteristics of urinary tract infections (UTI) in children <2 years of age with and without anatomic urinary tract abnormalities (AA). METHODS: All children hospitalized with UTI during 1.1.2005-31.12.2018 were included. The study group (patients with AA) included 76 patients. The control group (99 patients) included patients without AA. RESULTS: 1163 children were hospitalized. Age at diagnosis was younger in the study group vs. controls (5.2 ± 6.0 vs. 7.9 ± 7.5 months, P = 0.038). Uropathogens distribution was different (P = 0.007), with lower Escherichia coli (Ec) and Proteus mirabilis (Pm) percentages in the study group and higher percentages of Enterococcus spp. (Ent) in controls. In the study group, Ec nonsusceptibility rates to ampicillin, amoxicillin/clavulanic acid, cefazolin, cefuroxime, TMP/SMX and ceftriaxone were 58%, 40%, 14%, 14%, 12% and 10%, respectively, with no differences vs. controls. Ultrasound (US) was performed in 69/76 (98%) patients with AA (84.1%, abnormal); bilateral (39.7%) and unilateral (32.7%) ureteral dilatation were the most frequent findings. Voiding cystourethrography was performed in 46 patients (pathologic in 35, 76%); 31 (81.6%) patients had vesicoureteral reflux (VUR) (bilateral in 11, 35.5%; grade 4/5 in 7 patients). Uropathogens distribution in VUR patients differed between study and control groups, with lower Ec and Pm in the first group and higher Pseudomonas aeruginosa and Ent percentages in the control group. CONCLUSION: Age at diagnosis was lower and pathogen distribution was different in patients with AA. Antibiotic susceptibility patterns of the main uropathogens were similar between patients with or without AA.

Reduction in self-reported influenza-like-illness in school children and household members following influenza vaccine administration - a cohort study, Israel, 2016-7.

BACKGROUND: Second-grade pupils in Israel have been vaccinated against influenza since the winter of 2016-2017. This study aims to appraise the rate reduction of seasonal influenza vaccine among vaccinated children and their household members, and that of the vaccinated cohort and their household members. METHODS: This retrospective cohort study was performed in winter 2016-2017 in Tel-Aviv District, Israel and compared second-grade pupils who were vaccinated at school, with third-grade pupils- who were not vaccinated at school. Parents in nine schools were asked to report prior vaccination against influenza and influenza-like illness (ILI) of their children and other household members. Rate reduction was defined as [(ILI among unvaccinated) - (ILI among vaccinated)] / (ILI among vaccinated) (%). RESULTS: Of 527 participants, 359 (68.1%) were unvaccinated and 168 (31.9%) vaccinated. Unvaccinated children reported more ILI compared with vaccinated children (19.5% vs. 7.7%), yielding a rate reduction of 60.5%. Unvaccinated children also had a greater number of physicians' visits and missed school days (35.7% vs. 14.9 and 42.9% vs. 25.6%, respectively). The rate of ILI among household members of unvaccinated children was 34.5%, compared with 25.0% among household members of vaccinated children. The vaccinated cohort (defined as all children in second grade) reported less ILI compared with the unvaccinated cohort (defined as all children in third grade), with a rate reduction of 44.6%. Pupils of the unvaccinated cohort were more likely to miss school days (42.1% vs. 32.0%, respectively), and a higher rate of ILI was reported among household members of the unvaccinated cohort (35.4% vs. 27.3%, respectively). CONCLUSION: Influenza vaccine administered in school setting reduced ILI among the vaccinated cohort and their household members by 60.5 and 27.5%, respectively, compared with the unvaccinated cohort. Expansion of the vaccination program in a school setting increased the public health benefit of influenza vaccines among both school children and their household members.

Ethnic Disparities in the Diagnosis of Autism in Southern Israel.

