Michal Shani

The association between physicians’ and patients’ preventive health practices

Background: Although much has been written about the potential power of the association between physicians’ personal health practices and those of their patients, objective studies of this relationship are lacking. We investigated this association using objectively measured health care indicators. Methods: We assessed 8 indicators of quality of health care (screening and vaccination practices) for primary care physicians (n = 1488) and their adult patients (n = 1 886 791) in Israel’s largest health maintenance organization; the physicians were also patients in this health care system. Results: For all 8 indicators, patients whose physicians were compliant with the preventive practices were more likely (p < 0.05) to also have undergone these preventive measures than patients with noncompliant physicians. We also found that more similar preventive practices showed somewhat stronger relations. For example, among patients whose physician had received the influenza vaccine, 49.1% of eligible patients received flu vaccines compared with 43.2% of patients whose physicians did not receive the vaccine (5.9% absolute difference, 13.7% relative difference). This is twice the relative difference (7.2%) shown for pneumococcal vaccine–eligible patients of influenza-vaccinated versus nonvaccinated physicians (60.9% v. 56.8%). When we examined the rates of unrelated practices, we found that, for example, mammography rates were identical for patients whose physicians did and did not receive the influenza vaccine. Interpretation: We found a consistent, positive relation between physicians’ and patients’ preventive health practices. Objectively establishing this healthy doctor–healthy patient relation should encourage prevention-oriented health care systems to better support and evaluate the effects on patients of improving the physical health of medical students and physicians.

Characteristics of Diabetics with Poor Glycemic Control Who Achieve Good Control

Objective: To find the characteristics of diabetics with poorly controlled diabetes that became well controlled compared with the patients with poorly controlled diabetes that remained poorly controlled. Methods: The sample included diabetic patients, aged 40 years and older, from the Central district of Clalit Health Service in Israel, with at least one HbA1c measure greater than 9.5 mg% during 2001. They were divided into 2 categories according to their HbA1c levels in 2003, well controlled (HbA1c <7.5 mg%) and poorly controlled (HbA1c >9.5 mg%). Patients with 7.5< HbA1c <9.5 in 2003 were excluded from analysis. Results: Two thousand sixty-two diabetic patients met the inclusion criteria and care was provided by one of 249 primary care physicians. Of these patients, 1232 (41.6%) had well-controlled diabetes and 1760 (58.4%) had poorly controlled diabetes in 2003. The well-controlled group had fewer patients with low socioeconomic status (30.3% vs 41.9%; P < .001) and more men (52% vs 43.8%; P < .001). The individual primary care physician was the most significant predictor of good glycemic control. Total patient costs in 2004 were 8% lower among the group with well-controlled diabetes. Conclusion: The primary care physician has an important role in the patients chances of achieving glycemic control. Further investigation of how and why some primary care physicians achieve better diabetes control in their patients would be worthwhile.

Obstructive Sleep Apnea and Cardiovascular Comorbidities: A Large Epidemiologic Study

AbstractObstructive sleep apnea (OSA) is a common disorder, characterized by cyclic cessation of airflow for 10 seconds or more. There is growing awareness that OSA is related to the development and progression of cardiovascular disease. However, only a few studies have associated OSA directly to major cardiovascular events. The aim of this study was to evaluate the relationship between OSA and cardiovascular morbidity in a well defined population of patients.The electronic database of the central district of a major health management organization was searched for all patients diagnosed with OSA in 2002–2010. For each patient identified, an age- and sex-matched patient was randomly selected from the members of the same health management organization who did not have OSA. Data on demographics, socioeconomic status, and relevant medical parameters were collected as well.The study population included 2797 patients, average age 58.1, in which 76.6% were males. There was a significant correlation between OSA and the presence of ischemic heart disease (P < 0.001), pulmonary hypertension (P < 0.001), congestive heart failure (P < 0.001), cardiomyopathy (P = 0.003), and arrhythmia (P < 0.001). OSA was also significantly correlated with low socioeconomic status (P < 0.001).OSA and cardiovascular disease were strongly correlated. As such, early diagnosis and treatment of OSA may change the course of both diseases. We suggest that sleep disordered breathing should be routinely assessed in patients with cardiovascular problems. An ear–nose–throat evaluation may also be important to rule out anatomic disorders that cause upper airway obstruction.

