Ronit Almog

Effect of adherence to evidence-based therapy after acute myocardial infarction on all-cause mortality.

Our aim is to estimate the effect of nonadherence to evidence‐based cardioprotective medications on all‐cause mortality in survivors of acute myocardial infarction (AMI).

Thiopurine effectiveness in patients with Crohn's disease: a study of genetic and clinical predictive factors.

Background: Thiopurines are efficacious in the treatment of Crohns disease and were recently shown to induce T-cell apoptosis by modulation of Rac1 activation. To assess whether polymorphisms in Rac1 and other apoptosis-related genes, combined with clinical parameters, can predict response to thiopurines. Methods: A retrospective cohort of 156 thiopurine-treated patients with Crohns disease was genotyped for 11 single-nucleotide polymorphisms (SNPs): 9 SNPs in Rac1, 1 SNP in the Fas ligand −843 T>C, and 1 SNP in the Caspase-9 93 C>T. Clinical data were extracted from the medical charts. Odds ratios (ORs) and 95% confidence intervals (CIs) of the association between demographic, clinical, and genetic variables and thiopurine response rates were calculated. Results: The overall response rate to thiopurines was 74% (115/156). The Rac1 SNP rs34932801 heterozygote genotype GC was associated with a lower response rate compared with the wild-type GG genotype (46% versus 76%; OR = 0.26; 95% CI, 0.08–0.91; P = 0.036). Only wild-type homozygotes were found for 5 Rac1 SNPs. None of the other 3 Rac1 SNPs were associated with response to thiopurines. Patients with Montreal B3 behavior pattern responded worse than those with a B1 behavior pattern (59%, versus 80%; OR = 0.37; 95% CI, 0.17–0.83; P = 0.016). Sephardic Jews had a lower response rate to thiopurines compared with Jews of Ashkenazi or mixed ancestry (60% versus 82%; OR = 0.32; 95% CI, 0.15–0.69, P = 0.003). Conclusions: Rac1 SNP rs34932801carriage, Montreal B3 disease behavior, and a Sephardic Jewish origin were associated with unfavorable response to thiopurines. Corroboration of these associations in larger cohorts is warranted.

Determinants of adherence to evidence-based therapy after acute myocardial infarction

Background The extent to which drug adherence may be affected by patient characteristics remains unclear. This study investigated potential determinants of adherence to evidence-based cardioprotective medications in patients with acute myocardial infarction. Design Patient-based retrospective cohort study of 4655 elderly one-year survivors of acute myocardial infarction, members of a health organization in Israel, between 2005 and 2010. Methods All patients filled at least one prescription for any key medication. Adherence was measured using the proportion-of-days-covered (PDC) metric and defined as PDC ≥ 80%. Results Nonadherence to aspirin, β-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers or statins approximated 50%, and 80% for combined therapy of all medications. In multivariable analyses, compared with nonadherents to all medications, adherers to at least one medication were more likely to be of Jewish origin (adjusted odds ratio (AOR), 2.11; 95% confidence interval (CI), 1.60–2.78), inhabitants of the central or northern districts, and attending a cardiologist at least once during the first year of follow-up (AOR, 1.26; 95% CI, 1.05–1.51). Increasing number of outpatient visits was associated with improved adherence and followed a significant dose–response gradient. Factors significantly associated with reduced adherence were presence of comorbid conditions, particularly chronic ischemic heart disease (AOR 0.69; 95% CI, 0.57–0.83) and readmissions (AOR, 0.65; 95% CI, 0.55–0.78). Results were consistent when evaluating adherence to each medication separately. Conclusions Outpatient adherence to recommended therapy in patients with acute myocardial infarction is suboptimal and is related to health services utilization. Further research is needed to investigate patient subjective behavioral-related drivers for medication therapy discontinuation after myocardial infarction in the absence of a clinical reason.

