Overall medication adherence as an indicator for health outcomes among elderly patients with hypertension and diabetes.

OBJECTIVES: To assess overall medication adherence as an indicator for emergency room (ER) visits, hospitalizations, and mortality among elderly patients. METHODS: The study included individuals aged 75 to 90 years, diagnosed with diabetes or hypertension, who were treated with at least one antihypertensive, or antidiabetic medication in 2017. We determined personal adherence rates by calculating the mean adherence rates of the medications prescribed to each individual. We retrieved information on all ER visits and hospitalizations in internal medicine and surgical wards from 2017 to 2019 and mortality in 2019. RESULTS: Of the 171,097 individuals included in the study, 60% were women. The mean age was 81.2 years. 93% had hypertension, 46% had diabetes, and 39% had both diabetes and hypertension. In 2017, 61,668 (36.0%) patients visited the ER, 44,910 (26.2%) were hospitalized in internal medicine wards, and 13,305 (7.8%) were hospitalized in surgical wards. Comparing the highest adherence quintile to the lowest, ORs were 0.69 (0.63, 0.76) for ER visits, 0.40 (0.36, 0.45) for hospitalization in internal medicine wards, and 0.61 (0.52, 0.72) for hospitalization in surgery wards. ORs were similar for the three consecutive years 2017, 2018, and 2019. The adjusted OR for all-cause mortality in 2019 comparing the highest adherence quintile to the lowest was 0.60 (0.54, 0.66). CONCLUSION: Better medication adherence was associated with fewer ER visits and hospitalizations among elderly patients with diabetes and hypertension and lower mortality rates. Overall medication adherence is an indicator for health outcomes unrelated to the patient's underlying health status.

Psoriasis and hidradenitis suppurativa: A large-scale population-based study.

BACKGROUND: The coexistence of psoriasis and hidradenitis suppurativa (HS) has been described, but the association between these conditions is yet to be firmly established. OBJECTIVE: To study the association between psoriasis and HS by using a large-scale real-life computerized database. METHODS: A cross-sectional study was conducted to compare the prevalence of HS among patients with psoriasis with that among age-, sex- and ethnicity-matched control subjects. RESULTS: A total of 68,836 patients with psoriasis and 68,836 controls were included in the study. The prevalence of HS was increased in patients with psoriasis versus in those in the control group (0.3% vs 0.2%, respectively; odds ratio, 1.8; 95% confidence interval, 1.5-2.3; P < .001). In a multivariate analysis adjusting for smoking, obesity, and other comorbidities, psoriasis was still associated with HS (odds ratio, 1.8; 95% confidence interval, 1.4-2.2; P < .001). Patients with coexistent psoriasis and HS were significantly younger (39.0 ± 15.7 vs 42.6 ± 21.2 years [P = .015]) and had a higher prevalence of obesity (35.1% vs 25.3% [P = .001]) and smoking (58.5% vs 37.3% [P < .001]) compared with patients with psoriasis alone. LIMITATIONS: Retrospective data collection. CONCLUSIONS: A positive association was observed between HS and psoriasis. Further longitudinal observational studies are necessary to establish these findings in other study populations.

Anxiety in Patients with Neovascular Age-related Macular Degeneration.

PURPOSE: The main objective of the study is to investigate the prevalence of anxiety in patients with neovascular age-related macular degeneration (nAMD). METHODS: A retrospective cross-sectional study of 3 304 nAMD patients and 16 515 age- and gender-matched controls. The proportions of patients with anxiety were compared between the groups using univariate analyses and a multivariate logistic regression model. Proportion of anxiety in patients with nAMD was compared with the proportion of anxiety in controls, matched for age and gender. Data was obtained from the largest health maintenance organization in Israel (Clalit Health Services) with 4 200 000 members. RESULTS: The mean age of patients was 79.7 years; 54.8% were females; Anxiety was more common in patients with nAMD (13.2%) compared to the control group (10.2%) (OR 1.3; 95%CI 1.2-1.5). Multivariate logistic regression analysis revealed a significant association between anxiety and nAMD (OR 1.3; 95% CI: 1.2-1.5), adjusted for age, gender, and socio-economic status. CONCLUSION: Our study demonstrated that anxiety is more common in patients with nAMD compared to a control group. Physicians treating patients with nAMD should be aware of this association, in order to provide appropriate care for the anxiety associated with nAMD.