N-Acetylcysteine Improves Residual Renal Function in Peritoneal Dialysis Patients: A Pilot Study

♦ Background: Preservation of peritoneal membrane function and residual renal function is important for the optimal care of peritoneal dialysis patients. N-Acetylcysteine may ameliorate oxidative stress, which is thought to be involved in peritoneal membrane dysfunction. In addition, N-acetylcysteine may have a positive effect on renal function in the setting of nephrotoxic contrast media administration. The aim of this study was to investigate the effect of N-acetylcysteine on peritoneal and residual renal function in peritoneal dialysis patients. ♦ Methods: Ten prevalent peritoneal dialysis patients were administered oral N-acetylcysteine 1200 mg twice daily for 4 weeks. At baseline and at the end of treatment, peritoneal membrane function and residual renal function were assessed using a 4.25% dextrose peritoneal equilibration test and 24-hour dialysate and urine collection for calculation of peritoneal and residual renal Kt/V and mean urea and creatinine residual renal clearance. ♦ Results: No significant changes were demonstrated in peritoneal membrane function, including dialysate-to-plasma creatinine ratio, sodium sieving, and net ultrafiltration. Residual renal function improved significantly: urine volume increased from 633 ± 426 to 925 ± 552 mL/24 hours (p = 0.022), residual renal Kt/V increased from 0.56 ± 0.41 to 0.75 ± 0.47 (p = 0.037), and mean residual urea and creatinine clearance increased from 4.96 ± 3.96 to 5.95 ± 4.08 mL/min/1.73 m2 (p = 0.059). ♦ Conclusions: N-acetylcysteine may improve residual renal function in patients treated with peritoneal dialysis.

N‐acetylcysteine may improve residual renal function in hemodialysis patients: A pilot study

Clinical outcomes in chronic dialysis patients are highly dependent on preservation of residual renal function (RRF). N‐acetylcysteine (NAC) may have a positive effect on renal function in the setting of nephrotoxic contrast media administration. In our recent study, we showed that NAC may improve RRF in peritoneal dialysis patients. The aim of the present study was to investigate the effect of NAC on RRF in patients treated with chronic hemodialysis. Prevalent chronic hemodialysis patients with a residual urine output of at least 100 mL/24 hours were included. The patients were administered oral NAC 1200 mg twice daily for 2 weeks. Residual renal function was assessed at baseline and at the end of treatment using a midweek interdialytic urine collection for measurement of urine output and calculation of residual renal Kt/V and glomerular filtration rate (GFR). Residual GFR was measured as the mean of urea and creatinine residual renal clearance. Each patient served as his own control. Twenty patients were prospectively enrolled in the study. Administration of NAC 1200 mg twice daily for 2 weeks resulted in significant improvement in RRF: urine volume increased from 320 ± 199 to 430 ± 232 mL/24 hours (P < 0.01), residual renal Kt/V increased from 0.19 ± 0.12 to 0.29 ± 0.14 (P < 0.01), and residual GFR increased from 1.6 ± 1.6 to 2.4 ± 2.3 mL/minute/1.73 m2 (P < 0.01). N‐acetylcysteine may improve RRF in patients treated with chronic hemodialysis.

Effect of Timing of Thrombectomy on Survival of Thrombosed Arteriovenous Hemodialysis Grafts

Background: The use of an arteriovenous (AV) graft for hemodialysis is associated with a relatively high rate of thrombosis. Unfortunately, the urgent thrombectomy is not always readily available. Our aim was to investigate a possible association between the timing of thrombectomy and the patency rates of AV grafts. Methods: A retrospective single-center study on patients who underwent thrombectomy of clotted AV grafts was conducted. According to the time of thrombectomy, all patients were divided into 4 groups. Results: Primary graft patency at 6 months after thrombectomy was 28.3%, with no significant difference between the study groups (P = .161). Secondary graft patency at 6 months was significantly worse in the group that underwent thrombectomy between the third and fifth days than in the whole cohort: 15.4% versus 45.6% (P = .038). Conclusions: Timing of thrombectomy of a clotted AV graft may have a significant impact on the graft survival.

Effect of Arteriovenous Hemodialysis Shunt Location on Cardiac Events in Patients Having Coronary Artery Bypass Graft Using an Internal Thoracic Artery

The possibility of developing coronary steal in patients having coronary artery bypass graft (CABG) using internal thoracic artery (ITA) and ipsilateral upper extremity arteriovenous (AV) hemodialysis shunt has been reported. The impact of this phenomenon on clinical outcomes is uncertain. The aim of this study was to investigate an association between the AV dialysis shunt location regarding the side of the ITA CABG and clinical outcomes. This retrospective cohort study included chronic hemodialysis patients having ITA CABG and upper extremity AV shunt. The patients were divided into two groups: those with ipsilateral and those with contralateral location of ITA CABG and AV shunt. The outcomes were: death from any cause, cardiac death and a first cardiac event. In a group of 112 chronic hemodialysis patients having CABG, 32 had an ipsilateral and 25 had a contralateral location of ITA CABG and an upper extremity AV shunt. Significantly more cardiac events occurred in the group with an ipsilateral compared to a contralateral location of ITA CABGs and dialysis AV shunts (hazard ratio, 2.16 [95% CI, 1.11 to 4.19], P = 0.023). There was no difference between the groups in the all cause mortality risk (hazard ratio, 1.005 [95% CI, 0.43 to 2.37], P = 0.990) or the risk of cardiac death (hazard ratio, 2.43 [95% CI, 0.64 to 9.17], P = 0.191). The ipsilateral location of a CABG with the use of ITA and upper extremity AV hemodialysis shunt may be associated with increased risk of cardiac events.