The prevalence of autism spectrum disorder (ASD) is continuously rising worldwide, with remarkable differences in ASD rates being reported across ethnic and socioeconomic groups. We conducted a prospective cohort study to identify the reasons for differences in ASD rates between the Bedouin and Jewish populations in southern Israel. Screening, referral, and diagnosis of toddlers aged 16-36 months were compared between Bedouin and Jewish populations. ASD screening was conducted at 35 randomly selected mother and child health centers (MCHCs) by trained nurses using the Modified Checklist for Autism in Toddlers with follow-up (M-CHAT/F) instrument. Toddlers screened positive at the MCHCs were monitored throughout the referral and diagnosis process at a single medical center until a diagnosis was determined by a physician specialist using DSM-5 criteria. The study cohort comprised 3,343 toddlers (996 Jewish and 2,347 Bedouin). Bedouin toddlers, compared to Jewish toddlers, were less likely to screen positive with M-CHAT/F (3.0% vs. 3.9%; P = 0.165), were significantly less likely to begin the hospital diagnosis process (HR = 0.38, 95% CI: 0.14-1.08; P = 0.068), and had a higher rates of loss-to-follow-up during the hospital diagnosis process (42.9% vs. 15.6%, respectively; P = 0.001). The results suggest that ethnic-specific barriers in the diagnosis process of ASD contribute to under-diagnosis of ASD in the Bedouin population. Facilitating the diagnosis process for Bedouin families will help to identify more children with ASD at earlier ages and consequently close the ethnic gap in ASD rates. LAY SUMMARY: We followed Bedouin and Jewish toddlers aged 16-36 months from southern Israel through their autism spectrum disorder (ASD) screening referral and diagnosis to identify the reasons for the differences in ASD prevalence between these ethnic groups. Jewish and Bedouin toddlers were equally identified in the ASD screening. However, Bedouin toddlers were less likely to complete the diagnosis process due to higher rates of loss-to-follow-up and slower diagnosis process. Facilitating ASD diagnosis for the Bedouin population will help identifying more toddlers with ASD.

Polygamy and birth outcomes among Bedouin women of the Negev: The contribution of social determinants and pregnancy complications.

Polygamy has been associated with adverse health outcomes. We examined the association between polygamy and adverse birth outcomes (composite score of preterm birth, low birth weight, small for gestational age, Apgar score < 7) using survey data linked to retrospective medical data of 9,872 cohort Bedouin women who bore live singletons in a large medical center in Southern Israel between 2008 and 2014. Women in polygamous marriages (18%) were more likely to have adverse birth outcomes after considering different factors (AOR = 1.28, 95% CI = 1.09-1.51), indicating that polygamy is an independent risk factor for birth outcomes that should be considered in research and clinical practice.

Sex effect on growth faltering in an indigenous ethnic minority population of infants in Israel.

OBJECTIVE: We examined sex effects on growth faltering in an indigenous population of Bedouin Arab infants born in Israel, an economically developed country. DESIGN: Retrospective cohort study. Height-for-age Z-score (HAZ) at age 6, 12, 18 and 24 months was calculated for full-term, normal-birth-weight Bedouin infants born during years 2000-2009 and attending maternal and child health (MCH) clinics. Multivariate linear regression analysis (MLRA) was used to calculate the association between sex and HAZ, controlling for year of birth, birth weight (BW) and residence by type of settlement (established settlement (ES); non-established settlement (NES)). SETTING: Bedouin are an indigenous poor community of semi-nomadic Arabs, with the highest infant mortality rate in Israel. Fifty per cent of Bedouin infants live in NES with inadequate access to running water, electricity, and rubbish and sewage disposal. All Bedouin receive free well-baby care in community-based MCH clinics. PARTICIPANTS: Full-term, normal Bedouin infants (n 5426) born during 2000-2009 and attending computerized MCH clinics who had growth measurements at age 6, 12, 18 and 24 months. RESULTS: At all ages, girls had significantly higher mean HAZ than boys (P < 0·05). Increasing birth year, residence in ES and increasing BW were positively associated with HAZ (P < 0·05) at all ages. In MLRA controlling for birth year, BW and type of settlement, sex still had a significant effect, with lower HAZ among boys at 6, 12, 18 and 24 months of age (P < 0·001 at all ages). CONCLUSIONS: Our results indicated that sex effects on growth faltering can occur in an indigenous population with low socio-economic status within an economically developed country.