The quality of periconception medical care in women with diabetes needs improvement

OBJECTIVE We evaluated the quality of periconception medical care in pregnant women with diabetes and assessed the influence of sociodemographic characteristics. RESEARCH DESIGN AND METHODS The study was based on retrospective data collection from electronic database on cohort of Israeli women at Clalit Health Services (CHS) with pre-existing diabetes who gave birth in 2008–2011. It included data on A1C and other laboratory test results, prescription fillings, diet and ophthalmology consultations, and sociodemographics extracted from CHS computerized systems. The performance of each of nine recommended measures in the periconception period and a composite quality score was evaluated; the score ranged from 0–8. Multivariate logistic regression was used to examine independent sociodemographic predictors of low-quality overall scores. RESULTS A total of 166 women gave birth to 180 infants; the performance of the different quality parameters ranged from 81% for A1C and kidney function tests to only 30% for dietary consultation and 41.1% for ophthalmology exam. Forty-nine percent of women had A1C <7.0% (53 mmol/mol). Only 45% took folic acid, whereas 13.9% continued the use of potentially teratogenic drugs in the first trimester. One-third of women were in the low-quality (0–3) overall score. In the multiple logistic regression analysis, the only significant variables to predict lower composite quality scores were multiparity odds ratio of 3.43 (95% CI 1.66–7.10; P = 0.001), Arabian ethnicity 3.76 (1.78–7.92; P = 0.001), and immigrant 3.73 (1.25–11.16; P = 0.018). CONCLUSIONS The periconception medical care of diabetic women is suboptimal. More intensive and targeted care is needed in order to optimize periconception care of diabetic patients, especially in the high-risk subpopulations.

Missed opportunities for appropriate postpartum care in women with pregestational diabetes.

Abstract Objective: Our aim was to evaluate postpartum glycemic control in women with pregestational diabetes and to assess contributing factors. Methods: Retrospective data collection from an electronic database on a cohort of Israeli women at Clalit Healthcare Services with pregestational diabetes who gave birth in 2008–2011, including data on HbA1C, prescription fillings, and socio-demographics. HbA1C level was assessed during a 2 year time-period, from periconception until one-year postpartum. Results: There were 180 deliveries to 166 women. Compared with the periconception period, the HbA1C level improved significantly during the last 6 months of pregnancy (6.7% versus 6.0%, p < 0.05). However, there was rapid continuous deterioration in glycemic control in the postpartum period with median HbA1C = 6.9% in the first 6 months postpartum and 7.2% in the late postpartum period (p < 0.05). One-year postpartum 107 women (59.4%) had suboptimal care (defined as HbA1C > 7.0% or no test). In the multiple logistic regression analysis, the only significant predictor of 1-year postpartum suboptimal care was suboptimal periconception care, OR = 6.1 (95% CI 3.15–11.84, p = 0.001). Conclusions: Postpartum glycemic control deteriorated rapidly despite excellent control in most women in the last 6 month of pregnancy. More intensive and targeted intervention is needed in order to optimize postpartum care of diabetic patients.

The risk for a first acute coronary syndrome in patients treated with different types of antidepressants: A population based nested case-control study

BACKGROUND Tricyclic antidepressants (TCAs) are still used in 30% of anxiety/depression cases and have been related to increased cardiovascular risk. Newer serotonin/norepinephrine reuptake inhibitors (SSRIs/SNRIs) safety remains conflicting. Our aim was to assess the risk of a first acute coronary syndrome (ACS) in patients treated by various types of antidepressants. METHODS Study was a retrospective nested case-control of 40-80 years old northern-Israeli members of Clalit Health Services (CHS) during 1.1.2003-31.12.2013. Patients with severe psychiatric, cardiac or systemic diseases, or pre-enrollment antidepressants were excluded. Cases that had a first ACS during the study period were matched in 1:30 ratio with controls. The association between antidepressants use and ACS was tested by adjusted multivariable conditional logistic regression. RESULTS The cohort included 535,315 individuals 128,550 of whom met the exclusion/inclusion criteria. 3391 Cases with first ACS, (incidence rate of 24.6/10,000 person years) were matched with 88,016 controls. ACS was not associated with use of either SSRIS/SNRIS or TCAs compared with no antidepressants use. However, treatment by SSRIS/SNRIS was associated with a 36% decreased risk ACS compared to TCAs, OR = 0. 64, 95%CI (0.43-0.95), p = 0.029. Age 40-64 years, male gender and metabolic syndrome associated with reduced risk of ACS among SSRIS/SNRIS compared to TCAs users. CONCLUSION In this study of patients without prior cardiovascular disease- neither antidepressant group imposed excess risk for ACS, compared to-no treatment. SSRIs treatment seemed safer compared to TCAs in regard of ACS. This study probably adds to our confidence of preferring SSRIs over TCAs in patients without prior cardiovascular disease.

