Doron Comaneshter

Cumulative Evaluation of a Quantitative Immunochemical Fecal Occult Blood Test to Determine Its Optimal Clinical Use

Quantified, human hemoglobin (Hb)‐specific, immunochemical fecal occult blood test (IFOBT) measurements are now used for colorectal cancer (CRC) screening. The objective was to evaluate sensitivity and specificity for CRC and advanced adenomatous polyps (APs) by the fecal Hb threshold used to determine a positive test and the number of IFOBTs prepared per test, so as to determine the least number of colonoscopies required to detect a neoplasm.

The association between continuity of care in the community and health outcomes: a population- based study

BackgroundThe study goal was to assess indices of continuity of care in the primary care setting and their association with health outcomes and healthcare services utilization, given the reported importance of continuity regarding quality of care and healthcare utilization.MethodsThe study included a random sample of enrollees from Clalit Health Services 19 years-of-age or older who visited their primary care clinic at least three times in 2009. Indices of continuity of care were computed, including the Usual Provider Index (UPC), Modified Modified Continuity Index (MMCI), Continuity of Care Index (COC), and Sequential Continuity (SECON). Quality measures of preventive medicine and healthcare services utilization and their costs were assessed as outcomes.Results1,713 randomly sampled patients were included in the study (mean age: 48.9 ± 19.2, 42% males). Continuity of care indices were: UPC: 0.75; MMCI: 0.81; COC: 0.67; SECON: 0.70. After controlling for patient characteristics in a multivariate analysis, a statistically significant association was found between higher values of UPC, COC, and SECON and a decrease in the number and cost of ED visits. Higher MMCI values were associated with a greater number and higher costs of medical consultation visits. Continuity of care indices were associated with BMI measurements, and inversely associated with blood pressure measurements. No association was found with other quality indicators, e.g., screening tests for cancer.ConclusionsSeveral continuity of care indices were associated with decreased number and costs of ED visits. There were both positive and negative associations of continuity of care indices with different aspects of healthcare utilization. The relatively small effects of continuity might be due to the consistently high levels of continuity in Clalit Health Services.

Hyperthyroidism association with SLE, lessons from real-life data – A case–control study

Abstract Background: Despite the frequently encountered association between thyroid disease and systemic lupus erythematosus (SLE) is well known, it is of surprise that only several reports compromised of small population size support this observation. Objectives: To investigate the association of comorbid SLE and hyperthyroidism. Methods: Using the database of the largest health maintenance organization (HMO) in Israel, the Clalit Health Services, we searched for the co-existence of SLE and hyperthyroidism. Patients with SLE were compared with age- and sex-matched controls regarding the prevalence of hyperthyroidism in a case–control study. Chi-square and t-tests were used for univariate analysis and a logistic regression model was used for multivariate analysis. Results: The study included 5018 patients with SLE and 25 090 age- and sex- matched controls. The prevalence of hyperthyroidism in patients with SLE was increased compared with the prevalence in controls (2.59% and 0.91%, respectively, p < 0.001). In a multivariate analysis, SLE was associated with hyperthyroidism (odds ratio 2.52, 95% confidence interval 2.028–3.137). Conclusions: Patients with SLE have a greater prevalence of hyperthyroidism than matched controls. Therefore, physicians treating patients with SLE should be aware of this possibility of this thyroid dysfunction.

All disease begins in the gut: Celiac disease co-existence with SLE

BACKGROUND Case reports and case series have indicated a possible association between celiac disease (CD) and systemic lupus erythematosus (SLE), but additional population-based studies are required. The true prevalence of CD in SLE patients is still unknown, but is indeed an important factor when considering the clinical implications, notably the necessity of screening strategies in SLE patients. Our objective was to investigate the association between CD and SLE using a community-based approach in a real-life population database. METHODS Patients with SLE were compared with age- and sex-matched controls regarding the prevalence of CD in a case-control study. Chi-square and t-tests were used for univariate analysis and a logistic regression model was used for multivariate analysis. The study was performed utilizing the medical database of Clalit Health Services. RESULTS The study included 5018 patients with SLE and 25,090 age- and sex-matched controls. The prevalence of CD was significantly higher in patients with SLE than in controls in univariate analysis (0.8% and 0.2%, respectively, p<0.001). Also, SLE was associated with CD (OR 3.92, 95% CI 2.55-6.03, p<0.001) in a multivariate logistic regression model. CONCLUSIONS Patients with SLE had a greater prevalence of CD than matched controls in a large case-control study. A complex combination of genetic, immunological and novel environmental factors may explain this positive association. Physicians should keep in mind that CD can be a tricky diagnosis in SLE patients, yet a treatable condition, probably more common in this population than we used to think.