Symptomatic Management of Febrile Illnesses in Children: A Systematic Review and Meta-Analysis of Parents' Knowledge and Behaviors and Their Evolution Over Time.

Recommendations to guide parents' symptomatic management of febrile illnesses in children have been published in many countries. The lack of systematic appraisal of parents' knowledge and behaviors and their evolution over time precludes an analysis of their impact and identification of targets for future educational messages. We systematically searched for studies published between 1980 and 2016 that reported a quantitative evaluation of knowledge and behaviors of >50 parents for managing fever in children. We used MEDLINE and tracked related articles, citations and co-authors personal files. Study selection and data extraction were independently performed by two reviewers. For each item of knowledge and behaviors, we calculated mean frequencies during the first and last quinquennials of the studied period and assessed temporal trends with inverse-variance weighted linear regression of frequencies over years. We observed substantial methodological heterogeneity among the 62 included articles (64 primary studies, 36,791 participants, 30 countries) that met inclusion criteria. Statistically significant changes over time were found in the use of rectal (98 to 4%) and axillary temperature measurement (1-19%), encouraging fluid intake (19-62%), and use of acetylsalicylic acid (60 to 1%). No statistically significant change was observed for the accurate definition of fever (38-55%), or the use of acetaminophen (91-92%) or ibuprofen (20-43%). Parents' knowledge and behaviors have changed over time but continue to show poor concordance with recommendations. Our study identified future targets for educational messages, including basic ones such as the definition of fever.

The association between health attitudes and behaviors and oral-health-related practices.

OBJECTIVE: The objective was to examine the association between health attitudes and behaviors, and oral health practices in Israel. METHOD AND MATERIALS: Secondary data analysis was performed of a cross-sectional national Knowledge, Attitudes and Practices (KAP) survey in Israel. Univariate and multivariate analysis assessed the association between health attitudes and behaviors and oral health practices, namely tooth brushing frequency and routine dental clinic attendance. RESULTS: A statistically significant association was found between gender (women), ethnicity (Jews), socioeconomic status (higher), education (higher), and employment (yes), and better oral health practices. A statistically significant association was also observed between clustered health-compromising behaviors (HCB) and oral health practices: the higher the score, the higher the likelihood of inappropriate tooth brushing and dental clinic attendance (OR = 1.56, 95% CI = 1.85-2.62, and OR = 2.20, 95% CI =1.31-1.86, respectively). A significant association was also observed using a compound variable of negative health attitudes (NHA): the higher the score, the higher the likelihood of inappropriate tooth brushing and dental clinic attendance (OR = 1.43, 95%CI = 1.55-2.17, and OR = 1.84, 95% CI = 1.22-1.68, respectively). CONCLUSION: Positive general health behaviors and attitudes are associated with better oral health behaviors in a dose-response association. These findings should be used to design appropriate and tailored health promotion programs in order to achieve oral and general behavioral change. Interventions should be also targeted toward high-risk groups in the population.

[TRAINING WORKSHOPS FOR BEDOUIN MOTHERS: PREVENTION OF IRON DEFICIENCY ANEMIA IN CHILDREN - RESULTS FROM A COMMUNITY TRIAL STUDY].

INTRODUCTION: Anemia is the most common nutritional deficiency in the world, contributing to childhood morbidity and mortality. Knowledge, attitudes and behavior of caretakers and parents of toddlers can significantly prevent anemia. OBJECTIVES: Assessment of workshop intervention to alter knowledge, attitudes and behavior in mothers of toddlers in the Bedouin population. METHODS: Community trial study. The intervention group included: 150 mothers of healthy one-year-old toddlers receiving workshops culturally tailored for a month in addition to standard training in "Tipat-Halav" (Baby clinic). The control group included: 101 mothers of healthy one-year-old toddlers who received standard training. At the endpoint, mothers were tested in both groups to determine levels of knowledge based on the knowledge and attitudes questionnaire, and the food intake of their children was reviewed according to the Food Frequency Questionnaire (FFQ). RESULTS: Intervention group mothers correctly answered significantly more questions on knowledge and attitudes than the control group; 87.3% of the intervention group recognized the importance of giving iron supplements to prevent anemia compared to 73.3% in the control group (p=0.004). Over three-quarters of the intervention group and half of the control group knew that food affects mental development (p=0.001). In logistic regression, neutralization of SES variables, the intervention increased the rate mothers correctly answered questions 2 to 2.6 fold compared with the control group (p˂0.05). According to the FFQ, children in the intervention group ate more iron-rich foods of animal and vegetarian origin compared to the control group (p<0.05). CONCLUSIONS: The intervention improved the knowledge and behavior of mothers in preventing anemia in toddlers. It should be required to provide information and training activities for mothers of toddlers beyond standard training, increasing the awareness of foods rich in iron. This activity can be performed using cultural workshops on iron deficiency, as was performed in this study.