A case-control analysis of the associations between Fibromyalgia Syndrome and Osteoporosis.

BACKGROUND: Fibromyalgia syndrome (FMS) is characterized by widespread musculoskeletal pain and tenderness with associated neuropsychological symptoms such as fatigue, unrefreshing sleep, cognitive dysfunction, anxiety, and depression. Osteoporosis is defined as a reduction of bone density. Previous studies to determine an association of FMS with osteoporosis showed mixed results, partially due to small sample sizes and lack of statistical power. OBJECTIVES: To evaluate the association of FMS with osteoporosis. METHODS: We conducted a case-control study utilizing the database from Israel's largest health maintenance organization. FMS patients were compared to age- and sex-matched controls. Data were analyzed using chi-square and t-tests. Multivariable logistic regression models assessed the association between osteoporosis and FMS. Spearman's rho test was used for correlation. RESULTS: We utilized data from 14,296 FMS patients and 71,324 age- and sex-matched controls. Spearman's rho test showed a significant correlation between FMS and osteoporosis (correlation coefficient 0.55, P < 0.001). A logistic regression for osteoporosis showed an odds ratio [OR] of 1.94 (95% confidence interval [95%CI] 1.83-2.06, P < 0.001) for FMS compared to controls and found higher body mass index to be slight protective (OR 0.926, 95%CI 0.92-0.93, P < 0.001). CONCLUSIONS: There is a significant correlation between FMS and osteoporosis. Early detection of predisposing factors for osteoporosis in FMS patients and implementation of suitable treatments and prevention measures (such as dietary supplements, resistance or weight bearing exercise, and bone-mineral enhancing pharmacological therapy) may reduce both occurrence rate and severity of osteoporosis and its complications, such as fractures.

Association of anti-Ro seropositivity with cardiac rhythm and conduction disturbances.

AIMS: Anti-Ro/La autoantibodies are especially prevalent in autoimmune diseases but are also relatively frequent in healthy adults. Their arrhythmogenic effect on the immature cardiac conductive system is well established, with substantial evidence demonstrating an increased risk for congenital atrioventricular block in neonates of seropositive mothers. Despite their wide distribution and their arrhythmogenic potential effect, there are no large population studies conducted in seropositive adults. Thus, this is the first large population-based study to examine the association of anti-Ro/La seropositivity with cardiac rhythm and conduction disturbances. METHODS AND RESULTS: This cross-sectional designed study involved the electronic health records of the largest health maintenance organization in Israel. All subjects that were tested positive for anti-Ro/anti-La antibodies between the years 2002 and 2019 were included and were matched by age, gender, and place of residence, with controls. Rates of different cardiac rhythm and conduction disturbances were compared between groups. Sensitivity analyses were performed using propensity score matching. The study population included 17 231 anti-Ro/La seropositive subjects and 84 368 controls. Anti-Ro seropositive patients had higher rates of conduction disturbances (3.0 vs. 1.7%, P < 0.001) and rhythm disturbances (10.5 vs. 7.0%, P < 0.001). Patients who tested positive for anti-La alone did not demonstrate a significant association with arrhythmias. Multivariate logistic regression analysis, controlling for possible confounders, showed an increased risk for cardiac conduction disturbances [odds ratio (OR) 1.44, 95% confidence interval (CI) 1.25-1.66, P < 0.001], as well as for cardiac rhythm disturbances (OR 1.21, 95% CI 1.11-1.31, P < 0.001) among anti-Ro seropositive patients. However, the association with rhythm disturbances was more robust in certain subgroup analyses. CONCLUSIONS: Anti-Ro seropositivity is positively associated with adult cardiac conduction disturbances and, to a lesser extent, cardiac rhythm disturbances, regardless of the presence of concurrent autoimmune disease.

The importance of having good quality indicators for care of patients with COPD: a look at hospital readmission rates.

