Poor self-rated health is associated with faster cognitive decline and greater small vessel disease in older adults with type 2 diabetes.

OBJECTIVE: Self-rated health (SRH) is a predictor for poor health outcomes and cognition. Older adults with type 2 diabetes mellitus (T2D) have multi-morbidity and greater cognitive impairment. In the present study we investigated the association of SRH with cognitive decline and brain pathology in older adults with T2D. METHODS: Participants (n = 1122) were from the Israel Diabetes and Cognitive Decline study, and SRH was categorised as low (n = 202), moderate (n = 400) or high (n = 520). Cognition was measured by four cognitive domains: episodic memory, executive functions, language, and attention/working memory. Global cognition was the average of the cognitive domains. Statistical models adjusted for sociodemographic, cardiovascular, and clinical variables. In a randomly selected subsample (n = 230) that had magnetic resonance imaging, we examined relationships between baseline SRH and brain characteristics (white matter hyperintensities [WMHs], hippocampal, and total grey matter [GM] volumes). RESULTS: Low SRH was associated with a decline in executive functions, which accelerated over time when compared to high SRH (est = -0.0036; p = <0.001). Compared to high SRH, low SRH was associated with a faster decline in global cognition (est = -0.0024; p = 0.009). Low SRH at baseline was associated with higher volumes of WMHs (est = 9.8420; p < 0.0008). SRH was not associated with other cognitive domains, or with hippocampal and total GM. CONCLUSIONS: Low SRH is associated with cognitive decline in T2D older adults and may serve as a risk assessment. WMHs may represent an underlying mechanism.

An After-Hours Telemedicine Urgent Care Service May Not Improve Access to Care for Underserved Populations.

Background: After-hours telemedicine services for emergency care are thought to offer a solution for patients who live at a distance from traditional face-to-face emergency services. This study evaluates such a service in a Health Maintenance Organization, focusing on the differences between central and peripheral populations. Methods: In this cross-sectional database study, we collected data regarding the encounter and patient characteristics, including prescriptions, referrals for further evaluation in a traditional emergency department (ED), and the distance from a traditional ED. Other outcome measures included health care utilization after the encounter such as primary care physician (PCP) encounters, additional telemedicine encounters, ED visits, and hospitalization. Results: In total, 45,411 patient visits were analyzed. Medication was prescribed in 25% of the encounters, and a referral to an ED was given in 22%. In total, 17.7% of the patients visited an ED within 24 h of the index encounter. In total, 64.8% of patients visited a PCP in the following 30 days. No further care was needed in 32.4% of the encounters. In multivariable logistic regression, the odds of using the service were lower for low socio-economic status groups and inhabitants of the periphery than the central areas. A weak reverse correlation was observed in Jewish sectors regarding distance from traditional ED, whereas no correlation was found in the Arab sector. Conclusion: It is commonly believed that telemedicine overcomes geographical barriers. The results of this research do not support this hypothesis.

Behavioral and Brain Correlates of Emotional Distress in Older Adults During COVID-19 Quarantine.

COVID-19 led to unprecedented lockdowns and changes in older adults' lives, especially those with type 2 diabetes who have high risk of complications and mortality. We investigated the associations of cognitive and motor function and gray matter volumes (GMVs) with COVID-19 lockdown-related emotional distress of type 2 diabetes older adults, participating in the Israel Diabetes and Cognitive Decline Study. We administered a questionnaire to obtain information about anxiety, depression, general well-being, and optimism during a mandated lockdown. Lower grip strength before lockdown was associated with increased sadness, anxiety, and less optimism. Slower gait speed was associated with greater sadness. Lower GMV was related to greater anxiety during the lockdown when compared with anxiety levels before the COVID-19 outbreak. Yet, global cognition was not associated with any emotional distress measure. These results support the role of good motor function on emotional well-being during acute stress and GMV as a potential underlying mechanism.

Neuroticism is associated with increase in depression symptoms over time in older adults with type 2 diabetes.