Infantile cataract: comparison of two surgical approaches.

OBJECTIVE: To compare the results of 2 cataract extraction techniques with primary intraocular lens (IOL) implantation in children. DESIGN: Retrospective comparative case series study. METHODS: This study included children with congenital or developmental cataract. In all cases, anterior capsulorhexis, lens aspiration, posterior continuous curvilinear capsulorhexis, and primary IOL implantation were performed. We compared 2 surgical approaches. In the first approach, after IOL implantation in the bag, posterior optic capture (OC) was performed without anterior vitrectomy (OC technique); in the second approach, anterior vitrectomy was performed without OC of the IOL (AV technique). Patient demographic data as well as ethnic origin, child's age at cataract diagnosis, child's age at surgery, axial length, IOL power in diopters, visual acuity, visual axis opacification, and complications were assessed. RESULTS: One hundred twenty-three eyes were included for surgical approach outcomes comparison; 21 eyes underwent the OC surgical approach and 102 the AV surgical approach. The mean patient age at surgery was 57.3 ± 47.1 months. The mean follow-up was 63.13 months (range 12-202 months). Epithelial lens reproliferation was the major adverse event in our series, affecting 21.1% of patients' eyes; the mean time to epithelial lens reproliferation development was 90 ± 9.70 months. There was no statistically significant difference between the two groups in best spectacle-corrected visual acuity or epithelial lens reproliferation incidence. CONCLUSIONS: In our case series we did not find any difference between surgical techniques.

Maternal and child health in Israel: building lives.

Israel is home to a child-oriented society that values strong family ties, universal child benefits, and free education for all children from 3 years of age to school grade 12. Alongside the universal health-care services that are guaranteed by the National Health Insurance Law and strong, community-based primary and preventive care services, these values have resulted in good maternal and child health. In 2015, infant and maternal mortality (3·1 deaths per 1000 livebirths and 2·0 deaths per 100 000 livebirths, respectively) were lower than the mean infant and maternal mortality of countries within the Organisation for Economic Co-operation and Development. Israel has already exceeded the developed regions' Sustainable Development Goal 2030 targets for maternal mortality, neonatal mortality, and mortality in children younger than 5 years in all population groups. Yet these accomplishments are marred by Israel's high prevalence of child poverty (more than 30%), particularly among Arabs (63%) and ultra-Orthodox Jews (67%). Although infant mortality has improved in all subpopulations since Israel was founded in 1948, infant mortality among Arabs is still more than twice as high as among Jews. To address these disparities in health, the Israeli Ministry of Health has created a special division and has funded an intervention programme to reduce the infant mortality among Bedouin Arabs. Other interventions include targeted and culturally appropriate health-care programmes and services for communities with a high number of at-risk children and young adults, dental health service for all children up to 15 years, and improved collaboration between health, education, and welfare services. The challenges faced by the Israeli health-care system include a growing trend towards medicalisation of prenatal care, ensuring staff are trained to treat developmental, behavioural, and psychosocial issues in children and their families, securing sustainable funding for health promotion and injury prevention programmes, expanding and improving the coordination of services for children with special needs or who are at risk, and programme assessment. Ensuring adequate funding for dedicated, preventive paediatric care and taking action on a nationwide scale to reduce child poverty are essential for maintaining health gains in children. In this Series paper, we describe the health indices, highlight disparities, and discuss the challenges in delivering and maintaining maternal and child health care in Israel.