BACKGROUND: Readmission after hospitalization for acute COPD exacerbation (AE-COPD) has been proposed as a healthcare quality indicator (QI) in Israel. We studied patients hospitalized for AE-COPD, towards determining whether AE-COPD readmission is an appropriate national QI in order to improve COPD patient care. METHODS: Data were retrieved for all Clalit Health Service (CHS) members age 40-90 years hospitalized in CHS hospitals during 2016 with a diagnosis of acute COPD exacerbation. Information retrieved included demographics, medical history, Charleson comorbidity score, readmissions within 90 days, chronic medication use and family physician and pulmonologist visits. Patients readmitted within 90 days were compared to those who were not readmitted. Patients were also analyzed according to whether they were hospitalized during the year before the index hospitalization. RESULTS: In 2016 there were 70,601 members with a recorded diagnosis of COPD in CHS. Of these, 1,203 patients (1.7%) were hospitalized in a CHS hospital with a diagnosis of acute COPD exacerbation during 2016. Average age was 70.6 years, 63% were men. 78% were active smokers. 61% of the patients were readmitted to internal medicine wards within 90 days of the index hospitalization. Patients who were readmitted were more likely to have been hospitalized during the year before the index hospitalization (Odds ratio (OR) 2.5, Confidence Interval ((CI)(1.85, 3.38)) and had a higher Charlson comorbidity score (OR 1.07 (CI 1.01, 1.11)). Healthcare utilization by patients who were readmitted, both before and after admission, was generally greater. One yr mortality was 15.1% and 9.2% in those readmitted and not readmitted, respectively (p = 0.003). CONCLUSIONS: Readmitted COPD patients appear to be the sickest group of COPD patients with advanced disease and poor prognosis, and it may not be possible to prevent readmissions. This questions the utility of COPD readmissions as a healthcare quality indicator.

Reducing infantile anemia: insight on patterns of process and outcome indicators by ethnicity and socioeconomic class during a 10-year intervention program and 5 years after.

BACKGROUND: In 2005, Clalit Health Services (CHS), the largest health maintenance organization in Israel, initiated an intervention program aimed at reducing the prevalence rate of infantile anemia (IA). This study evaluated the progress made during the intervention (2005-2014) and its yield 5 years after it ended (2019). METHODS: The CHS database was retrospectively reviewed twice yearly from 2005 to 2014 for repetitive samples of children aged 9 to 18 months regarding the previous half-year interval, and a single sample in 2019. Data were collected on gender, ethnicity (Jewish/non-Jewish), socioeconomic class (SEC; low/intermediate/high), hemoglobin testing (yes/no), and hemoglobin level (if tested). Excluded were infants with documented or suspected hemoglobinopathy. RESULTS: At study initiation, the rate of performance of hemoglobin testing was 54.7%, and the IA prevalence rate was 7.8%. The performance rate was lower in the Jewish than the non-Jewish subpopulation. The low-SEC subpopulation had a similar hemoglobin testing rate to the high-SEC subpopulation but double the IA prevalence rate. Overall, by the end of the intervention (2014), the performance rate increased to 87.5%, and the AI prevalence rate decreased to 3.4%. In 2019, there was little change in the performance rate from the end of the intervention (88%) and the IA prevalence was further reduced to 2.7%. The non-Jewish and low-SEC subpopulations showed the most improvement which was maintained and even bettered 5 years after the intervention ended. CONCLUSIONS: The 10-year IA intervention program introduced by CHS in 2005 led to a reduction in IA prevalence rate to about 3.5% in all sub-populations evaluated. By program end, the results in the weaker subpopulations, which had the highest prevalence of IA at baseline, were not inferior to those in the stronger subpopulations. We recommended to the Israel Ministry of Health to adopt the intervention countrywide, and we challenge other countries to consider similar interventions.

Mortality in Ankylosing Spondylitis According to Treatment: A Nationwide Retrospective Cohort Study of 5,900 Patients From Israel.