Aortic aneurysm association with SLE – a case–control study

Objectives Aortic aneurysm is a life threatening cardiovascular complication in patients with systemic lupus erythematosus (SLE).The purpose of this study was to investigate the association between SLE and occurrence of aortic aneurysms. Methods Patients with SLE were compared with age- and sex-matched controls regarding the proportion of aortic aneurysm in a case–control study. Chi-square and t-tests were used for univariate analysis and a logistic regression model was used for multivariate analysis. The study was performed utilizing the medical database of Clalit Health Services. Results The study included 5018 patients with SLE and 25,090 age- and sex-matched controls. The proportion of aortic aneurysm in patients with SLE was increased compared with the proportion in controls (0.6% and 0.1%, respectively, p < 0.001). In a multivariate analysis SLE was associated with the coexistence of aortic aneurysms (odds ratio 2.06, 95% confidence interval 1.21–3.51). Conclusions Patients with SLE have a higher proportion of aortic aneurysms as compared with matched controls. Therefore, physicians treating patients with SLE should be aware of this life threatening association.

Does inflammatory bowel disease coexist with systemic lupus erythematosus

BACKGROUND The data regarding the association between inflammatory bowel disease (IBD) and systemic lupus erythematosus (SLE) is mostly composed of case reports and case series indicating an infrequent association. OBJECTIVES To investigate the association between IBD and SLE. METHODS Patients with SLE were compared with age- and sex-matched controls regarding the prevalence of ulcerative colitis (UC) and Crohns disease (CD) in a case-control study. Chi-square and t-tests were used for univariate analysis and a logistic regression model was used for multivariate analysis. The study was performed utilizing the medical database of Clalit Health Services. RESULTS The study included 5018 patients with SLE and 25,090 age- and sex-matched controls. The prevalence of UC was significantly higher in patients with SLE than in controls in a univariate analysis (0.4% and 0.2%, respectively; p<0.017). However, in a multivariate logistic regression model SLE was not associated with UC (OR 1.67, 95% CI 0.99-2.815, p<0.052). The prevalence of CD was higher in patients with SLE than in controls in a univariate analysis (0.7% and 0.3%, respectively; p<0.001). A multivariate logistic regression model confirmed this finding and corroborated that SLE was associated with comorbid CD (OR 2.23, 95% CI 1.46-3.4, p<0.001). CONCLUSIONS Patients with SLE have a greater prevalence of CD than matched controls. The distinction of IBD from SLE gastrointestinal involvement can be challenging as clinical manifestations, laboratory tests, and radiographic findings may appear similar between the two diseases. Therefore, physicians treating patients with rather IBD or SLE should consider this potential association.

Smoking and obesity in systemic lupus erythematosus: a cross-sectional study

Both smoking and obesity have been demonstrated as risk factors in several autoimmune diseases. Little is known about the relationship between systemic lupus erythematosus (SLE) and both smoking and obesity.

