[FUNCTIONAL TRAJECTORIES BEFORE, DURING AND AFTER ACUTE HOSPITALIZATION OF OLDER ADULTS IN INTERNAL MEDICINE WARDS].

INTRODUCTION: Hospital-associated functional decline (HAFD) is recognized as a leading cause of adverse hospitalization outcomes, such as prolonged hospitalization, falls, readmission, and mortality. Since most patients hospitalized in internal medicine wards are older-adults, HAFD presents a major challenge to internal medicine. OBJECTIVES: Describe functional trajectories of older-adults (aged ≥70 years) before, during and after acute hospitalization in internal-medicine units. METHODS: A prospective cohort study was conducted of 741 older-adults, hospitalized in two tertiary hospitals in Israel during the period 2009-2011. Basic functional status two weeks before admission, on-admission, at-discharge and one-month post-discharge was assessed using the modified Barthel Index (BI). Eight trajectories were identified. RESULTS: Two-thirds of the participants were completely or almost independent at the pre-morbid period. About a half of the older-adults were hospitalized with pre-admission functional decline, a quarter deteriorated or died during hospitalization, and one-third improved during hospitalization. Most of the older-adults who were stable in functioning at the pre-admission period (57.1%) remained stable during and post-hospitalization; however, about a third of them did not return to their pre-morbid functioning levels. Approximately half of those with pre-morbid functional decline experienced additional deterioration of at least 5 points on the BI scale. Pre-morbid instrumental functional status, comorbidity and depressive symptoms have been found to distinguish older adults with similar pre-admission and in-hospital functional trends. DISCUSSION: Eight functional trajectories describe the hospitalization period of older-adults in internal-medicine units. On-admission personal characteristics may be used to identify older-adults who are at risk of unwarranted hospitalization outcomes and thus allow intervention in the hospital-community interface.

Interaction Between the Haptoglobin Genotype and Vitamin E on Cardiovascular Disease in Diabetes.

PURPOSE OF REVIEW: Despite compelling evidence regarding the importance of oxidant stress in the development of vascular complications and observational studies suggesting that vitamin E may be protective from these complications, multiple clinical trials have failed to show benefit from vitamin E supplementation in the prevention of vascular complications in diabetes. One possible explanation for this failure of vitamin E may have been inappropriate patient selection. This review seeks to provide the clinical evidence and mechanistic basis for why a subset of individuals defined by their haptoglobin (Hp) genotype may derive cardiovascular protection by vitamin E supplementation. RECENT FINDINGS: Clinical trial data from the HOPE, ICARE, and WHS studies is presented showing a pharmacogenomic interaction between the Hp genotype and vitamin E on the development of CVD. Specifically, in individuals with diabetes and the Hp2-2 genotype, vitamin E has been shown to be associated with an approximately 35% reduction in CVD. Cardioprotection by vitamin E in individuals with the Hp2-2 genotype appears to be mediated in part by an improvement in HDL functionality as demonstrated in three independent trials in both type 1 diabetes and type 2 diabetes. Vitamin E may provide benefit in reducing CVD in Hp2-2 individuals with diabetes. However, in order for this pharmacogenomic algorithm to be accepted as a standard of care and used clinically, an additional large prospective study will need to be performed.

Clinical Features and Gaps in the Management of Probable Familial Hypercholesterolemia and Cardiovascular Disease.