OBJECTIVE: In this large population-based study we aimed: 1) to assess mortality in patients with ankylosing spondylitis (AS) compared to the general population, considering demographics, comorbidities, and treatment, and 2) to assess factors associated with mortality within patients with AS. METHODS: This study was designed as a retrospective cohort study using the electronic database of the largest health maintenance organization in Israel. All patients with AS diagnosed between 2002 and 2018 were included. Controls were matched by age, sex, clinic, and enrollment time. Follow-up continued until death or the end of the study. RESULTS: The study comprised 5,930 AS patients and 29,018 matched controls who were followed up for a median period of 7.5 years. There were 667 deaths within the AS cohort and 2,919 deaths within controls; the mean age at death was 76.9 years and 77.1 years, respectively (P = 0.74). A total of 3,249 AS patients (54.8%) were treated only with nonsteroidal antiinflammatory drugs, 1,760 (29.7%) were treated with tumor necrosis factor inhibitors (TNFi), and 1,687 (28.4%) with disease-modifying antirheumatic drugs (DMARDs). Mortality rates were increased among AS patients compared to controls, with an age- and sex-adjusted hazard ratio (HR) of 1.19 (95% confidence interval [95% CI] 1.10-1.30). The association was significant for men (HR 1.15 [95% CI 1.04-1.27]) and women (HR 1.32 [95% CI 1.13-1.54]), and after adjusting for background comorbidities (HR 1.14 [95% CI 1.05-1.24]). AS patients treated with TNFi or with a combination of TNFi and DMARDs did not have significant difference in mortality rates compared to controls (HR 0.67 [95% CI 0.38-1.18] and HR 0.93 [95% CI 0.69-1.25], respectively). Age, male sex, mean C-reactive protein (CRP) levels and general comorbidities were predictors of mortality within the AS cohort. CONCLUSION: AS patients had an increased mortality risk compared to the general population after adjusting for age, sex, and baseline comorbidities. AS patients treated with TNFi did not demonstrate excess mortality compared to matched controls. Within the AS cohort, age, male sex, background comorbidities, and higher CRP levels were identified as risk factors for mortality.

Associations of Chronic Medication Adherence with Emergency Room Visits and Hospitalizations.

INTRODUCTION: Good medication adherence is associated with decreased healthcare expenditure; however, adherence is usually assessed for single medication. We aim to explore the associations of adherence levels to 23 chronic medications with emergency room (ER) visits and hospitalizations. The primary endpoints are ER visits and hospitalizations in internal medicine and surgical wards. METHODS: Individuals aged 50-74 years, with a diagnosis of diabetes mellitus or hypertension, treated with at least one antihypertensive or antidiabetic medication during 2017 were included. We determined personal adherence rates by calculating the mean adherence rates of the medications prescribed to each individual. Adherence rates were stratified into categories. We retrieved information about all the ER visits, and hospitalizations in internal medicine and surgical wards during 2016-2018. RESULTS: Of 268,792 persons included in the study, 50.6% were men. The mean age was 63.7 years. Hypertension was recorded for 217,953 (81.1%), diabetes for 160,082 (59.5%), and both diabetes and hypertension for 109,225 (40.6%). The mean number of antihypertensive and antidiabetic medications used was 2.2 ± 1.1. In total, 51,301 (19.1%) of the cohort visited the ER at least once during 2017, 21,740 (8.1%) were hospitalized in internal medicine wards, and 10,167 (3.8%) in surgical wards during 2017. Comparing the highest adherence category to the lowest, adjusted odds ratios were 0.64 (0.61, 0.67) for ER visits, 0.56 (0.52, 0.60) for hospitalization in internal wards, and 0.63 (0.57, 0.70) for hospitalization in surgical wards. Odds ratios were similar for the three consecutive years 2016-2018. CONCLUSION: Better medication adherence was associated with fewer ER visits and hospitalizations among persons with diabetes and hypertension. Investing in improving medication adherence may reduce health costs and improve patients' health.

The Association between Sarcoidosis and Ischemic Heart Disease-A Healthcare Analysis of a Large Israeli Population.

