Vitamin D deficiency is associated with higher risks for SARS-CoV-2 infection and COVID-19 severity: a retrospective case-control study.

Robust evidence of whether vitamin D deficiency is associated with COVID-19 infection and its severity is still lacking. The aim of the study was to evaluate the association between vitamin D levels and the risks of SARS-CoV-2 infection and severe disease in those infected. A retrospective study was carried out among members of Clalit Health Services (CHS), the largest healthcare organization in Israel, between March 1 and October 31, 2020. We created two matched case-control groups of individuals for which vitamin D levels and body mass index (BMI) were available before the pandemic: group (A), in which 41,757 individuals with positive SARS-CoV-2 PCR tests were matched with 417,570 control individuals without evidence of infection, and group (B), in which 2533 patients hospitalized in severe condition for COVID-19 were matched with 2533 patients who were tested positive for SARS-CoV-2, but were not hospitalized. Conditional logistic models were fitted in each of the groups to assess the association between vitamin D levels and outcome. An inverse correlation was demonstrated between the level of vitamin D and the risks of SARS-CoV-2 infection and of severe disease in those infected. Patients with very low vitamin D levels (< 30 nmol/L) had the highest risks for SARS-CoV-2 infection and also for severe COVID-19 when infected-OR 1.246 [95% CI 1.210-1.304] and 1.513 [95% CI 1.230-1.861], respectively. In this large observational population study, we show a significant association between vitamin D deficiency and the risks of SARS-CoV-2 infection and of severe disease in those infected.

Pre-diagnosis thyroid hormone dysfunction is associated with cancer mortality.

Research on the association between thyroid hormone levels and cancer mortality remains limited and inconclusive. We determined the relation of thyroid stimulating hormone (TSH), free T4 (FT4), and free T3 (FT3) levels with mortality in overall cancer and specific tumor types. Thyroid hormone levels 1-5 years prior to cancer diagnosis, as well as multiple clinical and demographic parameters, were retrospectively collected for 10,325 Israeli cancer patients, diagnosed between 2000 and 2016. Patients treated with thyroid altering medications were excluded. Cancer diagnosis was determined via the Israel National Cancer Registry. Multivariate-adjusted Cox proportional hazards model was used to assess the hazard ratios (HRs) based on thyroid hormone function for cancer mortality. A total of 5265 patients died during the follow-up period (median of 4.4 years). TSH, FT4, and FT3 levels in the hypothyroid range were associated with increase in overall mortality (adjusted HR 1.20, 1.74, 1.87, respectively). We further analyzed the association between TSH and mortality in 14 cancer subgroups. Specifically, TSH in both the hyperthyroid and hypothyroid range was associated with melanoma mortality (adjusted HR 2.20, 4.47, respectively). In conclusion, pre-diagnosis of thyroid dysfunction is associated with increased cancer mortality, a relation likely driven by specific cancer types. These findings suggest that thyroid hormones may potentially serve as prognostic markers in cancer.

Opposing effects of thyroid hormones on cancer risk: a population-based study.

OBJECTIVE: The association between dysregulated thyroid hormone function and cancer risk is inconclusive, especially among different age groups and uncommon malignancies. We sought to determine the relation of TSH and free T4 levels with overall cancer risk as well as risk of specific cancer types. DESIGN AND METHODS: Data on thyroid hormone profile was collected from 375 635 Israeli patients with no prior history of cancer. Cancer cases were identified via the Israel National Cancer Registry. Cox proportional hazards model was used to assess hazard ratios for overall cancer as well as 20 cancer subgroups. RESULTS: In this study, 23 808 cases of cancer were detected over median follow up of 10.9 years. Among patients younger than 50 at inclusion, TSH in the hyperthyroid range, elevated free T4 and subclinical hyperthyroidism were associated with increased cancer risk (HR: 1.3, 1.28 and 1.31, respectively). In contrast, patients 50 or older with clinical hyperthyroidism were at lower cancer risk (HR: 0.64). Elevated TSH was associated with decreased risk of prostate cancer (HR: 0.67). Log-TSH elevation was associated with decreased risk of thyroid cancer (HR: 0.82) and increased risk of melanoma (HR: 1.11) and uterine cancer (HR: 1.27). Elevated free T4 was associated with increased lung cancer risk (HR: 1.54), while free T4 levels above the normal range and clinical hyperthyroidism were related to lower colorectal cancer risk (HR: 0.59 and 0.08, respectively). CONCLUSIONS: Thyroid hormones display opposing effects on cancer risk, based on patient age and cancer type.