BACKGROUND: Familial hypercholesterolemia (FH) is associated with premature atherosclerotic cardiovascular disease (ASCVD). The introduction of potent therapeutic agents underlies the importance of improving clinical diagnosis and treatment gaps in FH.Methods and Results:A regional database of 1,690 adult patients with high-probability FH based on age-dependent peak-low-density lipoprotein cholesterol (LDL-C) cut-offs and exclusion of secondary causes of severe hypercholesterolemia, was examined to explore the clinical manifestations and current needs in the management of ASCVD, which was present in 248 patients (15%), of whom 83% had coronary artery disease (CAD); 19%, stroke; and 13%, peripheral artery disease. ASCVD was associated with male gender, higher peak LDL-C, lower high-density lipoprotein cholesterol (HDL-C), and traditional risk factor burden. Despite high-intensity statin (prescribed in 83% and combined with ezetimibe in 42%), attainment of LDL-C treatment goals was low, and associated with treatment intensity and drug adherence. Multivessel CAD (adjusted hazard ratios (HR), 3.05; 95% CI: 1.65-5.64), myocardial infarction, and the presence of ≥1 traditional risk factor (HR, 2.59; 95% CI: 1.42-4.71), were associated with repeat coronary revascularizations, in contrast with peak LDL-C >300 mg/dL (HR, 1.13; 95% CI: 0.66-1.91). CONCLUSIONS: Main manifestations of ASCVD in FH patients were premature, multivessel CAD with need for recurrent revascularization, associated with classical cardiovascular risk factors but not with peak LDL-C. In spite of intensive therapy with lipid-lowering agents, treatment gaps were significant, with low attainment of LDL-C treatment goals.

An Intervention to Reduce the Time Interval Between Hospital Entry and Emergency Coronary Angiography in Patients with ST-Elevation Myocardial Infarction.

BACKGROUND: Outcomes of patients with acute ST-elevation myocardial infarction (STEMI) are strongly correlated to the time interval from hospital entry to primary percutaneous coronary intervention (PPCI). Current guidelines recommend a door to balloon time of < 90 minutes. OBJECTIVES: To reduce the time from hospital admission to PPCI and to increase the proportion of patients treated within 90 minutes. METHODS: In March 2013 the authors launched a seven-component intervention program:  Direct patient evacuation by out-of-hospital emergency medical services to the coronary intensive care unit or catheterization laboratory Education program for the emergency department staff Dissemination of information regarding the urgency of the PPCI decision Activation of the catheterization team by a single phone call Reimbursement for transportation costs to on-call staff who use their own cars Improvement in the quality of medical records Investigation of failed cases and feedback. RESULTS: During the 14 months prior to the intervention, initiation of catheterization occurred within 90 minutes of hospital arrival in 88/133 patients(65%); during the 18 months following the start of the intervention, the rate was 181/200 (90%) (P < 0.01). The respective mean/median times to treatment were 126/67 minutes and 52/47 minutes (P < 0.01). Intervention also resulted in shortening of the time interval from hospital entry to PPCI on nights and weekends. CONCLUSIONS: Following implementation of a comprehensive intervention, the time from hospital admission to PPCI of STEMI patients shortened significantly, as did the proportion of patients treated within 90 minutes of hospital arrival.

[PUBLIC MEDICINE AND RESEARCH-- IMPORTANT AND CHALLENGING].

Fellows who travel to the US are familiar with the American concept of combining clinical medicine and research. Research activity enforces reading, being updated, thinking creatively initiating, opening horizons, and being in contact with researchers all over the world. Thus, performing research is advantageous not only for research itself, the public, the patients and the knowledge, but also for the development of the researcher, the hospital, and the academic institute with which the hospital is affiliated. However, given the huge clinical workload and obligations, along with the shortage of physicians, the time consuming nature of research activity and the difficulties in obtaining research funds, it is certainly not obvious that clinicians can manage to conduct research and publish it. Decision makers, policy determinants and the individual drive to academic progress, encourage research activity by physicians, albeit the external support is commonly theoretical and moral, and is not commonly combined with time or appropriate resource allocation. In the current issue of "Harefuah", physicians from the Lady Davis Carmel Medical Center publish their own research and review articles. The hospital is the second largest in the Haifa region, providing services to a population of over a million people. The manuscripts reflect only a small sample of the research and clinical activities of the hospital.

[THE ROLE OF SIMULATION IN SURGICAL TRAINING--A NEW ERA].

Surgical training, which was traditionally based on the apprentice model, is undergoing a fundamental change since the introduction of virtual reality simulators into the training program of surgical residents. With the introduction of these simulators we can expect to see an improvement in the surgical abilities of new surgeons and a decrease in costs--as seen in the aviation world. Virtual reality simulators include a visual and tactile interface which is meant to train young surgeons in full procedure before the actual surgery. The available operation encompasses a multitude of surgical disciplines--gynecology, urology, orthopedics, vascular surgery, general surgery and more. The simulator allows the surgeon to practice complicated procedures and to be exposed to emergency situations without risking the patient's life. We opened in the Carmel Medical Center a multi disciplinary simulation center 18 months ago. The center includes simulators for gynecology, orthopedics, urology, general surgery, vascular surgery and advanced cardiac life support. The center cooperates with the Faculty of Medicine at the Technion in order to train young surgeons in all surgical disciplines. In this period of time we followed the improvement in the endoscopic abilities of the basic skills course participants.