OBJECTIVES: The likelihood of depression symptoms in those with type 2 diabetes (T2D) is high. Psychological risk factors enhancing comorbidity of depression symptoms in T2D are yet to be determined. The present study examines the cross-sectional and longitudinal relationship between personality traits and distinct depression dimensions in older adults with T2D. METHODS: Participants were older adults (age ≥65yeas) with T2D from the Israel Diabetes and Cognitive Decline (IDCD) study (N = 356), with complete data on depression [Geriatric Depression Scale (GDS) - 15 item version] and its dimensions- namely, dysphoric mood, apathy, hopelessness, memory complains and anxiety, and on personality [Big Five Inventory (BFI)]. Logistic and mixed linear regression models examined cross-sectional and longitudinal associations while adjusting for socio-demographics, cognition, cardiovascular and diabetes-related factors. RESULTS: Cross-sectionally, high neuroticism was associated with high scores in total GDS and in all depression-dimensions, except memory complaints. Higher extroversion was associated with lower total GDS and with lower scores on all depression dimensions, except anxiety. High levels of neuroticism were associated with increase in total number of depression symptoms over time. CONCLUSIONS: In older adults with T2D, neuroticism and extroversion are associated with most depression dimensions suggesting that these traits relate to a global depression symptomatology rather than to any specific dimension or phenomenology. High neuroticism was associated with increase in depression symptoms over time, highlighting its role in the development of depression symptoms in older adults with T2D.

Intra-articular and soft-tissue corticosteroid injections and risk of infections: Population-based self-controlled-risk-interval design.

PURPOSE: Chronic and short-term treatment with oral corticosteroids is associated with an increased risk of infection. However, the potential risk of infection that may be associated with intra-articular and soft-tissue injections of corticosteroids has not been reported. The aim of this study was to assess the risk for infection following intra-articular or soft-tissue corticosteroid injections. METHODS: Self-controlled-risk-interval study with 15 732 adults who were treated with intra-articular or soft-tissue corticosteroid injections during 2015-2018. The study was conducted in a large Israeli Health Maintenance Organization. We self-matched the participants and analyzed the incidence of infection over three periods: an exposure-period of 90 days following the injection, and two 90-day control periods. We identified the occurrence of several common infections in the patient's electronic medical record and analyzed the incidence rates of all infections (composite end-point) as well as each infection separately. RESULTS: The incidence of any infection was higher during postexposure period compared with the control periods (46.5 vs. 42.1 events per 1000 persons), number needed to harm was 227 persons. Self-matching analysis showed increased incidence-rate-ratio (IRR) for the combined incidence of infections in the post-exposure period compared with the control periods (IRR = 1.10, 95% confidence interval [CI] 1.01-1.21). A sensitivity analysis showed that the highest IRR was during the first 30 days (IRR = 1.19, 95% CI 1.03-1.38), with higher IRR for patients aged 65 years and older (IRR = 1.37, 95% CI 1.08-1.73). CONCLUSIONS: Intra-articular and soft-tissue corticosteroids injections may be associated with an increased risk of infections; however, the absolute risk increase is low.

Continuity of care after attempted suicide: the primary care physicians' role.

BACKGROUND: Suicide prevention is an important public health concern, and primary care physicians (PCPs) often serve as the first point of contact for individuals at risk. Few interventions in the primary care setting have been linked to reduced suicide attempt (SA) rates. The Continuity of Care (COC) protocol was developed to improve the primary care treatment of high-risk suicidal patients. OBJECTIVES: This study examined PCPs' awareness of the COC protocol, its perceived effectiveness, and PCPs' attitudes towards post-SA-discharge visits. METHODS: A survey was administered to 64 PCPs who had a recent office visit with a patient who had attempted suicide. Data were collected between May and July 2021 and analyzed anonymously. RESULTS: Thirty of the 64 PCPs answered the questionnaires, giving a response rate of 47%. Most were unaware of the COC protocol. Seventeen physicians (57%) felt that the visit strengthened their physician-patient relationship, and while nearly half of the physicians (47%, n = 14) agreed they had the knowledge and tools to manage a post-SA-discharge visit, 43% of them (n = 13) preferred that the visit would have been handled by a mental health professional rather than a PCP. Analysis of open-ended questions uncovered three themes: knowledge gap, system limitation, and the PCP's role in maintaining the COC. CONCLUSION: The findings of this study highlighted the important role PCPs can play to prevent future SAs, as well as exposed gaps in the knowledge and system constraints that impede them from carrying out this role as effectively as possible.