Guideline deviation and its association with specific chronic diseases among patients with multimorbidity: a cross-sectional cohort study in a care management setting.

OBJECTIVES: To assess whether the extent of deviation from chronic disease guideline recommendations is more prominent for specific diseases compared with combined-care across multiple conditions among multimorbid patients, and to examine reasons for this deviation. DESIGN: A cross-sectional cohort. SETTING: Multimorbidity care management programme across 11 primary care clinics. PATIENTS: Patients aged 45-95 years with at least two common chronic conditions, sampled according to being new (≤6 months) or veteran (≥1 year) to the programme. MAIN OUTCOME MEASURES: Deviation from guideline-recommended care was measured for each patient's relevant conditions, aggregated and stratified across disease groups, calculated as measures of 'disease-specific' guideline deviation and 'combined-care' (all conditions) guideline deviation for: atrial fibrillation, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disorder, depression, diabetes, dyslipidaemia, hypertension and ischaemic heart disease. Combined-care deviation was evaluated for its association with specific diseases. Frequencies of previously derived reason types for deviation (biomedical, patient personal and contextual) were reported by nurse care managers, assessed across diseases and evaluated for their association with specific diseases. RESULTS: Among 204 patients, disease-specific deviation varied more (from 14.7% to 48.2%) across diseases than combined-care deviation (from 14.7% to 25.6%). Depression and diabetes were significantly associated with more deviation (mean: 6% (95% CI: 2% to 10%) and 5% (95% CI: 2% to 9%), respectively). For some conditions, assessments were among small patient samples. Guideline deviation was often attributed to non-disease-specific reasons, such as physical limitations or care burden, as much as disease-specific reasons, which was reflected in the likelihood for guideline deviation to be due to different types of reasons for some diseases. CONCLUSIONS: When multimorbid patients are considered in disease groups rather than as 'whole persons', as in many quality of care studies, the cross-cutting factors in their care delivery can be missed. The types of reasons more likely to occur for specific diseases may inform improvement strategies. TRIAL REGISTRATION NUMBER: NCT01811173; Pre-results.

Assessing guideline-concordant care for patients with multimorbidity treated in a care management setting.

BACKGROUND: Disease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated across multiple guidelines. OBJECTIVE: Measure guideline-concordant care for patients with multimorbidity; assess in what types of care and by whom (clinician or patient) deviation from guidelines occurs and evaluate whether patient characteristics are associated with concordance. METHODS: A retrospective cohort study of care received over 1 year, conducted across 11 primary care clinics within the context of multimorbidity-focused care management program. Patients were aged 45+ years with more than two common chronic conditions and were sampled based on either being new (≤6 months) or veteran to the program (≥1 year). MEASURES: Three guideline concordance measures were calculated for each patient out of 44 potential guideline-recommended care processes for nine chronic conditions: overall score; referral score (proportion of guideline-recommended care referred) and patient-only score (proportion of referred care completed by patients). Guideline concordance was stratified by care type. RESULTS: 4386 care processes evaluated among 204 patients, mean age = 72.3 years (standard deviation = 9.7). Overall, 79.2% of care was guideline concordant, 87.6% was referred according to guidelines and patients followed 91.4% of referred care. Guideline-concordant care varied across care types. Age, morbidity burden and whether patients were new or veteran to the program were associated with guideline concordance. CONCLUSIONS: Patients with multimorbidity do not receive ~20% of guideline recommendations, mostly due to clinicians not referring care. Determining the types of care for which the greatest deviation from guidelines exists can inform the tailoring of care for multimorbidity patients.

Gestational diabetes risk in a multi-ethnic population.