"When the medium massages perceptions: Personal (vs. public) displays of information reduce crowding perceptions and outsider mistreatment of frontline staff": Correction.

Reports an error in "When the medium massages perceptions: Personal (vs. public) displays of information reduce crowding perceptions and outsider mistreatment of frontline staff" by Jean-Nicolas Reyt, Dorit Efrat-Treister, Daniel Altman, Chen Shapira, Arie Eisenman and Anat Rafaeli (Journal of Occupational Health Psychology, 2022[Feb], Vol 27[1], 164-178). In the original article, changes were needed to the labels under the images in the Appendix. Personal media were mistakenly labeled as public and vice versa. The four legends, from left to right, top to bottom, should be "Low crowding, public medium," "Low crowding, personal medium," "High crowding, public medium," and "High crowding, personal medium." The results and conclusions are unchanged. The online version of this article has been corrected. (The following abstract of the original article appeared in record 2022-30403-003). Crowded waiting areas are volatile environments, where seemingly ordinary people often get frustrated and mistreat frontline staff. Given that crowding is an exogenous factor in many industries (e.g., retail, healthcare), we suggest an intervention that can "massage" outsiders' perceptions of crowding and reduce the mistreatment of frontline staff. We theorize that providing information for outsiders to read while they wait on a personal medium (e.g., a leaflet, a smartphone) reduces their crowding perceptions and mistreatment of frontline staff, compared to providing the same information on a public medium (e.g., poster, wall sign). We report two studies that confirm our theory: A field experiment in Emergency Departments (n = 939) and an online experiment simulating a coffee shop (n = 246). Theoretical and managerial implications are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

When the medium massages perceptions: Personal (vs. public) displays of information reduce crowding perceptions and outsider mistreatment of frontline staff.

Crowded waiting areas are volatile environments, where seemingly ordinary people often get frustrated and mistreat frontline staff. Given that crowding is an exogenous factor in many industries (e.g., retail, healthcare), we suggest an intervention that can "massage" outsiders' perceptions of crowding and reduce the mistreatment of frontline staff. We theorize that providing information for outsiders to read while they wait on a personal medium (e.g., a leaflet, a smartphone) reduces their crowding perceptions and mistreatment of frontline staff, compared to providing the same information on a public medium (e.g., poster, wall sign). We report two studies that confirm our theory: A field experiment in Emergency Departments (n = 939) and an online experiment simulating a coffee shop (n = 246). Theoretical and managerial implications are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Patient-Centered Information System (myED) for Emergency Care Journeys: Design, Development, and Initial Adoption.

BACKGROUND: Medical care is highly complex in that it addresses patient-centered health goals that require the coordination of multiple care providers. Emergency department (ED) patients currently lack a sense of predictability about ED procedures. This increases frustration and aggression. Herein, we describe a system for providing real-time information to ED patients regarding the procedures in their ED medical journey. OBJECTIVE: This study aimed to develop a system that provides patients with dynamically updated information about the specific procedures and expected waiting times in their personal ED journey, and to report initial evaluations of this system. METHODS: To develop the myED system, we extracted information from hospital databases and translated it using process mining and user interface design into a language that is accessible and comprehensible to patients. We evaluated the system using a mixed methods approach that combined observations, interviews, and online records. RESULTS: Interviews with patients, accompanying family members, and health care providers (HCPs) confirmed patients' needs for information about their personal ED journey. The system developed enables patients to access this information on their personal mobile phones through a responsive website. In the third month after deployment, 492 of 1614 (30.48%) patients used myED. Patients' understanding of their ED journey improved significantly (F8,299=2.519; P=.01), and patients showed positive reactions to the system. We identified future challenges, including achieving quick engagement without delaying medical care. Salient reasons for poor system adoption were patients' medical state and technological illiteracy. HCPs confirmed the potential of myED and identified means that could improve patient experience and staff cooperation. CONCLUSIONS: Our iterative work with ED patients, HCPs, and a multidisciplinary team of developers yielded a system that provides personal information to patients about their ED journey in a secure, effective, and user-friendly way. MyED communicates this information through mobile technology. This improves health care by addressing patients' psychological needs for information and understanding, which are often overlooked. We continue to test and refine the system and expect to find positive effects of myED on patients' ED experience and hospital operations.