Healthcare Services Utilization and Drug Use in Patients with Chronic Urticaria

TO THE EDITOR Chronic urticaria (CU) is defined as continuous urticaria occurring in a period of 6 weeks or more while off treatment (Zuberbier, 2012). Second-generation antihistamines with up-dosing up to fourfold constitute the firstand second-line treatments for CU, and are the mainstay of pharmacologic management for most patients (Bernstein et al., 2014). About 40–70% of patients attending tertiary care clinics will become symptom-free at appropriate doses of antihistamines treatment. Antihistamine therapy failure is considered only after the patient does not respond to augmented dosage (Zuberbier et al., 2014). Third-line therapies, is used as add-on therapy and include omalizumab, cyclosporine, and the leukotriene receptor antagonist, montelukast. Many other treatments have been used in patients with refractory CU such as sulfasalazine, colchicine, methotrexate, mycophenolate mofetil, azathioprine, and cyclophosphamide (Grattan et al., 1992; Grattan et al., 2000; Jiang et al., 2008; Di Lorenzo et al., 2008; Mitzel-Kaoukhovet al., 2010; Perez et al., 2010; Pho et al., 2011; Orden et al., 2014). Nonetheless, the level of evidence supporting use of the modalities beyond third-line treatments is rather weak and based on anecdotal reports or small case series. Notably, systemic corticosteroids may eliminate urticarial lesions in the short-term; however, their long-term use (more than 10 days) is undesirable due to cumulative severe adverse effects (Makris et al., 2013; Zuberbier et al., 2014). The aim of our study was to investigate utilization of health-care services and drug use among patients with CU using a large community-based database from Clalit Health Services (CHS). Our study was designed as a crosssectional study of CU patients and ageand gender-matched controls, based on CHS database–a large public healthcare provider organization in Israel. We used a conservative definition for CU as follows: four couples of urticaria diagnoses, recorded within a period of 6 weeks, registered by physicians in community services, out-patient clinics, or during hospitalization, from January 2002 to December 2012. The control group consisted of randomly selected ageand gender-matched patients without CU, extracted from the general population of CHS enrollees. Patients with one or more diagnoses of urticaria were excluded from the control group. Health-care services utilization during 2013 was extracted for both cases and controls. Drug use data was based on pharmacy claims during 2013. Since ~50% of CU patients experience spontaneous resolution within 6–12 months from symptoms onset, patients with high use of CU-related medications during 2013 were considered patients with persistent disease. To assess the number of patients with chronic steroid treatment, we evaluated the lag period between two consecutive systemic corticosteroid prescriptions among patients treated with more than one prescription. This subgroup of patients was subLETTER TO THE EDITOR

The association between systemic lupus erythematosus and valvular heart disease: an extensive data analysis

Association between antiphospholipid syndrome in systemic lupus erythematosus (SLE) and valvular heart disease (VHD) is well reported, but relatively few studies have been carried out to establish the linkage between VHD and SLE itself. We aimed to investigate link between VHD and SLE and to evaluate the association of diverse factors with VHD among these patients in a large‐scale population‐based study.

Association Between Pemphigus and Neurologic Diseases

Importance The association between pemphigus and neurologic diseases was not evaluated systematically in the past. In a recent uncontrolled cross-sectional study, Parkinson disease was found to be significantly associated with pemphigus; in the same study, epilepsy had a nonsignificant association with pemphigus. Several case reports have suggested that pemphigus coexists with multiple sclerosis and dementia. Objective To estimate the association between pemphigus and 4 neurologic conditions (dementia, epilepsy, Parkinson disease, and multiple sclerosis), using one of the largest cohorts of patients with pemphigus. Design, Setting, and Participants A retrospective population-based cross-sectional study was performed between January 1, 2004, and December 31, 2014, using the database of Clalit Health Services, the largest public health care organization in Israel, in the setting of general community clinics, primary care and referral centers, and ambulatory and hospitalized care. A total of 1985 patients with a new diagnosis of pemphigus and 9874 controls were included in the study. Main Outcomes and Measures The proportion of dementia, epilepsy, Parkinson disease, and multiple sclerosis was compared between patients diagnosed with pemphigus and age-, sex-, and ethnicity-matched control participants. Logistic regression was used to calculate odds ratios (ORs) for dementia, epilepsy, Parkinson disease, and multiple sclerosis. The association was examined after a sensitivity analysis that included only patients treated with long-term, pemphigus-specific medications (corticosteroids, immunosuppressants, or rituximab) and after adjustment for several confounding factors. Results When comparing the 1985 cases (1188 women and 797 men; mean [SD] age, 72.1 [18.5] years) with the 9874 controls (5912 women and 3962 men; mean [SD] age, 72.1 [18.5] years), dementia was seen in 622 cases (31.3%) vs 1856 controls (18.8%), with an OR of 1.97 (95% CI, 1.77-2.20). Epilepsy was present in 74 cases (3.7%) vs 210 controls (2.1%), with an OR of 1.78 (95% CI, 1.36-2.33). Parkinson disease was seen in 175 cases (8.8%) vs 437 controls (4.4%), with an OR of 2.09 (95% CI, 1.74-2.51). Multiple sclerosis was present in 2 cases (0.1%) vs 6 controls (0.01%), with an OR of 1.65 (95% CI, 0.34-8.22). Study findings were robust to sensitivity analysis that included patients receiving pemphigus-specific treatments. Estimates were not altered significantly after controlling for comorbidities and overuse of health care. Conclusions and Relevance An association was observed between pemphigus and specific neurologic diseases, including dementia, Parkinson disease, and epilepsy. Physicians treating patients with pemphigus should be aware of this possible association. Patients with pemphigus should be carefully assessed for comorbid neurologic disorders and receive appropriate treatment.