AIMS: To compare gestational diabetes mellitus (GDM) risk among two ethnic minority groups, with high type-2 diabetes (T2DM) prevalence, as compared to the Jewish population majority group. METHODS: A historical cohort study was conducted using clinical data collected between January 1, 2007, and December 31, 2011. The study sample included 20-45-year-old women; 2938 Ethiopian, 5849 Arab and 5156 non-Ethiopian Jewish women. GDM was defined according to the two-step strategy: step 1: glucose ≥ 140 mg/dl and step 2: using Coustan and Carpenter's diagnostic criteria. GDM risk was tested in a multivariable model, adjusted for age, parity and pre-gestational values of the metabolic syndrome components. RESULTS: Mean body mass index (BMI) values and morbid obesity rates were lowest among Ethiopian women and highest among Arab women. The prevalence of pre-gestational diabetes was significantly higher among Ethiopian (2.7%) and Arab (4.1%) women than among non-Ethiopian Jewish women (1.6%), and GDM screening rates were relatively high (85.5%, 87.2% and 83%, respectively). The proportion of pregnancies complicated with GDM was higher among Ethiopian women (4.3%) but not significantly different between Arab (2.9%) and non-Ethiopian Jewish (2.2%) women. In multivariable analysis, GDM was associated with Ethiopian ancestry (OR, 2.55; 95% CI, 1.60-4.08), adjusted for age, BMI, plasma triglyceride level and parity. Arab ethnicity was not significantly associated with GDM risk in multivariable analysis. CONCLUSIONS: Both Ethiopian and Arab minority ethnicities have a higher risk of T2DM in comparison with other Israeli women, but only Ethiopian origin is an independent risk factor for GDM while Arab ethnicity is not.

Incident gout and chronic Kidney Disease: healthcare utilization and survival.

BACKGROUND: Uncontrolled gout can cause significant joint and organ damage and has been associated with impairments in quality of life and high economic cost. Gout has also been associated with other comorbid diseases, such as chronic kidney disease. The current study explored if healthcare resource utilization (HRU) and survival differs between patients with incident gout in the presence or absence of chronic kidney disease (CKD). METHODS: Clalit Health Services (CHS) data were used to conduct a retrospective population-based cohort study of incident gout between 1/1/2006-31/12/2009. Incident cases of gout were identified and stratified by CKD status and by age group (< 55 and 55+ years). CKD status was defined as a pre-existing diagnosis of chronic kidney disease, chronic renal failure, kidney transplantation, or dialysis at index date. Demographic and clinical characteristics, as well as healthcare resource use, were reported. RESULTS: A total of 12,940 incident adult gout patients, with (n = 8286) and without (n = 4654) CKD, were followed for 55,206 person-years. Higher rates of HRU were observed for gout patients with CKD than without. Total annual hospital admissions for patients with gout and CKD were at least 3 times higher for adults < 55 (mean = 0.51 vs 0.13) and approximately 1.5 times higher for adults 55+ (mean = 0.46 vs 0.29) without CKD. Healthcare utilization rates from year 1 to year 5 remained similar for gout patients < 55 years irrespective of CKD status, however varied according to healthcare utilization by CKD status for gout patients 55+ years. The 5-year all-cause mortality was higher among those with CKD compared to those without CKD for both age groups (HR< 55 years = 1.65; 95% CI 1.01-2.71; HR55+ years = 1.50; 95% CI 1.37-1.65). CONCLUSIONS: The current study suggests important differences exist in patient characteristics and outcomes among patients with gout and CKD. Healthcare utilization differed between sub-populations, age and comorbidities, over the study period and the 5-year mortality risk was higher for gout patients with CKD, regardless of age. Future work should explore factors associated with these outcomes and barriers to gout control in order to enhance patient management among this high-risk subgroup.

Adult Arabs have higher risk for diabetes mellitus than Jews in Israel.

OBJECTIVE: Diabetes mellitus is an emerging epidemic in the Arab world. Although high diabetes prevalence is documented in Israeli Arabs, information from cohort studies is scant. METHODS: This is a population study, based on information derived between 2007-2011, from the electronic database of the largest health fund in Israel, among Arabs and Jews. Prevalence, 4-year-incidence and diabetes hazard ratios [HRs], adjusted for sex and the metabolic-syndrome [MetS]-components, were determined in 3 age groups (<50 years, 50-59 years, and ≥60 years). RESULTS: The study cohort included 17,044 Arabs (males: 49%, age: 39.4±17.3) and 16,012 Jews (males: 50%, age: 40.5 ±17.6). The overall age and sex-adjusted diabetes prevalence rates were much higher among Arabs 18.4% (95%CI: 17.6-19.1); and 10.3% (95%CI: 9.7-10.9) among Jews. Arab females had higher prevalence rates 20.0% (95%CI: 19-21) than Arab males 16.7% (95%CI: 15.7-17.8). Annual incidence rates were also significantly higher among Arabs 2.9% (95%CI: 2.7-3.1) than among Jews 1.7% (95%CI: 1.6-1.8). This held true across all age and sex subgroups. Adjustment for body mass index [BMI] attenuated HR estimates associated with Arab ethnicity across all age subgroups, mainly in the <50yrs age group from HR 2.04 (95%CI: 1.74-2.40) to 1.64 (95%CI: 1.40-1.92). BMI at incident diabetes among females was higher in Arabs than Jews. Males, however, did not differ by ethnicity. CONCLUSION: Arabs, mainly female, have high incidence and prevalence of diabetes. This excess risk is only partially explained by the high prevalence of obesity. Effective culturally-congruent diabetes prevention and treatment and an effective engagement partnership with the Arab community are of paramount need.

