Identification and Characterization of Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) is characterized by substantial diagnostic and evaluation gaps with no systematic screening. Even recognized cases are undercoded because of the perceived benign nature of disease and current absence of approved pharmacologic treatment. NAFLD is often detected incidentally, particularly in the asymptomatic early phase. We doubled NAFLD detection via natural language processing of 1 million imaging reports combined with laboratory data from an unselected population. We describe NAFLD comorbidities and health care utilization as compared with age, sex, and body mass index matched control subjects.

Effect of a tailor-made continuous medical education program for primary care physicians on self-perception of physicians' roles and quality of care.

BACKGROUND: A survey conducted among Israel Defense Force primary care physicians in 2001 revealed that they consider patients' needs more than they do organizational needs and that the education PCPs currently receive is inadequate. In 2003 the medical corps initiated a multi-format continuous medical education program aimed at improving skills in primary care medicine. OBJECTIVES: To measure and analyze the effect of the tailor-made CME program on PCPs' self-perception 3 years after its implementation and correlate it to clinical performance. METHODS: In 2006 a questionnaire was delivered to a representative sample of PCPs in the IDF. The questionnaire included items on demographic and professional background, statements on self-perception issues, and ranking of roles. We compared the follow-up survey (2006) to the results of the original study (2001) and correlated the survey results with clinical performance as measured through objective indicators. RESULTS: In the 2006 follow-up survey PCPs scored higher on questions dealing with their perception of themselves as case managers (3.8 compared to 4.0 on the 2001 survey on a 5 point scale, P = 0.046), perceived quality of care and education (3.5 vs. 3.8, P = 0.06), and on questions dealing with organizational commitment (3.5 vs. 3.8, P = 0.01). PCPs received higher scores on clinical indicators in the later study (odds ratio 2.05, P < 0.001). CONCLUSIONS: PCPs in the IDF perceived themselves more as case managers as compared to the 2001 survey. A tailor-made CME program may have contributed to the improvement in skills and quality of care.

Changes in triglyceride levels over time and risk of type 2 diabetes in young men.

OBJECTIVE: The association between changes in triglyceride concentrations over time and diabetes is unknown. We assessed whether two triglyceride determinations obtained 5 years apart can predict incident type 2 diabetes. RESEARCH DESIGN AND METHODS: Triglyceride levels at baseline (time 1) and 5 years later (time 2), followed by subsequent follow-up of 5.5 years, were measured in 13,953 apparently healthy men (age 26-45 years) with triglycerides <300 mg/dl (<3.39 mmol/l). RESULTS: During 76,742 person-years, 322 cases of diabetes occurred. A multivariate model adjusted for age, BMI, total cholesterol-to-HDL cholesterol ratio, family history of diabetes, fasting glucose, blood pressure, physical activity, and smoking status revealed a continuous independent rise in incident diabetes with increasing time 1 triglyceride levels (P(trend) < 0.001). Men in the lowest tertile of time 1 triglyceride levels who progressed to the highest tertile over follow-up (low-high) exhibited a hazard ratio (HR) of 12.62 (95% CI 3.52-31.34) compared with those remaining in the lowest tertile at both time points (reference group: low-low). Whereas men who were at the top triglyceride level tertile throughout follow-up (high-high) had a HR for diabetes of 7.08 (2.52-14.45), those whose triglyceride level decreased to the lowest tertile (high-low) exhibited a HR of 1.97 (0.67-6.13). Alterations in triglyceride levels during follow-up were associated with changes in BMI, physical activity, and eating breakfast habit (P < 0.05), but remained an independent modifier of diabetes risk even after adjustment for such changes. CONCLUSIONS: Two measurements of fasting triglyceride levels obtained 5 years apart can assist in identifying apparently healthy young men at increased risk for diabetes, independent of traditional risk factors and of associated changes in BMI and lifestyle parameters.

Changes in triglyceride levels and risk for coronary heart disease in young men.