Primary care physicians (PCPs) are often the first point of contact for individuals at risk of suicide and can play a critical role in suicide prevention. Our study examined the perceptions and attitudes of PCPs towards the Continuity of Care (COC) protocol, an intervention designed to improve primary care treatment of high-risk suicidal patients. The study surveyed 64 PCPs who had recently seen a patient who had attempted suicide, and 47% of them responded to the survey. While the study revealed areas for improvement, it also highlighted the perceived importance of the physician­patient relationship in preventing future suicide attempts. The study also revealed that many PCPs felt they had the knowledge and tools to manage a post-attempt discharge visit and that the visit strengthened their physician­patient relationship. However, the study also identified gaps in knowledge and system limitations that can impede PCPs from carrying out their role effectively. It is important to continue to improve training and support for PCPs in order to better equip them to handle high-risk suicidal patients and prevent future suicide attempts.

Shared Decision Making and Trust Matter: Patient's Use of Video Consultations and a Remote Medical Device in Primary Care.

Background: There is growing interest in the incorporation of video consultations in primary care. Remote medical devices used for remote physical examinations are a new complementary addition to these consultations and may increase their effectiveness. This study examines a social behavioral-technological model by the factors predicting the acceptance of video consultation with or without a technological medical device, their perceived ease of use (PEU), and their perceived usefulness (PU), as well as social behavioral factors: trust and shared decision making. Methods: We conducted an online survey among patients who had visited a physician during 2021 and had the option to receive video consultations with or without remote medical devices. Structural equation modeling was applied to assess the proposed model of predicting the extent of future telemedicine use. Results: Among the 1,198 patient responders, the intention to use telemedicine video consultation had a significant positive association with trust, shared decision making, PEU, and PU and with high socioeconomic constructs. The intention to use telemedicine video consultation with a medical device had a significant positive association with shared decision making, PEU, and PU. The statistical results suggest a good fit with the proposed models. Conclusions: The proposed social behavioral-technological model demonstrated that to successfully adopt video consultations and new remote medical devices in primary care, there is a need for trust and shared decision making to be established in patient-physician relationships.

Primary care physicians' attitudes and knowledge regarding medical cannabis and willingness to prescribe it: the Israeli experience.

BACKGROUND: Use of medical cannabis (MC) in Israel has increased since its regulatory approval in 2016. Currently, more than 1% of Israeli adults are treated with MC; this requires primary care physicians (PCPs) to be familiar with this treatment option. OBJECTIVES: We assessed the attitudes and knowledge of Israeli PCPs toward MC and evaluated their willingness to prescribe it for different medical conditions. METHODS: A cross-sectional survey which was distributed to PCPs in Israel. Physicians were asked about their opinions, knowledge, and willingness to prescribe MC. RESULTS: Two hundred and one PCPs answered the questionnaire. Their average age was 47 years (±11.2), 71% were specialists. 51% of the respondents thought that MC is an effective treatment. 63% replied that they had little knowledge and 75% indicated that they would like to deepen it. 61% of the respondents were willing to initiate an MC treatment for a dying patient, while less than 50% were willing to initiate MC treatment for various other conditions. Most respondents indicated that they were willing to renew a prescription for any approved medical condition. Willingness to prescribe MC increased for physicians who agreed that MC was effective (odds ratio [OR] 21.9, 95% confidence interval [CI] 2.40-200.85), for physicians who strongly agreed with the statement that they had sufficient knowledge (OR 5.0, 95% CI 1.58-15.83) and for residents compared with specialists (OR 4.0, 95% CI 1.52-10.73). CONCLUSIONS: Our survey revealed PCPs' differing opinions and insufficient knowledge regarding treatment with MC. These findings suggest that continuing medical education regarding MC is needed.