Vitamin E supplementation reduces cardiovascular events in a subgroup of middle-aged individuals with both type 2 diabetes mellitus and the haptoglobin 2-2 genotype: a prospective double-blinded clinical trial.

OBJECTIVE: Clinical trials of vitamin E have failed to demonstrate a decrease in cardiovascular events. However, these studies did not address possible benefit to subgroups with increased oxidative stress. Haptoglobin (Hp), a major antioxidant protein, is a determinant of cardiovascular events in patients with Type 2 diabetes mellitus (DM). The Hp gene is polymorphic with 2 common alleles, 1 and 2. The Hp 2 allelic protein product provides inferior antioxidant protection compared with the Hp 1 allelic product. We sought to test the hypothesis that vitamin E could reduce cardiovascular events in DM individuals with the Hp 2-2 genotype, a subgroup that comprises 2% to 3% of the general population. METHODS AND RESULTS: 1434 DM individuals > or = 55 years of age with the Hp 2-2 genotype were randomized to vitamin E (400 U/d) or placebo. The primary composite outcome was myocardial infarction, stroke, and cardiovascular death. At the first evaluation of events, 18 months after initiating the study, the primary outcome was significantly reduced in individuals receiving vitamin E (2.2%) compared with placebo (4.7%; P=0.01) and led to early termination of the study. CONCLUSIONS: Vitamin E supplementation appears to reduce cardiovascular events in individuals with DM and the Hp 2-2 genotype (ClinicalTrials.gov NCT00220831).

Attitudes of Arab-Muslims toward integration of complementary medicine in primary-care clinics in Israel: the Bedouin mystery.

INTRODUCTION: In this study, we have compared attitudes of two social groups within the Israeli-Muslim population in order to examine the influence of modernization on the use of traditional and Complementary/Alternative Medicine (CAM). RESEARCH DESIGN AND METHODS: We developed a 13-item questionnaire that addresses issues of CAM use, expectations from the primary-care physicians concerning CAM and attitudes toward CAM integration within the patient's primary-care clinic. Data for statistical analysis were obtained from 472 respondents who defined themselves as Bedouins and 869 non-Bedouins attending five primary-care clinics. RESULTS: Respondents in the two groups were equally distributed by demographic characteristics. Bedouin respondents reported less CAM use during the previous year (26.3% vs. 50.2%, P<0.0001), and less use of traditional medicine and herbs. Compared to non-Bedouins, Bedouin respondents who were considering CAM use expressed more drug reluctance. Respondents in both groups greatly supported a theoretical scenario of CAM integration in primary-medical care, and expected their family practitioner to initiate the referral to CAM. Bedouin respondents held higher expectations for their physician to refer them to CAM and to offer CAM treatment in the clinic. Moreover, Bedouins expected to receive CAM in a primary-care setting, and supported the option that their family physician would provide CAM in such a setting more than the non-Bedouin Muslims did. CONCLUSIONS: We hypothesize that the two communities differ due to later modernization in the Bedouin society that may highly regard and pursue medical science while forsaking traditional and herbal medicine.

Increased Risk of Antithyroid Drug Agranulocytosis Associated with Amiodarone-Induced Thyrotoxicosis: A Population-Based Cohort Study.