Predicting type 2 diabetes mellitus using haemoglobin A1c: a community-based historic cohort study.

Abstract Background: The ADA 2010 guidelines added HbA1c ≥ 6.5% as a criterion for diagnosing diabetes mellitus type 2. Objective: To evaluate the HbA1c test in predicting type 2 diabetes in a high risk population. Methods: A community-based historic cohort study was conducted including 10 201 patients, who had not been diagnosed with diabetes, and who underwent HbA1c test during the years 2002–2005. Data was retrieved on diabetes risk factors and the onset of diabetes (according to the ADA 2003 criteria), during a follow-up period of five-to-eight years. Results: Mean age was 58.25 ± 15.58 years; mean HbA1c level was 5.59 ± 0.55% and 76.8% had a BMI > 25 kg/m2 (mean: 30.74 ± 8.30). In a Cox proportional hazards regression model, the risk of developing type 2 diabetes was 2.49 (95% CI: 1.29–3.71) for 5.5% ≤ HbA1c < 6% at baseline, 4.82 (95% CI: 2.83–8.20) for 6% ≤ HbA1c < 6.5% at baseline and 7.57 (95% CI: 4.43–12.93) for 6.5% ≤ HbA1c < 7% at baseline, compared to HbA1c < 4.5%. The risk of developing diabetes was 1.14 (95% CI: 1.05–1.25) for male gender, 1.16 (95% CI: 1.04–1.28) for cardiovascular diseases and 2.06 (95% CI: 1.80–2.35) for overweight (BMI > 25 kg/m2) at baseline. Neither age nor low socio-economic status was associated with increased risk of diabetes. Conclusion: Levels of HbA1c ≥ 5.5% were associated with increased risk of type 2 diabetes during a five-to-eight-year follow-up period. Findings support the use of HbA1c testing as a screening tool in populations at risk of developing diabetes.

Effect of Timing of the First Cannulation on Survival of Arteriovenous Hemodialysis Grafts

The use of an arteriovenous graft as vascular access for hemodialysis is associated with a high rate of patency loss. The influence of timing of the first cannulation of the graft on graft survival has not been sufficiently studied. The purpose of this study was to investigate an association between the timing of the first cannulation of the polytetrafluoroethylene arteriovenous graft and the incidence of 12‐month failure. This is a retrospective study on a cohort of chronic hemodialysis patients treated in a single center. According to the time, in weeks, between graft construction and its first successful cannulation, the grafts were divided into six groups: 2nd, 3rd, 4th, 5th, 6th and 7th or more week after surgery. The primary outcome was primary graft failure at 12 months, defined as the first occurrence of graft thrombosis or any invasive access procedure. The secondary outcome was cumulative graft failure at 12 months, defined as complete loss of the access site for dialysis. Fifty‐eight patients with 64 newly‐created arteriovenous grafts were included in the study. In the whole cohort, the incidence of primary graft failure at 12 months was 72.2%, and the incidence of cumulative graft failure at 12 months was 40.7%. The incidences of primary graft failure and cumulative graft failure at 12 months did not differ significantly between the study groups. In our study, timing of the first cannulation of a new arteriovenous polytetrafluoroethylene graft had no significant impact on graft survival.

Amlodipine treatment of hypertension associates with a decreased dementia risk

ABSTRACT Hypertension has been shown to be a risk factor for development of dementia. However, medical treatment of hypertension failed to reduce consistently the risk of dementia. Experimental study pointed to the possibility of difference between different calcium channel blockers (CCB) in their neuro-protective effect. The aim of our study was to evaluate the risk of dementia during treatment of hypertension with different CCBs. This is a retrospective cohort study based on electronic database of a large public health care organization. Study period was 11 years and it included patients aged 40–75 years old, having diagnosis of hypertension without diagnosis of dementia at the starting point, treated with either single specific CCB (study group) or with other than CCBs antihypertensive medications (control group) for at least 30 months during the study period. A total of 15,664 patients that satisfied these criteria were identified: 3,884 were treated with amlodipine, 2,062 were treated with nifedipine, 609 were treated with lercanidipine, and 9,109 never received CCBs. Dementia developed in 765 (4.9%) patients. Adjusted hazard ratio (HR) for dementia in patients treated with amlodipine, nifedipine, and lercanidipine was 0.60 (p < 0.001), 0.89 (NS), and 0.90 (NS). Decreased adjusted HR of dementia with amlodipine was demonstrated in the patients aged 60 or more (HR 0.61 [0.49–0.77], p < 0.001), but not in the patients aged less than 60 years old. This study shows that amlodipine therapy may be associated with a decreased dementia risk in hypertensive individuals older than 60 years, compared to those treated without CCBs.