Diabetes among Ethiopian Immigrants to Israel: Exploring the Effects of Migration and Ethnicity on Diabetes Risk.

OBJECTIVE: Diabetes prevalence among ethnic minorities and immigrants often differs from the majority indigenous population. We compared diabetes prevalence, incidence and risk among Ethiopian and non-Ethiopian Jews. Within these main groups, we controlled for the effect of migration on diabetes risk by comparing the subgroups of Ethiopian and former Soviet Union (FSU) immigrants, and compared both with Israeli-born non-Ethiopian Jews. METHODS: The study cohort included adult Ethiopian (n = 8,398) and age-matched non-Ethiopian Jews (n = 15,977) and subgroups: Ethiopian immigrants (n = 7,994), FSU immigrants (n = 1,541) and Israeli-born non-Ethiopian Jews (n = 10,828). Diabetes prevalence, annual incidence, and hazard ratios (HRs) adjusted for sex and metabolic syndrome (MetS)-components, were determined in three age groups (<50yrs, 50-59yrs, and ≥60yrs). Comparisons of body mass index (BMI) at diabetes incidence were made. RESULTS: Younger (<50yrs) Ethiopians had higher prevalence rates, 3.6% (95%CI: 3.1-4.1) and annual incidence, 0.9% (95%CI: 0.8-1.0) than non-Ethiopians, 2.7% (95%CI: 2.3-3.0) and 0.5% (95%CI: 0.4-0.6), respectively. These differences were particularly pronounced among Ethiopian women. Diabetes risk among Ethiopians was higher and adjustment for MetS-components was important only for BMI, which further increased hazard ratio (HR) estimates associated with Ethiopian ethnicity from 1.81 (95% CI:1.50-2.17) to 2.31 (95% CI:1.91-2.79). The same differences were seen when comparing Ethiopian to FSU immigrants. BMI before incident diabetes was lower among younger Ethiopian immigrants than younger FSU immigrants and Israeli-born. CONCLUSIONS: Ethiopian ethnicity is associated with increased diabetes risk, which is age and BMI dependent. Young Ethiopians<50yrs, particularly women, had the greatest increase in risk. Lower BMI cut-offs should be defined to reflect diabetes risk among Ethiopians.

Cognitive Dysfunction: Part and Parcel of the Diabetic Foot.

OBJECTIVE: The presence of a foot ulcer increases the self-treatment burden imposed on the individual with diabetes. Additionally, this condition increases the cognitive demands needed for adherence to medical recommendations. A potential gap could exist between medical recommendations and the individual's ability to implement them. Hence, the goal of this study was to examine whether the cognitive profile of people with diabetic foot ulcers differs from that of people with diabetes without this complication. RESEARCH DESIGN AND METHODS: This was a case-control study. Ninety-nine individuals with diabetic foot ulcers (case patients) and 95 individuals with type 2 diabetes (control subjects) (age range 45-75 years), who were matched for diabetes duration and sex, underwent extensive neuropsychological evaluation using a NeuroTrax computerized battery, digit symbol, and verbal fluency tests. A global cognitive score after standardization for age and education was computed as well as scores in the following six cognitive domains: memory, executive function, reaction time, attention, psychomotor abilities, and estimated premorbid cognition. RESULTS: Individuals with diabetic foot ulcers had significantly (P < 0.001) lower cognitive scores than individuals with diabetes without this complication, in all tested cognitive domains, excluding estimated premorbid cognition. Individuals with diabetic foot ulcers demonstrated a significant difference between precognitive and current cognitive abilities, as opposed to the nonsignificant difference among control subjects. The differences persisted in multivariable analysis after adjusting for depression and smoking. CONCLUSIONS: Individuals with diabetic foot ulcers were found to possess fewer cognitive resources than individuals with diabetes without this complication. Thus, they appear to face more self-treatment challenges, while possessing significantly fewer cognitive resources.