BACKGROUND: Current triglyceride levels might be only a weak predictor of risk for coronary heart disease (CHD). OBJECTIVE: To assess the association between changes over time in fasting triglyceride levels and CHD risk in young adults. DESIGN: Follow-up study over 5.5 years after 2 measurements of fasting triglycerides 5 years apart. SETTING: The Staff Periodic Examination Center of the Israel Defense Forces, Zrifin, Israel. PATIENTS: 13,953 apparently healthy, untreated, young men (age 26 to 45 years) with triglyceride levels less than 3.39 mmol/L (<300 mg/dL). MEASUREMENTS: Two triglyceride measurements (at enrollment [time 1] and 5 years later [time 2]), lifestyle variables, and incident cases of angiography-proven CHD. RESULTS: Within 5.5 years, 158 new cases of CHD were identified. The multivariate model was adjusted for age; family history; fasting glucose; high-density lipoprotein cholesterol; blood pressure; body mass index; and changes between time 1 and time 2 in body mass index, physical activity, smoking status, and habit of eating breakfast. Investigators categorized triglyceride levels according to low, intermediate, and high tertiles (as measured at time 1 and time 2 [expressed as tertile at time 1/tertile at time 2]). The risk for CHD in men with high-tertile triglyceride levels at time 1 changed depending on the tertile at time 2 (hazard ratios, 8.23 [95% CI, 2.50 to 27.13] for high/high, 6.84 [CI, 1.95 to 23.98] for high/intermediate, and 4.90 [CI, 1.01 to 24.55] for high/low, compared with the stable low/low group). The risk for CHD in men with low-tertile levels at time 1 also changed depending on the tertile at time 2 (hazard ratios, 3.81 [CI, 0.96 to 15.31] for low/intermediate and 6.76 [CI, 1.34 to 33.92] for low/high, compared with the stable low/low group). LIMITATIONS: Participants were healthy and had a low incidence rate of CHD. The study was observational. CONCLUSIONS: Two triglyceride measurements obtained 5 years apart may assist in assessing CHD risk in young men. A decrease in initially elevated triglyceride levels is associated with a decrease in CHD risk compared with stable high triglyceride levels. However, this risk remains higher than in those with persistently low triglyceride levels.

Autoimmune diseases in asthma.

BACKGROUND: Previous research has suggested an inverse relationship between T-helper 2-related atopic disorders, such as asthma, and T-helper 1-related autoimmune diseases. One controversial hypothesis postulates that asthma provides a protective effect for the development of autoimmune-related disorders. OBJECTIVE: To assess the rate of newly diagnosed autoimmune disorders in a large cohort of young adults. DESIGN: Using cross-sectional data from the Israeli Defense Force database, the authors analyzed the prevalence of autoimmune disorders in asthmatic and nonasthmatic military personnel between 1980 and 2003. A follow-up study traced newly diagnosed autoimmune disorders among asthmatic and nonasthmatic individuals from the time of enrollment in military service until discharge (22 and 36 months for women and men, respectively). SETTING: General community. PATIENTS: 307,367 male and 181,474 female soldiers in compulsory military service who were between 18 and 21 years of age. MEASUREMENTS: Cases of type 1 diabetes mellitus, vasculitis, immune thrombocytopenic purpura, inflammatory bowel disease, rheumatoid arthritis, and the antiphospholipid syndrome. RESULTS: Of 488,841 participants at enrollment, significantly more women than men had autoimmune disorders. Compared with asthmatic women, nonasthmatic women had a significantly higher prevalence of all autoimmune disorders except for the antiphospholipid syndrome. Type 1 diabetes mellitus, vasculitis, and rheumatoid arthritis were less prevalent in men with asthma than in those without. During the follow-up period, vasculitis and rheumatoid arthritis were more frequently diagnosed in nonasthmatic persons of both sexes. There was a significantly higher incidence of immune thrombocytopenic purpura, inflammatory bowel disease, and the antiphospholipid syndrome in nonasthmatic women and a statistically significantly higher incidence of type 1 diabetes mellitus in nonasthmatic men. LIMITATIONS: The study was limited to a population of young military recruits; therefore, its findings are not necessarily applicable to the general population. Because of the noninterventional nature of the study, it describes associations but cannot prove causality. CONCLUSIONS: Asthma status may affect the prevalence of major autoimmune disorders. Preexisting asthma seems to protect against the development of autoimmune disorders to varying degrees in men and women.