(1) Background: Inflammation plays a pivotal role in atherosclerosis, and the association between chronic inflammatory states and ischemic heart disease (IHD) has been shown in several rheumatic diseases. Persistent inflammation might also be a risk factor for IHD in sarcoidosis patients. (2) Methods: Demographic and clinical data of 3750 sarcoidosis patients and 18,139 age- and sex-matched controls were retrieved from the database of Clalit Health Services, Israel's largest healthcare organization. Variables associated with IHD were assessed by a logistic regression model. To assess for variables that were related to increased risk of all-cause mortality, the Cox proportional hazards method was used, and a log-rank test was performed for survival analysis. (3) Results: Both groups were composed of 64% females with a median age of 56 years. An association between sarcoidosis and IHD was demonstrated by a multivariate analysis (adjusted odds ratio (OR) 1.5; 95% confidence interval (CI) 1.36-1.66). Long-term follow-up revealed increased mortality among sarcoidosis patients: 561 (15%) deaths compared to 1636 (9%) deaths among controls (p < 0.001). Survival analysis demonstrated that sarcoidosis patients were also at increased risk for all-cause mortality compared to controls (multivariate model, adjusted HR 1.93; 95% CI 1.76-2.13).

The Relationship Between Patient Medication Adherence and Following Preventive Medicine Recommendation.

BACKGROUND: To study the relationship between adherence to chronic medications and adherence to preventive medicine recommendations among persons with diabetes mellitus and hypertension. METHODS: Data were collected from the Clalit database included all members of Clalit aged 50 to 74 years, diagnosed with diabetes mellitus or hypertension before 2016 and treated with at least 1 medication (statins hypotensive or antidiabetic drugs) during 2017. We analyzed all the monthly prescriptions that were filled during 2017. We determined personal adherence rates by calculating each individual's average adherence rate to all the prescribed medications. Adherence rates were stratified by quintiles. We checked whether each person included followed the Israeli recommendations for influenza vaccine, colon cancer screening, and mammography. RESULTS: Of 268,792 persons, 81.1% had hypertension, and 59.5% had diabetes; 40.6% had diabetes and hypertension. The mean age was 63.7 years; 50.6% were men. The mean number of medications used was 2.2 ± 1.1. An adherence rate of ≤20% was found in 4.2%, and >80% in 42.5%. Overall, 59.6% had received an influenza vaccine, 68.0% had undergone colon cancer screening, and 75.2% of the women had undergone mammography. Increased adherence to medications was associated with increased adherence to preventive recommendations. For persons in the study cohort, adjusted odds ratios comparing the highest to the lowest quintile of medication adherence were 1.52 (1.46-1.59) for influenza vaccine, 1.59 (1.53-1.66) for colon cancer screen, and 1.35 (1.27-1.44) for mammography. DISCUSSION: A positive association was observed between adherence to chronic medications and adherence to preventive medicine among persons with hypertension and diabetes.

Adherence to Oral Anticoagulant Medications.

BACKGROUND: Oral anticoagulants (OAC) reduce the risk for stroke and death from all causes in patients with non-valvular atrial fibrillation (NVAF). OBJECTIVES: To explore adherence rates of OAC among patients with NVAF in long-term use in a real-world setting and to examine patient characteristics associated with good adherence. METHODS: We conducted a population-based cohort study with members of Clalit Health Services, Israel. All patients aged ≥ 30 years with a diagnosis of NVAF before 2016 who were treated with OAC were included. We included patients who filled at least one prescription per year in the three consecutive years 2016-2018. We analyzed all prescriptions that were filled for the medications from 1 January 2017 to 31 December 2017. We considered purchasing of at least nine monthly prescriptions during 2017 as good medication adherence. RESULTS: We identified 26,029 patients with NVAF who were treated with OAC; 10,284 (39.5%) were treated with apixaban, 6321 (24.3%) with warfarin, 6290 (24.1%) with rivaroxaban, and 3134 (12.0%) with dabigatran. Rates of good medication adherence were 88.9% for rivaroxaban, 84.9% for apixaban, 83.6% for dabigatran, and 55.8% for warfarin (P < 0.0001). Advanced age was associated with higher adherence rates (P < 0.001). Socioeconomic status was not associated with medication adherence. Good adherence with OAC was associated with lower low density lipoprotein (LDL) cholesterol and glucose levels. CONCLUSIONS: Adherence rates to OAC in chronic use among patients with chronic NAVF are high. Investing in OAC adherence may have a wider health impact than expected.