Use of medical cannabis (MC) in Israel has increased substantially since its regulatory approval in 2016. Currently, more than 1% of Israeli adult population receive MC; this requires primary care physicians (PCPs) to be familiar with this treatment option. We assessed the attitudes and knowledge of Israeli PCPs toward MC and evaluated their willingness to prescribe it for different medical indications. Two hundred and one PCPs answered our questionnaire. 51% of the respondents thought that MC was an effective treatment. 63% of physicians stated that they had little knowledge regarding MC and 75% indicated that they would like to deepen it. 61% of the respondents were willing to initiate MC treatment for a dying patient, while less than 50% were willing to initiate MC treatment for other conditions. Willingness to initiate treatment with MC was low for most indications, while renewal was more acceptable. Our survey revealed PCPs' different opinions and insufficient knowledge regarding the utilization of MC in primary care. These findings emphasize the necessity for continuous medical education regarding MC.

Increase in Number of Depression Symptoms Over Time is Related to Worse Cognitive Outcomes in Older Adults With Type 2 Diabetes.

OBJECTIVE: Older adults with type 2 diabetes (T2D) are at increased risk for depression, cognitive decline, and dementia compared to those without T2D. Little is known about the association of simultaneous changes in depression symptoms and cognitive decline over time. METHODS: Subjects (n=1021; mean age 71.6 [SD=4.6]; 41.2% female) were initially cognitively normal participants of the Israel Diabetes and Cognitive Decline study who underwent evaluations of depression and cognition approximately every 18 months. Cognitive tests were summarized into four cognitive domains: episodic memory, attention/working memory, executive functions, and semantic categorization. The average of the z-scores of the four domains defined global cognition. Depression symptoms were assessed using the Geriatric Depression Scale, 15-item version. We fit a random coefficients model of changes in depression and in cognitive functions, adjusting for baseline sociodemographic and cardiovascular variables. RESULTS: Higher number of depression symptoms at baseline was significantly associated with lower baseline cognitive scores in global cognition (estimate = -0.1175, SE = 0.021, DF = 1,014, t = -5.59; p < 0.001), executive functions (estimate = -0.186, SE = 0.036, DF = 1,013, t = -5.15; p = <0.001), semantic categorization (estimate = -0.155, SE = 0.029, DF = 1,008, t = -5.3; p < 0.001), and episodic memory (estimate = -0.08165, SE = 0.027, DF = 1,035, t = -2.92; p = 0.0036), but not with rate of decline in any cognitive domain. During follow-up, a larger increase in number of depression symptoms, was associated with worse cognitive outcomes in global cognition (estimate = -0.1053, SE = 0.027, DF = 1,612, t = -3.77; p = 0.0002), semantic categorization (estimate = -0.123, SE = 0.036, DF = 1,583, t = -3.36; p = 0.0008), and in episodic memory (estimate = -0.165, SE = 0.055, DF = 1,622, t = -3.02; p = 0.003), but the size of this effect was constant over time. CONCLUSION: In elderly with T2D, increase in depression symptoms over time is associated with parallel cognitive decline, indicating that the natural course of the two conditions progresses concurrently and suggesting common underlying mechanisms".

Trajectories of depression symptoms over time differ by APOE4 genotype in older adults with type 2 diabetes.