Severe acne vulgaris and tobacco smoking in young men.

As the relationship between tobacco smoking and acne remains unclear, we examined the relationship between cigarette smoking and severe acne in a large cohort of young men. Trained nurses interviewed subjects upon discharge from compulsory military service, regarding family history, habits, and tobacco smoking habits. Data was correlated with severe acne status, as diagnosed and coded by board-certified dermatologists. In total, 27,083 male subjects participated in the study from 1983 to 2003, of which 237 (0.88%) had severe acne, 11,718 (43.27%) were active smokers, and 15,365 (56.73%) were nonsmokers at the time of interviews. Active smokers showed a significantly lower prevalence of severe acne (0.71%) than nonsmokers (1.01%) (P = 0.0078). An inverse dose-dependent relationship between severe acne prevalence and daily cigarette consumption became significant from 21 cigarettes a day (chi2 and trend test: P < 0.0001), odds ratio: 0.2 (95% CI: 0.06-0.63). The study did not aim to establish a temporal correlation, and passive smoking and acne treatments were not measured. Previous in vitro and clinical studies strongly support an association with nicotine. We suggest a trial with topical nicotine treatment for acne to further investigate this association.

Normal fasting plasma glucose levels and type 2 diabetes in young men.

BACKGROUND: The normal fasting plasma glucose level was recently defined as less than 100 mg per deciliter (5.55 mmol per liter). Whether higher fasting plasma glucose levels within this range independently predict type 2 diabetes in young adults is unclear. METHODS: We obtained blood measurements, data from physical examinations, and medical and lifestyle information from men in the Israel Defense Forces who were 26 to 45 years of age. RESULTS: A total of 208 incident cases of type 2 diabetes occurred during 74,309 person-years of follow-up (from 1992 through 2004) among 13,163 subjects who had baseline fasting plasma glucose levels of less than 100 mg per deciliter. A multivariate model, adjusted for age, family history of diabetes, body-mass index, physical-activity level, smoking status, and serum triglyceride levels, revealed a progressively increased risk of type 2 diabetes in men with fasting plasma glucose levels of 87 mg per deciliter (4.83 mmol per liter) or more, as compared with those whose levels were in the bottom quintile (less than 81 mg per deciliter [4.5 mmol per liter], P for trend <0.001). In multivariate models, men with serum triglyceride levels of 150 mg per deciliter (1.69 mmol per liter) or more, combined with fasting plasma glucose levels of 91 to 99 mg per deciliter (5.05 to 5.50 mmol per liter), had a hazard ratio of 8.23 (95 percent confidence interval, 3.6 to 19.0) for diabetes, as compared with men with a combined triglyceride level of less than 150 mg per deciliter and fasting glucose levels of less than 86 mg per deciliter (4.77 mmol per liter). The joint effect of a body-mass index (the weight in kilograms divided by the square of the height in meters) of 30 or more and a fasting plasma glucose level of 91 to 99 mg per deciliter resulted in a hazard ratio of 8.29 (95 percent confidence interval, 3.8 to 17.8), as compared with a body-mass index of less than 25 and a fasting plasma glucose level of less than 86 mg per deciliter. CONCLUSIONS: Higher fasting plasma glucose levels within the normoglycemic range constitute an independent risk factor for type 2 diabetes among young men, and such levels may help, along with body-mass index and triglyceride levels, to identify apparently healthy men at increased risk for diabetes.

Teledermatology: quality assessment by user satisfaction and clinical efficiency.