Infectious disease burden and antibiotic prescribing in primary care in Israel

BackgroundAntibiotics are frequently prescribed at many of the visits to primary care clinics, often for conditions for which they provide no benefit, including viral respiratory tract infections.ObjectivesThe aim was to evaluate primary care visits due to infectious diseases, and to estimate antibiotic prescribing and antibiotic dispensing by pharmacies.MethodsDiagnosis of infectious disease, antibiotic prescribing and dispensing data at the individual patient level were extracted for 2015 from Clalit Health Services’ electronic medical records and linked to determine the condition for which the antimicrobial was prescribed.ResultsThere were 6.6 million visits due to infections, representing 22% of all primary care visits. The most common events were upper respiratory tract infections (38%) and pharyngitis (10%). Highest prescription rates were for urinary tract infections (80%), otitis media (64%), pharyngitis (71%), sinusitis (63%), and lower respiratory tract infections (76%). The highest rates of undispensed prescriptions were for acute gastroenteritis, urinary tract infections, and pharyngitis (24, 23, and 16%, respectively).ConclusionsInfectious diseases constitute a heavy burden on primary care, with overprescribing of antibiotics. Intervention to reduce unwarranted antibiotic use is needed. In pediatric care, interventions should focus on better controlling antibiotic consumption and encouraging adherence to guidelines for upper respiratory tract infections, pharyngitis, and otitis media. In adults interventions should aim to monitor antibiotic prescribing for upper respiratory tract infections and improve adherence to guidelines for urinary tract infections.

Cognitive Function of Patients with Crohn's Disease is Associated with Intestinal Disease Activity.

Background:Systemic inflammation and nutritional deficiencies are characteristics of Crohns disease (CD) and have been suggested to influence cognitive performance. This study assessed cognitive function in patients with CD. Methods:Participants were adult patients with CD arriving at routine follow-up. Subjective cognitive complaints, depression, anxiety, fatigue, and sleep were evaluated by validated questionnaires. CD characteristics, blood tests, and Crohns disease activity index were obtained. Nutritional risk index was derived from serum albumin and change in body weight. Montreal cognitive assessment was used for screening. Patients with either subjective cognitive complaints or Montreal cognitive assessment score ⩽26 were tested by a computerized cognitive testing battery, with analysis of scores in 7 cognitive domains (CogDs) and an average of the CogD scores-global cognitive score (GCS). Impaired CogD was defined as scoring more than 1 SD below age and education adjusted average. Results:A total of 105 patients were recruited and 61 were tested with computerized cognitive testing battery. Mean age was 39 ± 13 and mean education years were 14 ± 2. The most commonly impaired CogDs were information processing speed (33%) and verbal function (28%). Crohns disease activity index, nutritional risk index, and hemoglobin were significantly correlated with GCS (r = −0.34, 0.39, 0.33; P = 0.007, 0.003, 0.01). Linear regression revealed significant correlations between Crohns disease activity index, nutritional risk index, and GCS (&bgr; = −0.3, 0.29; P = 0.03, 0.04), independent of depression. This model explained 24% of the variance in GCS. Conclusions:Cognitive performance is related to CD activity and nutritional status. The results provide insight into potential influence of nutrition and inflammation on cognitive function. Further studies on cognitive function of patients with CD are warranted.