OBJECTIVES: The APOE-ε4 genotype has been associated with old-age depression, but this relationship has been rarely investigated in type 2 diabetes (T2D) older adults, who are at significantly increased risk for depression, a major contributor to T2D complications. We examined whether trajectories of depression symptoms over time differ by APOE-ε4 genotype in older adults with T2D. METHODS: Participants (n = 754 [13.1% APOE-ε4 carrier]s) were from the longitudinal Israel Diabetes and Cognitive Decline (IDCD) study. They were initially cognitively normal and underwent evaluations of depression approximately every 18 months using the 15-item version of the Geriatric Depression Scale (GDS) and the depression subscale of the Neuropsychiatric Inventory (NPI). APOE was defined as a dichotomy of ε4 carriers and non-carriers. We used Hierarchical Linear Mixed Models (HLMM) that modeled the effects of APOE status on repeated GDS and NPI-depression scores in an unadjusted model (Model 1), adjusting for demographic factors (Model 2) and additionally adjusting for cardiovascular factors and global cognition (Model 3). RESULTS: Participants' mean age was 71.37 (SD = 4.5); 38.2% female. In comparison to non-carriers, APOE-ε4 carriers had lower mean GDS scores (ß = -0.46, p = 0.018) and lower NPI-depression scores (ß = -0.170, p = 0.038) throughout all study follow period. The groups did not differ in the slope of change over time in GDS (ß = -0.005, p = 0.252) or NPI-depression (ß = -0.001, p = 0.994) scores. Additional adjustment for cardiovascular factors and global cognition did not alter these results. CONCLUSIONS: In older adults with T2D, APOE-ε4 carriers have less depressive symptoms in successive measurements suggesting they may be less susceptible to depression.

Preferences and barriers to the utilization of primary health care by sick physicians: a nationwide survey.

BACKGROUND: Physicians are often dissatisfied with their own medical care. Self-prescribing is common despite established guidelines that discourage this practice. From a pilot study, we know primary care physicians' (PCP) preferences, but we lack information regarding other specialties and work places. OBJECTIVES: The goal of this study was to examine whether physicians are satisfied with their personal primary care and how this could be improved. METHODS: We distributed an electronic survey to all physicians registered with the Israeli Medical Association. The questionnaire examined satisfaction with medical care, preferences for using formal care versus informal care, self-prescribing and barriers to using formal care. RESULTS: Two thousand three hundred and five out of 24 360 invited physicians responded. Fifty-six per cent of the respondents were satisfied with their personal primary care. Fifty-two per cent reported initiating self-treatment with a medication during the last year. Five and four per cent initiated treatment with a benzodiazepine and an antidepressant, respectively, during the last year. This was despite the fact that most physicians did not feel competent to treat themselves. Having a personal PCP was correlated with both a desire to use formal care and self-referral to formal care in practice. Regression analysis showed that the highest odds ratio (OR) for experiencing a large gap between desired and actual care were for physicians who had no personal PCP (OR = 1.92). CONCLUSIONS: Physicians frequently engage in self-treatment and in informal medical care. Whether the root cause is the health care system structure that does not meet their needs or the convenience of self-treatment is not known.

Higher BMI is associated with smaller regional brain volume in older adults with type 2 diabetes.

AIMS/HYPOTHESIS: There are established relationships between adiposity (obesity) and higher dementia risk, faster cognitive decline and associated neural injury. Type 2 diabetes is strongly linked to greater adiposity and has been consistently associated with neural injury and poor cognitive outcomes. However, although obesity is a major cause of type 2 diabetes, there is limited evidence on the association of adiposity with brain atrophy among individuals with type 2 diabetes. METHODS: We examined the association of BMI (a measure of adiposity), and of long-term trajectories of BMI (three empirically identified groups of trajectories-'normal', 'overweight' and 'obese'-using SAS macro PROC TRAJ), with regional brain volume, in a sample of older individuals (aged 64-84) with type 2 diabetes participating in the Israel Diabetes and Cognitive Decline Study (n = 198). RESULTS: Using linear regression, we found that greater BMI was associated with smaller volumes of the inferior frontal gyrus (IFG) (r = -0.25, p = 0.001) and the middle temporal gyrus (r = -0.19; p = 0.010) after adjusting for sociodemographic covariates and total intracranial volume. In addition, there were significant differences between BMI trajectory groups in IFG volume (F = 4.34, p = 0.014), such that a long-term trajectory of obesity was associated with a smaller volume. Additional adjustment for cardiovascular and diabetes-related potential confounders did not substantively alter the results. There were no associations of adiposity with superior frontal gyrus, middle frontal gyrus or total grey matter volumes. CONCLUSIONS/INTERPRETATION: In older adults with type 2 diabetes, long-term adiposity may have a detrimental impact on volume of brain regions relevant to cognitive functioning. Further studies to identify the underlying mechanisms are warranted. Graphical abstract.