[COMMON TREATMENT FOR ACUTE TONSILLITIS IN THE COMMUNITY].

BACKGROUND: Streptococcal tonsillitis among adults is a common diagnosis. There is wide agreement regarding the recommended treatment, which is Phenoxymethyl Penicillin (Penicillin V) 1000 mg daily (usually 500 mg BID for 10 days). OBJECTIVES: Description of the variability of routine antibiotic treatment prescribed by family physicians in the community for the treatment of acute tonsillitis (which represents a common diagnosis in primary care), and observation of the prescribed antibiotics adherence to the guidelines. METHODS: Nine primary care physicians in urban clinics of Clalit Health Services, were included in the study. Information regarding 320 adult patients, 18 years of age or older, treated by them, was collected. Patients allergic to penicillin were not included. Comparison between the different medications was performed with relevant statistical tests. RESULTS: Data regarding 95 men (30% of patients) and 224 women (70% of patients) was collected; the age range was 24 - 86 years old (average 38 years). Streptococcus group A was sensitive to all antibiotics prescribed; 70% (n=224) were prescribed with Penicillin V and the rest were given prescriptions for other antibiotics. From those who were given Penicillin V, 54% (n=121) were prescribed the recommended dosage (500 mg BID); 34% (n=77) were prescribed double dosage (1000 mg BID), whereas the rest of the patients received prescriptions for other dosages. Difference in treatment regimens was observed among the participating physicians regarding the choice and the dosage of the antibiotics they prescribed. In the medical files, there were no explanations regarding the different antibiotics or dosages. CONCLUSIONS: Streptococcus A tonsillitis is a common diagnosis with wide consensus regarding the recommended antibiotic treatment. In spite of this consensus, there is significant prescribing variability among different physicians. This is emphasized by the fact that all the physicians who were included in the study work in urban clinics with similar characteristics. In view of the variation among primary care physicians regarding antibiotic prescription for a very common diagnosis, we see a need to investigate other treatment protocols for other common diagnoses. This is in order to ensure proper care and avoiding health complications while saving funds.

Help-seeking preferences in the area of mild cognitive impairment: comparing family physicians and the lay public.

BACKGROUND: Mild cognitive impairment (MCI) or mild neurocognitive disorder is a well-established clinical entity included in current diagnostic guidelines for Alzheimer's disease and in major psychiatric classifications. In all, a loosely defined concern obtained from conceptually different sources (the individual, a knowledgeable informant, or a clinician) regarding a decline in cognition and change in functioning constitutes a sine qua non for initiating diagnostics and providing therapy and support. This concern in practice may translate into complex proactive help-seeking behavior. A better understanding of help-seeking preferences is required in order to promote early detection and management. OBJECTIVES: To compare help-seeking preferences of family physicians and the lay public in the area of MCI. METHODS: A structured questionnaire was used to collect data from 197 family physicians (self-administered) and 517 persons aged 45 and over from the lay public (face to face). Information regarding familiarity with MCI and help-seeking preferences was assessed. RESULTS: The vast majority in both samples reported that family physician, spouse, and children are the most highly recommended sources of help-seeking. In regard to professional sources of help-seeking, a higher percentage of the physicians than the lay public sample consistently recommended seeking help from nurses and social workers and psychiatrists, but a higher percentage of the lay public recommended turning to a neurologist for help. DISCUSSION: There were both similarities and differences between family physicians and the lay public in their preferences regarding help-seeking for a person with MCI. Most prominent is the physicians' greater tendency to recommend professional sources of help-seeking. CONCLUSION: Understanding of help-seeking preferences of both physicians and lay persons might help overcome barriers for establishing diagnosis, receiving care, and improving communication between doctors and patients.

Vitamin D levels for preventing acute coronary syndrome and mortality: evidence of a nonlinear association.

