Systemic Therapy for Psoriasis and the Risk of Herpes Zoster: A 500,000 Person-year Study.

IMPORTANCE: The risk for herpes zoster (HZ) in patients with psoriasis treated with biologic medications or other systemic treatments has been given little attention to date. OBJECTIVE: To describe the risk for HZ in patients with psoriasis and its relation to treatment. DESIGN, SETTING, AND PARTICIPANTS: A cohort study was performed using the administrative database of Clalit Health Services, the largest public health care provider organization in Israel, in the setting of general community clinics, primary care and referral centers, and ambulatory and hospitalized care. We extracted information for all patients who received a psoriasis diagnosis from January 2002 to June 2013. Follow-up was conducted until the end of July 2013. The study included 95,941 patients with psoriasis in the analysis, with 522,616 person-years of follow-up. Incidence of HZ events was calculated for each systemic antipsoriatic medication provided, during a follow-up period of 11 years and 7 months. We used a generalized estimating equation Poisson regression model to examine the effect of each systemic treatment for psoriasis on HZ incidence, adjusting for age, sex, psoriasis severity, Charlson comorbidity index, steroid treatment, and socioeconomic status. MAIN OUTCOMES AND MEASURES: Incidence of HZ associated with systemic therapies. RESULTS: In a multivariate analysis, it was observed that treatment with phototherapy (rate ratio [RR], 1.09 [95% CI, 0.62-1.93]; P = .99), methotrexate (RR, 0.98 [95% CI, 0.78-1.23]; P = .83), cyclosporine (RR, 1.16 [95% CI, 0.48-2.80]; P = .49), and biologic medications as a single agent (RR, 2.67 [95% CI, 0.69-10.3]; P = .14) was not associated with HZ. The use of combination treatment with biologic medications and methotrexate was significantly associated with an increased incidence of HZ (RR, 1.66 [95% CI, 1.08-2.57]; P = .02). The use of acitritin was associated with decreased incidence of HZ (RR, 0.69 [95% CI, 0.49-0.97]; P = .004). CONCLUSIONS AND RELEVANCE: Physicians may need to consider offering an HZ preventive vaccine to patients receiving combination treatment with biologic medications and methotrexate, particularly if they have additional risk factors for HZ.

Establishing an integrated gastroenterology service between a medical center and the community.

AIM: To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established. METHODS: Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators. RESULTS: An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer. CONCLUSION: Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

Deleterious effects of traditional Chinese medicine preparations on the course of psoriasis--a case report.

Psoriasis is a chronic, systemic and difficult to treat condition which negatively affects the patient's quality of life. Frustrated and unsatisfied with the conventional therapies, psoriatic patients start looking for alternative treatment which they believe to be safe and effective. Very common traditional Chinese medicine (TCM) appears to offer various topical and systemic herbal preparations, as well as massages, acupuncture, diet and lifestyle alternations. The presented study concerns a 48-year-old female patient with exacerbated psoriatic skin lesions (tending to become erythrodermic), and certain systemic complications that appeared after taking a TCM herbal medication, Fu Fang Quing Dai Wan, as well as the use of a Chinese herbal bath gel and staying on a diet rich in meat. After in vitro examinations were made of the herbal preparation and its biological properties determined, it was concluded that the TCM herbal preparation should not be considered harmless. Therefore, patients should be made aware of its adverse reactions.

Climatotherapy at the Dead Sea: an effective treatment modality for atopic dermatitis with significant positive impact on quality of life.

BACKGROUND: Atopic dermatitis (AD) has an appreciable effect on quality of life. Improving the quality of life of AD patients is a priority. OBJECTIVE: This study aimed to evaluate the impact of Dead Sea climatotherapy (DSC) as a treatment of AD and its influence on the quality of life of these patients. METHODS: Forty-nine adult patients with AD treated during the years 2009-2010 at the Deutsches Medizinisches Zentrum Medical Center participated in this prospective study. Climatotherapy was administered in accordance with a computer-designed protocol and included gradually increased sun exposure after a sea bath. Severity of AD was evaluated using the Scoring Atopic Dermatitis (SCORAD) index. Patient quality of life was evaluated using Skindex-29. Statistical analysis was performed using a paired t test and Wilcoxon and Mann-Whitney U tests. RESULTS: After treatment, the mean SCORAD value improved by 39 points (P < 0.001). The overall Skindex-29 score improved by a mean value of 33 points (P < 0.001). The pretreatment SCORAD, duration of AD, and maximal daily sun exposure predicted the posttreatment SCORAD values. Pretreatment Skindex-29 and patient age predicted the posttreatment Skindex-29 in a multiple linear regression model. CONCLUSIONS: Dead Sea climatotherapy provides an effective treatment modality for AD by improving the patient's skin condition and quality of life.

Traditional Chinese medicine herbs - are they safe for psoriatic patients?

Although traditional Chinese medicine (TCM) relies on remedies of natural origin, its use is not always safe as it can have not only beneficial but also deleterious effects. Psoriatic patients, disappointed by conventional treatment and unaware of the potential side effects of TCM preparations, are increasingly reaching for non-traditional therapeutic methods. This review presents brief characteristics of selected Chinese herbs self-prescribed by psoriatic patients. It is important that dermatologists should be able to recognize any potential hazards connected with current or previous taking of these herbs by their patients.

Physicians' knowledge and attitudes regarding periconceptional folic acid supplementation: a survey in Southern Israel.

BACKGROUND: Pre-conceptional folic acid supplementation is an effective way to reduce the incidence of neural tube defects (NTDs). Primary care providers are an important source of information to promote folic acid intake. This study aimed at evaluating primary care physicians' knowledge and attitudes regarding folic acid supplementation for childbearing women. MATERIAL/METHODS: A questionnaire on physicians' knowledge and attitudes, mostly including multiple-choice questions, was delivered by mail to all physicians (n=370) in a large health provider organization in southern Israel in 2006. Data regarding demographics as well as type of specialty, experience, and place of work were collected. RESULTS: Eighty-seven physicians were included in the study (response rate: 24%). Seventy physicians out of 81 (94%) reported routine recommendation of folic acid for their patients. Most physicians admitted that they needed more information regarding folic acid supplementation. Knowledge about folic acid's role in preventing congenital anomalies was suboptimal, with 2% of the physicians correctly estimating the efficacy of folic acid in decreasing the risk of NTDs and 8% recognizing the association between folic acid supplementation and decreased prevalence of malformations other than NTDs. Knowledge about the correct timing (12%) and dosage (47%) of folic acid preparations for average-risk women was also lacking. CONCLUSIONS: Primary care physicians report that they routinely prescribe folic acid to women in childbearing age in order to prevent congenital anomalies, but their knowledge about folic acid supplementation is insufficient.