Utilisation of healthcare services and drug consumption in fibromyalgia: A cross-sectional analysis of the Clalit Health Service database.

AIM: To investigate the health care utilisation and drug consumption of patients with fibromyalgia (FM). MATERIALS AND METHODS: This is a cross-sectional study using the Clalit Health Care database. Clalit is the largest HMO in Israel, serving more than 4.4 million enrollees. We identified FM patients and age and sex-matched controls. Indicators of healthcare utilisation and drug consumption were extracted and analysed for both groups. RESULTS: The study included 14 296 FM patients and 71 324 controls. The mean age was 56 years, with a women predominance of 92%. The mean number of visits across of all healthcare services (hospitalisations, emergency department visit, general practitioner clinic visits, rheumatology clinic visits, and pain clinic visits) and the mean difference (MD) were significantly higher for FM patients compared with controls (MD 0.66, P < .001; MD 0.23, P < .001; MD 7.49, P < .001; MD 0.31, P < .001; MD 0.13, P < .001), respectively. Drug use was significantly and consistently higher among FM patients compared with controls; NSAIDs (non-steroidal anti-inflammatory drugs) OR 2.56, P < .001; Opioids OR 4.23, P < .001; TCA (tricyclic antidepressants) OR 8.21, P < .001; Gabapentinoids OR 6.31, P < .001; SSRI (selective serotonin reuptake inhibitors) OR 2.07, P < .001; SNRI (serotonin-norepinephrine reuptake inhibitor) OR 7.43, P < .001. CONCLUSION: Healthcare utilisation and drug use are substantially higher among patients with FM compared with controls.

[ETIOLOGIES OF EXTREME HYPERFERRITINEMIA - ANALYSIS OF A LARGE DATABASE].

INTRODUCTION: Besides its role in iron homeostasis and storage, ferritin is also regarded as an acute-phase reactant. Extreme Hyperferritinemia is seen in severe inflammatory conditions, severe infections, iron storage diseases and malignancies. A direct linkage between high ferritin levels and poor prognosis has been observed. OBJECTIVES: To characterize patients with extreme high ferritin levels in the serum for possible etiologies and assessment of the correlation between ferritin levels, prognosis and mortality. METHODS: We conducted a retrospective cohort study between the years 2002-2016 using the large database of Clalit Health Services. Patients older than 18 years with ferritin levels above 10,000 ng/ml that were taken during hospitalization and ambulatory visits were included in the study. After examining the medical files of each patient, we evaluated the demographic characteristics, etiologies, clinical presentation and relevant laboratory parameters. We calculated the proportion of this data and compared it to the general population by using chi square test. RESULTS: The incidence of extreme hyperferritinemia was statistically significant in patients with autoimmune and rheumatologic diseases in particular adult onset Still's disease compared to the general population. Among hospitalized patients, bacterial and viral infections were the leading cause in 62% of cases. In ambulatory patients, hyperferritinemia was mainly secondary to chronic blood transfusions in patients with hemoglobinopathies and poor compliance to iron chelators. Among 21 biopsies from involved organs including lymph nodes, bone marrow and liver, hemophagocytosis was only observed in 5 cases (6.8%). CONCLUSIONS: Extreme hyperferritinemia with values higher than 10,000 ng/ml can be attributed to many inflammatory autoimmune conditions.

The co-occurrence of autistic spectrum disorder and schizophrenia: A nationwide population-based study.