Long-term trajectories of BMI predict carotid stiffness and plaque volume in type 2 diabetes older adults: a cohort study.

BACKGROUND: High body mass index (BMI) is a risk factor for type 2 diabetes and cardiovascular disease. However, its relationships with indices of carotid stiffness and plaque volume are unclear. We investigated associations of long-term measurements of BMI with indices of carotid stiffness and atherosclerosis among non-demented diabetes patients from the Israel Diabetes and Cognitive Decline (IDCD) study. METHODS: Carotid ultrasound indices [carotid intima media thickness (cIMT), distensibility, elastography and plaque volume] were assessed in N = 471 participants. Mean BMI across all MHS diabetes registry measurements and trajectories of BMI were calculated. BMI was categorized into three trajectory groups representing: a relatively stable normal weight (n = 185, 44%), overweight trajectory (n = 188, 44.8%) and a trajectory of obesity (n = 47, 11.2%). Linear and logistic regressions estimated associations of carotid indices with mean BMI and BMI trajectories. RESULTS: Compared to the normal weight trajectory, an obesity trajectory was associated with carotid distensibility (ß = - 3.078, p = 0.037), cIMT (ß = 0.095, p = 0.004), and carotid elastography (ß = 0.181, p = 0.004) but not with plaque volume (ß = 0.066, p = 0.858). Compared with the normal weight trajectory, an obesity trajectory was associated with increased odds for impaired carotid distensibility (OR = 2.790, p = 0.033), impaired cIMT (OR = 5.277, p = 0.001) and large carotid plaque volume (OR = 8.456, p = 0.013) but not with carotid elastography (OR = 1.956, p = 0.140). Mean BMI was linearly associated with Distensibility (ß = - 0.275, p = 0.005) and cIMT (ß = 0.005, p = 0.026). CONCLUSIONS: Long-term measurements of adiposity are associated with indices of carotid stiffness and plaque volume among older type 2 diabetes adults.

Deterioration in Motor Function Over Time in Older Adults With Type 2 Diabetes is Associated with Accelerated Cognitive Decline.

OBJECTIVE: Type 2 diabetes (T2D) is associated with motor impairments and a higher dementia risk. The relationships of motor decline with cognitive decline in T2D older adults has rarely been studied. Using data from the Israel Diabetes and Cognitive Decline study (N = 892), we examined associations of decline in motor function with cognitive decline over a 54-month period. METHODS: Motor function measures were strength (handgrip) and gait speed (time to walk 3 m). Participants completed a neuropsychologic battery of 13 tests transformed into z-scores, summarized into 4 cognitive domains: episodic memory, attention/working memory, executive functions, and language/semantic categorization. The average of the 4 domains' z-scores defined global cognition. Motor and cognitive functions were assessed in 18-months intervals. A random coefficients model delineated longitudinal relationships of cognitive decline with baseline and change from baseline in motor function, adjusting for sociodemographic, cardiovascular, and T2D-related covariates. RESULTS: Slower baseline gait speed levels were significantly associated with more rapid decline in global cognition (P = .004), language/semantic categorization (P = .006) and episodic memory (P = .029). Greater decline over time in gait speed was associated with an accelerated rate of decline in global cognition (P = .050), attention/working memory (P = .047) and language/semantic categorization (P<.001). Baseline strength levels were not associated with cognitive decline but the rate of declining strength was associated with an accelerated decline in executive functions (P = .025) and language/semantic categorization (P = .006). CONCLUSION: In T2D older adults, the rate of decline in motor function, beyond baseline levels, was associated with accelerated cognitive decline, suggesting that cognitive and motor decline share common neuropathologic mechanisms in T2D.

Depression is more strongly associated with cognition in elderly women than men with type 2 diabetes.