BACKGROUND: Agranulocytosis occurs in 0.2-0.5% of patients treated with the antithyroid drugs (ATDs) methimazole and propylthiouracil. The objectives of this study were to evaluate the risk of ATD-related agranulocytosis in patients with amiodarone-induced thyrotoxicosis (AIT), and to compare it with the agranulocytosis risk in patients with thyrotoxicosis due to other etiologies treated with ATDs. METHODS: This was a retrospective cohort study. Participants were 14,781 adult patients with thyrotoxicosis, newly treated with an ATD between January 1, 2002, and December 31, 2015. Among them were 593 patients treated by ATDs due to AIT. The main outcome measures were incidence rates and crude and adjusted hazard ratios using univariate and multivariable Cox regression models for ATD-related agranulocytosis within one year of treatment initiation, in association with AIT. RESULTS: Agranulocytosis occurred in 28 (0.19%) of patients newly treated with methimazole or propylthiouracil during the first year of follow-up. Of these 28 patients, 8/593 (1.35%) were AIT patients and 20/14,188 (0.14%) were thyrotoxic patients that was not AIT related (p < 0.001). Incidence rates were 22 (9.47-43.36) cases/1000 person-years of follow-up in AIT, and 1.79 (1.09-2.76)/1000 person-years of follow-up in non-AIT thyrotoxicosis (p < 0.0001). In univariate Cox regression analysis, risk for ATD agranulocytosis associated with AIT was 9.71 (4.28-22.05) compared to the risk in non-AIT thyrotoxicosis. In a multivariable model, adjusting for age, sex, body mass index, smoking history, year of cohort entry, diabetes mellitus, hypertension, renal failure, beta blockers, calcium channel blockers, anti-aggregants, and dose of ATDs, the risk associated with AIT was 5.70 (2.14-15.21). In a model adjusted for a propensity score to receive amiodarone, risk for ATD agranulocytosis associated with AIT was 6.32 (1.22-32.70). CONCLUSIONS: ATD use is associated with a higher risk for agranulocytosis in patients with AIT.

Severe Hypertriglyceridemia-Related Pancreatitis: Characteristics and Predictors of Recurrence.

OBJECTIVES: The diagnosis of severe hypertriglyceridemia (HTG) as a cause for acute pancreatitis is often delayed with limited data on the characteristics and predictors of recurrent pancreatitis in this population. METHODS: A regional database of severe HTG level of 1000 mg/dL or greater was analyzed to identify subjects with acute pancreatitis. Factors associated with recurrent pancreatitis during long-term follow-up were investigated. RESULTS: Severe HTG-associated pancreatitis was evident in 171 patients (75% diabetics). Recurrent pancreatitis was observed in 16%; this was associated with younger age, alcohol abuse, and an increase in triglyceride levels. In multivariable analysis, peak triglycerides level of greater than 3000 mg/dL (hazard ratio, 2.92; 95% confidence interval, 1.28-6.64; P = 0.011) and most recent triglycerides level of greater than 500 mg/dL (hazard ratio, 3.72; 95% confidence interval, 1.60-8.66; P = 0.002) remained independently associated with recurrent pancreatitis. These lipid measures as well as alcohol abuse were additionally correlated with a stepwise increase in the number of pancreatitis episodes. CONCLUSIONS: Severe HTG-related pancreatitis was closely associated with diabetes. Extreme HTG and a lack of attainment of lower triglyceride levels were independent long-term predictors of recurrent pancreatitis. These findings emphasize the importance of early identification and successful treatment of severe HTG and its underlying disorders to reduce the burden of recurrent pancreatitis.

Haptoglobin genotype is a regulator of reverse cholesterol transport in diabetes in vitro and in vivo.