Although the co-occurrence of autistic spectrum disorder (ASD) and schizophrenia have been previously reported, the scope and magnitude of this comorbidity across large samples have not been sufficiently established. This study was aimed to assess the co-occurrence between schizophrenia and ASD in a large dataset, and to examine its predominance across different age and sex groups. Schizophrenia patients and age and sex frequency controls (n = 49,334) were assessed for the prevalence of autism spectrum disorder. The sample was stratified by age and sex, and co-occurrence was assessed using univariate and multivariate logistic regressions. Results indicated that schizophrenia was associated with ASD (OR = 7.01, 95%CI 2.98-16.43, p < .0001) across all age groups aside from 50 to 70 years. This association was significant among male participants (OR = 11.69, 95%CI 3.59-38.01, p < .0001) but not among female participants (OR = 2.33, 95%CI 0.60-9.03, p = .21). These findings indicate a large overlap between schizophrenia and ASD, and point to the need to expand the understanding of the potential mediating mechanisms of this co-occurrence.

Should patients treated with oral anti-coagulants be operated on within 48 h of hip fracture?

To investigate if patients treated with oral anticoagulants (OAC) have delayed surgical intervention (more than 48 h) compared to patients without OAC therapy, and if there is an impact to surgery timing on hospitalization length and mortality. A retrospective cohort study of all patients aged over 65 registered with a new diagnosis of hip fracture who underwent surgery in one of the general hospitals run by Clalit, Israel between 01/01/2014 and 31/12/2017. Data was retrieved for patient demographics, OAC treatment, and Charlson comorbidity index. 5828 patients were operated for hip fractures, mean age was 82.8 years (65-108), 4013 (68.8%) were female. 415 were treated with direct oral anticoagulants (DOACs) (7.1%) and 311 with warfarin (5.3%) prior to their hospitalization. Patients taking OAC were less likely to be operated within 48 h from arrival to the hospital compared to patients not receiving OAC. The 30 day mortality was 4.2% among patients not receiving OAC, 6.0% among patients taking DOACs and 10.0% among patients receiving warfarin (p < 0.001). Adjusted odds ratio for mortality at 30 day among patients taking DOACs was similar to patients who didn't take OAC. (OR 1.0, CI 0.7, 1.6). The 30 day mortality rate of patients who were receiving OAC (either DOACs or warfarin) was not significantly different whether patients were operated within 48 h or not. Mortality rate was highest among patients taking warfarin. For patients who received DOACs, operation within 48 h wasn't associated with lower mortality rate. In these patients it seemed reasonable to adjust surgery time according to patients' characteristics and needs.

National study: Most elderly patients benefit from earlier hip fracture surgery despite co-morbidity.

OBJECTIVE: To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients. BACKGROUND: Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival. METHODS: A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015-2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age. RESULTS: Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment. CONCLUSIONS: Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account.

The long-term prognostic significance of heart failure in sarcoidosis patients ─ a cohort study.

OBJECTIVE: To evaluate the proportion and the long-term prognostic significance of heart failure (HF) in sarcoidosis patients. METHODS: Data extracted from a large Israeli healthcare provider's database were used to study sarcoidosis patients and matched non-sarcoidosis controls since 2000 to 2016. The proportion of HF was compared between the groups, and the associations between sarcoidosis, HF, and all-cause mortality were assessed. RESULTS: Included were 3,993 sarcoidosis patients and 19,856 age- and sex-matched controls. The proportion of HF patients was higher among the former (10.9% and 5.3%, respectively). A logistic regression model for multivariable analysis for covariates found sarcoidosis to be independently associated with HF (Odds Ratio (OR) 2.09 confidence interval (CI) 1.83-2.39). A total of 710 sarcoidosis patients (17.8%) and 2,121 controls (10.7%) died during the study period (p < 0.001). A multivariable survival analysis found an estimated hazard ratio (HR) of 1.84 (95%CI 1.67-2.02), indicating a significant association between sarcoidosis and risk for all-cause mortality. Our analysis also revealed a significant association between HF and risk for all-cause mortality (HR 3.05, 95%CI 2.77-3.36). CONCLUSIONS: Sarcoidosis is independently associated with HF, and both are independently associated with all-cause mortality.

Association Between Polyp Detection Rate and Post-Colonoscopy Cancer Among Patients Undergoing Diagnostic Colonoscopy.

Postcolonoscopy colorectal cancer (PCCRC) can arise from missed cancers, missed premalignant lesions, incomplete resection, and new cancers with an accelerated route to cancer.1.