Depression and cognitive impairment are highly prevalent in type 2 diabetes (T2D), yet little is known about how their relationship varies by sex. We examined this question in a large T2D sample (N = 897) of non-demented elderly (≥ 65) participating in the Israel Diabetes and Cognitive Decline (IDCD) Study. Cognition was evaluated by a comprehensive neuropsychological battery and depressive symptoms were assessed by the Geriatric Depression Scale (GDS). The results showed that in all but the executive function domain, the association of depressive symptoms with poorer cognitive function was stronger in women than men, with a significant interaction for language/semantic categorization and missed significance for episodic memory. When defining clinical depression as GDS of ≥6, women with depression had significantly poorer language/semantic categorization, episodic memory, and overall cognitive function. Inclusion of antidepressants in the model did not alter substantively the associations. Our results suggest that depressed T2D women may have poorer cognitive performance, highlighting the significance of sex-specific personalized management of depression in elderly diabetics.

Comparing assessment of diabetes-related quality of life between patients and their physicians.

BACKGROUND: Health-related quality of life (QoL) is a comprehensive, multidimensional construct encompassing physical and psychosocial wellbeing. Physicians frequently assess QoL as part of their decision making process without specifically asking their patients. This study examined the degree and predictors of concordance between physician and patient assessments of QoL among patients with diabetes in primary care and in multi-disciplinary diabetes clinics. METHODS: Patients completed a questionnaire regarding overall and diabetes-specific QoL before entering their physician's office. After the visit, the physician completed the same questionnaire in order to evaluate how he/she perceived that patient's QoL. In addition, medical data relating to the patient's health status were collected from the medical records. The concordance between patient-reported QoL and physician-estimated QoL was evaluated. Stepwise regression analysis was conducted to determine which factors contributed to the difference between physicians' and patients' assessment of QoL. RESULTS: A total of 136 patients and 39 treating physicians were surveyed. Patients' response rate was 95%. A strong concordance was found between patients' and physicians' ratings of current health status (r = 0.79, p < 0. 01); however, physicians perceived their patients' QoL as worse than the QoL assessed by the patients themselves. Primary care physicians were better at assessing their patients' overall wellbeing while diabetes-specialists were better at assessing their patients' diabetes-specific QoL. In addition, the longer the duration of diabetes, the more difficult is was for the physicians to accurately assess QoL. When entered in the regression analysis, familiarity did not explain physicians' ability to assess health-related QoL or diabetes-specific QoL. CONCLUSIONS: Physicians make reasonable assessments of their patients' QoL, however as the patients' disease progresses, it becomes harder for physicians to assess QoL. Primary care physicians are better at assessing overall well-being whereas diabetes specialists are better at assessing diabetes-specific QoL. TRIAL REGISTRATION NUMBER: Not registered. Assuta Medical Center institutional review board approval number 2009103.

Israeli general practitioners' dissatisfaction with their own primary healthcare.

Background: Many physicians treat themselves despite established guidelines against such practice. Aims: To examine whether general practitioners (GPs) are satisfied with their personal primary care and how this could be improved. Methods: We sent a questionnaire to GPs in Israel. We examined the gap between preference to use formal medical care and use in practice, satisfaction with physicians' primary healthcare, self-prescribing and ways to improve physician access to care. Results: There were 203 respondents (response rate 203/985; 21%). Sixty-one per cent reported not having a GP. Older respondents were less likely to have their own GP. Thirty-seven per cent of physicians reported receiving less formal medical care than they desired. This gap was higher in those reporting self-prescription of benzodiazepines and anti-depressants (P < 0.05) and was significantly associated with dissatisfaction with primary healthcare. Odds for being satisfied with personal care was reduced by more than 85% in GPs who reported receiving less formal medical care than they desired (odds ratio 0.146; 95% confidence interval 0.064-0.333). Conclusions: Our findings inform the profile of physician self-treatment and the dissatisfaction associated with it. Dissatisfaction was associated with a gap between desired and actual care rather than with having or not having a personal GP. There was no consensus regarding what would assist physicians to access GPs.

Impact of the Holocaust on the Rehabilitation Outcome of Older Patients Sustaining a Hip Fracture.