Two common alleles exist at the haptoglobin (Hp) locus, and the Hp2 allele is associated with an increased incidence of cardiovascular disease, specifically in diabetes mellitus (DM). Oxidative stress is increased in Hp2 mice and humans with DM. Oxidative modification of the apolipoprotein A-I inhibits reverse cholesterol transport. We sought to test the hypothesis that reverse cholesterol transport is impaired in Hp2 DM mice and humans. In vitro, using serum from non-DM and DM individuals, we measured cholesterol efflux from (3)H-cholesterol-labeled macrophages. In vivo, we injected (3)H-cholesterol-loaded macrophages intraperitoneally into non-DM and DM mice with the Hp1-1 or Hp2-2 genotype and monitored (3)H-tracer levels in plasma, liver, and feces. In vitro, in DM individuals only, we observed significantly decreased cholesterol efflux from macrophages incubated with serum from Hp2-1 or Hp2-2 as compared with Hp1-1 individuals (P<0.01). The interaction between Hp type and DM was recapitulated using purified Hp and glycated Hb. In vivo, DM mice loaded with (3)H-cholesterol-labeled macrophages had a 40% reduction in (3)H-cholesterol in plasma, liver, and feces as compared with non-DM mice (P<0.01). The reduction in reverse cholesterol transport associated with DM was significantly greater in Hp2-2 mice as compared with Hp1-1 mice (54% versus 25% in plasma; 52% versus 27% in liver; 57% versus 32% in feces; P<0.03). reverse cholesterol transport is decreased in Hp2-2 DM. This may explain in part the increased atherosclerotic burden found in Hp2-2 DM individuals.

Suspected radioactive contamination: evaluation of 45 Israeli citizens potentially exposed to polonium-210 in London.

The lethal poisoning of Alexander Litvinenco with the radioactive element polonium-210, and the risk that many civilians (including Israeli citizens) who were in the same location in London at the same time were exposed to radiation, was an unprecedented event in the western world. This was only the second known death due to 210Po, a natural alpha radiation-emitting element. A task team was created to handle the event. The team comprised representatives from the Ministry of Health's advisory committee for radiological events (which includes the Israel Defense Force, the Israeli Atomic Energy Commission and the Ministry of Environmental Protection), the Public Health Services Central District, and a public relations expert. Forty-seven people were located and underwent an epidemiological inquiry, and urine samples for detection of 210Po were sent abroad to a specialized laboratory. The radiotoxicological results were analyzed and evaluated by the expert team and follow-up recommendations were made. This unfamiliar and potentially stressful scenario was handled successfully by a multi-organizational multidisciplinary task team. The joint work of the task team was a real-life "exercise" simulating a radiological event in Israel. This team has recommended further evaluation of various vital missions in the event of any possible future radiological event, with special emphasis on a proactive communication approach to the media and the public.

[Challenges and barriers in conducting a clinical trial within an HMO].

Initiating and conducting large controlled clinical trials within an Health Maintenance Organization (HMO) is complex and challenging but also provides a unique opportunity to generate genuine independent research. The authors describe their experience in executing a large scale primary care based clinical trial, without any commercial funding or support. It relied on the organizational and information technology capabilities of the HMO and it's strict quality routines of medical care. Various options were explored for swift and effective recruitment of individuals for the study. Attentiveness to the needs and comments of the primary care teams proved to be important in creating effective collaboration. Methods were developed for the retrieval of pertinent clinical data, including hospitalization discharge summaries, without the need of collaboration from the primary clinics' staff within their busy work schedule. All treatment decisions regarding routine care of the patients remained at the discretion of the individual's primary care physician, enhancing their cooperation, and potentially resulting in better external validity. A designated database provided an interactive framework, which enabled a single coordination center to manage the study and create reliable documentation of clinical data and events. Eventually, within one year from study initiation, 3054 individuals were recruited for the study. The authors succeeded in retrieving reliable and significant clinical data, while relying on the organizational properties allowing for the centralized follow-up. This large scale clinical trial was conducted with very little resources, in a real life setting apparently providing extensive external validity.

Clinical features and outcomes of severe, very severe, and extreme hypertriglyceridemia in a regional health service.