BACKGROUND: The Israel Defense Forces implemented a pilot teledermatology service in primary clinics. OBJECTIVES: To assess user satisfaction and clinical short-term effectiveness of a computerized store and forward teledermatology service in urban and rural units. METHODS: A multi-center prospective uncontrolled cohort pilot trial was conducted for a period of 6 months. Primary care physicians referred patients to a board-certified dermatologist using text email accompanied by digital photographs. Diagnosis, therapy and management were sent back to the referring PCP. Patients were asked to evaluate the level of the CSAFTD service, effect of the service on accessibility to dermatologists, respect for privacy, availability of drugs, health improvement and overall satisfaction. PCPs assessed the quality of the teledermatology consultations they received, the contribution to their knowledge, and their overall satisfaction. RESULTS: Tele-diagnosis alone was possible for 95% (n=413) of 435 CSAFTD referrals; 22% (n=95) of referrals also required face-to-face consultation, Satisfaction with CSAFTD was high among patients in both rural and urban clinics, with significantly higher scores in rural units. Rural patients rated the level of service, accessibility and overall satisfaction higher than did urban patients. PCPs were satisfied with the quality of the service and its contribution to their knowledge. Rural physicians rated level of service and overall satisfaction higher than did urban physicians. Tele-referrals were completed more efficiently than referral for face-to-face appointments. CONCLUSIONS: CSAFTD provided efficient, high quality medical service to rural and urban military clinics in the IDF.

Smoking habits and obesity in young adults.

AIMS: The aim of this work was to study the association between obesity and smoking habits in young adults. Specifically, we tested the hypothesis that obesity does not prevent young adults from smoking and conversely smoking does not protect against obesity. DESIGN AND SETTING: Trained nurses interviewed participants concerning demographic data and health behaviors such as smoking. At the time of the interview, weight and height were measured. Data were analyzed retrospectively. PARTICIPANTS: A representative sample of Israel Defense Force (IDF) personnel upon discharge from compulsory service, usually at the age of 20-21 years. FINDINGS: Overall, 29 745 participants were included during the 13-year study (16,363 males and 13,382 females). Smoking rates were higher among obese participants than among overweight and non-obese participants (34.9%, 37.1%, 43.6% for non-obese, overweight and obese, respectively; P < 0.001). Mean number of cigarettes smoked per day were also higher among smokers that were obese and overweight compared to the non-obese (15.2 +/- 9.2, 15.6 +/- 10.7, 18.0 +/- 9.8, respectively; P < 0.001). Overweight and obesity were associated with the father's lower academic educational level. In logistic regression analysis, obesity, year of study and parental academic education were correlated independently with smoking (P < 0.001). CONCLUSION: The positive association between obesity and smoking suggests that obesity is not a deterrent to smoking and also that smoking does not help to prevent obesity.

The role of primary care physicians in the Israel Defense Forces: a self-perception study.

BACKGROUND: The health system of the medical corps of the Israel Defense Force is based primarily upon primary healthcare. In recent years, health management organizations have considered the primary care physician responsible for assessing the overall health needs of the patient and, accordingly, introduced the term "gatekeeper." OBJECTIVES: To describe and analyze how PCPs in the IDF view their roles as primary care providers and to characterize how they perceive the quality of the medical care that they provide. METHODS: We conducted a survey using a questionnaire that was mailed or faxed to a representative sample of PCPs. The questionnaire included demographic background, professional background, statements on self-perception issues, and ranking of roles as a PCP in the IDF. RESULTS: Statements concerning commitment to the patient were ranked higher than statements concerning commitment to the military organization. Most physicians perceive the quality of the medical care service that they provide as high; they also stated that they do not receive adequate continuous medical education. CONCLUSIONS: Our survey shows that PCPs in the IDF, like civilian family physicians, perceive their primary obligation as serving the needs of their patients but are yet to take on the full role of "gatekeepers" in the IDF's healthcare system. We conclude that the Medical Corps should implement appropriate steps to ensure that PCPs are prepared to take on a more prominent role as "gatekeepers" and providers of high quality primary medical care.