BACKGROUND: Holocaust survivors report a much higher prevalence of osteoporosis and fracture in the hip joint compared to those who were not Holocaust survivors. OBJECTIVES: To evaluate whether being a Holocaust survivor could affect the functional outcome of hip fracture in patients 64 years of age and older undergoing rehabilitation. METHODS: A retrospective cohort study compromising 140 consecutive hip fracture patients was conducted in a geriatric and rehabilitation department of a university-affiliated hospital. Being a Holocaust survivor was based on registry data. Functional outcome was assessed by the Functional Independence Measure (FIM)TM at admission and discharge from the rehabilitation ward. Data were analyzed by t-test, chi-square test, and linear regression analysis. RESULTS: Total and motor FIM scores at admission (P = 0.004 and P = 0.006, respectively) and total and motor FIM gain scores at discharge (P = 0.008 and P = 0.004 respectively) were significantly higher in non-Holocaust survivors compared with Holocaust survivors. A linear regression analysis showed that being a Holocaust survivor was predictive of lower total FIM scores at discharge (ß = -0.17, P = 0.004). CONCLUSIONS: Hip fracture in Holocaust survivors showed lower total, motor FIM and gain scores at discharge compared to non-Holocaust survivor patients. These results suggest that being a Holocaust survivor could adversely affect the rehabilitation outcome following fracture of the hip and internal fixation.

Ethnicity/culture modulates the relationships of the haptoglobin (Hp) 1-1 phenotype with cognitive function in older individuals with type 2 diabetes.

OBJECTIVE: The haptoglobin (Hp) genotype has been associated with cognitive function in type 2 diabetes. Because ethnicity/culture has been associated with both cognitive function and Hp genotype frequencies, we examined whether it modulates the association of Hp with cognitive function. METHODS: This cross-sectional study evaluated 787 cognitively normal older individuals (>65 years of age) with type 2 diabetes participating in the Israel Diabetes and Cognitive Decline study. Interactions in two-way analyses of covariance compared Group (Non-Ashkenazi versus Ashkenazi Jews) on the associations of Hp phenotype (Hp 1-1 versus non- Hp 1-1) with five cognitive outcome measures. The primary control variables were age, gender, and education. RESULTS: Compared with Ashkenazi Jews, non-Ashkenazi Jews with the Hp 1-1 phenotype had significantly poorer cognitive function than non-Hp 1-1 in the domains of Attention/Working Memory (p = 0.035) and Executive Function (p = 0.023), but not in Language/Semantic Categorization (p = 0.432), Episodic Memory (p = 0.268), or Overall Cognition (p = 0.082). After controlling for additional covariates (type 2 diabetes-related characteristics, cardiovascular risk factors, Mini-mental State Examination, and extent of depressive symptoms), Attention/Working Memory (p = 0.038) and Executive Function (p = 0.013) remained significant. CONCLUSIONS: Older individuals from specific ethnic/cultural backgrounds with the Hp 1-1 phenotype may benefit more from treatment targeted at decreasing or halting the detrimental effects of Hp 1-1 on the brain. Future studies should examine differential associations of Hp 1-1 and cognitive impairment, especially for groups with high prevalence of both, such as African-Americans and Hispanics.

Waist circumference is correlated with poorer cognition in elderly type 2 diabetes women.

INTRODUCTION: Waist circumference is associated with type 2 diabetes (T2D) and cognition, yet the relationship between waist circumference and cognition in individuals with T2D is not well understood. METHODS: We studied the relationship of waist circumference with five cognitive outcomes (executive functioning, language/semantic categorization, attention/working memory, episodic memory, and an overall cognition measure) in 845 cognitively normal elderly with type 2 diabetes (T2D). RESULTS: In women, waist circumference was correlated with significantly lower language and/or semantic categorization performance (P < .0001), executive functioning (P = .026), and overall cognition (P = .003) after controlling for age, education, BMI, and cardiovascular, diabetes-related, APOE ε4, and inflammatory potential confounders. Attention/working memory (P = .532) and episodic memory (P = .144) were not associated with waist circumference. These correlations were not found in men. DISCUSSION: These results suggest that central adiposity in elderly women with T2D may increase their risk for dementia.