BACKGROUND: Comprehensive data on severe hypertriglyceridemia (HTG) in the general population setting are limited and of importance due to the increase in metabolic risk factors and novel therapies under development. OBJECTIVE: To investigate contributing causes and outcomes of severe to extreme HTG. METHODS: Regional database retrospectively analyzed for subjects with severe HTG. Adverse outcomes were investigated in correlation to HTG severity, with follow-up initiating at first documentation of HTG > 1000 mg/dL. RESULTS: A total of 3091 subjects with severe (peak triglycerides 1000-1999 mg/dL; n = 2590), very severe (2000-2999 mg/dL; n = 369), and extreme (≥3000 mg/dL; n = 132) HTG were identified. Mean age was 48 ± 12 years; 73% males. Obesity (48%) and diabetes (62%) were main contributing factors. During follow-up (median 101 months), 4.7% subjects had pancreatitis, 4.7% myocardial infarction, and 6% stroke. Compared with severe HTG, the multivariate-adjusted hazard ratio for pancreatitis was 3.22 (95% confidence interval 2.21-4.70) for individuals with very severe HTG and 5.55 (3.53-8.71) for those with extreme HTG, P < .0001. In contrast, the extent of HTG severity at these levels was not associated with worse cardiovascular outcomes or death. Most subjects (81%) achieved triglyceride levels <500 mg/dL, associated with lower risk for developing pancreatitis but not myocardial infarction or stroke. CONCLUSIONS: Severity of HTG is closely related to cardiometabolic conditions, with a stepwise increase in the risk for pancreatitis, particularly if not attaining reduced triglyceride levels during the follow-up. In contrast, whereas mild-to-moderate HTG is a known established cardiovascular risk factor, very severe and extreme HTG may not further increase the risk for myocardial infarction, stroke, or mortality.

Clinical determinants and treatment gaps in familial hypercholesterolemia: Data from a multi-ethnic regional health service.

Background Familial hypercholesterolemia is characterized by markedly increased low-density lipoprotein cholesterol and risk for premature atherosclerotic cardiovascular disease. Models of care vary and reflect differing health policies and resources. The availability of electronic databases may enable better identification and assessment of familial hypercholesterolemia in the community. Methods A regional healthcare database was utilized to identify patients with a high probability of familial hypercholesterolemia, clinically defined by age-dependent-peak low-density lipoprotein cholesterol cutoffs and exclusion of secondary causes of severe hypercholesterolemia. Clinical characteristics, low-density lipoprotein cholesterol goal attainment, and treatment gaps were investigated. Results Probable familial hypercholesterolemia was diagnosed in 1932 of 685,314 individuals (1:355; median age 47 years). Atherosclerotic cardiovascular disease was present in 16.3% of adults (38% in males aged 50-74 years). Median peak low-density lipoprotein cholesterol was 264 mg/dl (interquartile range 252-288). Statins and/or ezetimibe were prescribed to 83% of patients and high-intensity statins to 53%, whereas prescriptions were filled in 57% and 40% cases respectively over the last six months, p < 0.001. Treatment gaps were wider among ethnic minorities, younger individuals, and those without atherosclerotic cardiovascular disease. Low-density lipoprotein cholesterol < 100 mg/dl was attained in 10.1% overall and 28.7% of those with atherosclerotic cardiovascular disease. Predictors of low-density lipoprotein cholesterol goal attainment included recent issue of high-intensity statins, presence of atherosclerotic cardiovascular disease, diabetes, older age and lack of smoking. Conclusions The population with high probability for familial hypercholesterolemia was characterized by low attainment of low-density lipoprotein cholesterol treatment goals despite high prescription rates of lipid-lowering medications. Low utilization of intensified therapies, non-adherence, and ethnic disparities were contributing factors. These findings emphasize the need to improve awareness and quality of care of familial hypercholesterolemia in the community.

Time clock requirements for hospital physicians.

An agreement negotiated following a doctors' strike in 2011 introduced a requirement that physicians in Israel's public hospitals clock in and out when starting and leaving work. The press reported strong negative reactions to this policy and predicted doctors deserting hospitals en masse. This study examines physicians' reactions toward the clock-in/clock-out policy 6 months after its implementation, and assesses the relationship between these reactions and aspects of their employment context. 676 physicians in 42 hospitals responded to a survey assessing doctor's reactions toward the clock, hospital policy makers, and aspects of their work. Reactions to the clock were generally negative. Sense of calling correlated positively with negative reactions to the clock, and the latter correlated positively with quit intentions. However, overall, respondents reported a high sense of calling and low quit intentions. We suggest that sense of calling buffers and protects physicians from quit intentions. Differences in reactions to the clock were associated with different employment characteristics, but sense of calling did not vary by hospital size or type or by physicians' specialty. The findings offer insights into how physicians' working environment affects their reactions to regulatory interventions, and highlight medical professionalism as buffering reactions to unpopular regulatory policies.