CONTEXT: Low serum calcidiol has been associated with multiple comorbidities and mortality but no "safe" range has been found for the upper concentration. OBJECTIVE: We aim to establish the upper threshold of serum calcidiol, beyond which there is an increased risk for acute coronary syndrome and/or mortality. DESIGN, SETTING, AND PARTICIPANTS: We extracted data for 1,282,822 Clalit Health Services members aged >45 between July 2007 and December 2011. Records of mortality or acute coronary syndrome were extracted during the follow-up period. Kaplan-Meier analysis calculated time to episode and Cox regression models generated adjusted hazard ratios for episode by calcidiol group (<10, 10.1-20, 20.1-36, and >36.1 ng/mL). OUTCOME MEASURES: Acute coronary syndrome subsuming all-cause mortality. RESULTS: During the 54-month study period, 422,822 Clalit Health Services members were tested for calcidiol, of which 12,280 died of any cause (905 with acute coronary syndrome) and 3933 were diagnosed with acute coronary syndrome. Compared to those with 20-36 ng/mL, the adjusted hazard ratios among those with levels of <10, 10-20, and >36 ng/mL were 1.88 (confidence interval [CI]: 1.80-1.96), 1.25 (CI: 1.21-1.30), and 1.13 (CI: 1.04-1.22) (P < .05), respectively. LIMITATIONS: The study cohort comprised only 30% of the population, those tested for vitamin D. The small sample size of those with calcidiol >36 ng/mL prevented further analysis of this group. CONCLUSIONS: Vitamin D in the 20-36 ng/mL range was associated with the lowest risk for mortality and morbidity. The hazard ratio below and above this range increases significantly.

Streptococcal pharyngitis: a prospective study of compliance and complications.

Background. Uncertainty exists concerning the necessity of 10-day antibiotic treatment of group A beta hemolytic streptococcus (GABHS) pharyngitis. Objective. To assess the incidence of GABHS recurrence and suppurative and nonsuppurative complications in relation to compliance. Methods. (Design). Prospective cohort observational study. (Subjects). 2,000 children aged 6 months to 18 years with sore throat and positive GABHS culture. (Main Outcome Measures). Recurrence of symptomatic culture positive GABHS pharyngitis, incidence of suppurative, and long-term, regional, nonsuppurative complications of GABHS pharyngitis, over a ten year period. Results. 213 (11%) of the children received no treatment. Most children received antibiotics for only 4-6 days (in correlation with the duration of fever, which in most cases lasted up to 3 days). Three hundred and six (15.3%) children had clinically diagnosed recurrent tonsillopharyngitis; 236 (12.3%) had positive GABHS findings within 10 to 14 days and thirty-four (1.7%) within 21-30 days after the index positive GABHS culture. The remaining 1.3% had no positive culture despite the clinical findings. Almost all recurrences [236 (11.6%)] occurred within 14 days and 156 (7.6%) in the fully treated group. The presence of fever during the first 3 days of the disease was the most significant predictor for recurrence. Other predictors were the age younger than 6 years and the presence of cervical lymphadenitis. No increase in the incidence of nonsuppurative or suppurative complications was noted during the 10-year follow-up period, compared to the past incidence of those complications in Israel. Conclusions. Our data suggests that the majority of children discontinue antibiotics for GABHS tonsillopharyngitis a day or two after the fever subsides. The incidence of complications in our study was not affected by this poor compliance.

The effect of the Internet on the patient-doctor relationship from the patient's perspective: a survey from primary care.

BACKGROUND: Internet use by patients as a source of information on health and disease is expanding rapidly with obvious effects on the doctor-patient relationship. Many of these effects remain undocumented or are poorly understood. OBJECTIVES: To assess the use of the internet for health information by patients in primary care in Israel and their perception of the effects of internet use on their relationship with their doctor. METHODS: A cross-sectional survey was conducted among a convenience sample of patients visiting 10 primary care clinics in central Israel using a questionnaire developed for this survey. The survey examined attitudes to using the internet for health-related information and attitudes to sharing this information with doctors. Associations between demographic variables, internet use and patient satisfaction with the doctor's response were tested using the chi-square statistic and t-tests. RESULTS: Completed questionnaires were received from 138 patients; the response rate was 69%. Patients in the study sample had a high rate of internet access (87%), with many using the internet as a source of health information (41%) although most patients using the internet never share this information with their doctor (81%). Among those who share information with the doctor, most felt that this has a positive effect on the relationship (870/%). Few patients reported being referred to websites by the doctor (28%). CONCLUSIONS: Internet use is prevalent in this population, though physicians may be unaware of this. Future study could examine the effects of doctors who ask patients actively about their internet use and inform them of relevant health information sources online.

The e-patient: a survey of israeli primary care physicians' responses to patients' use of online information during the consultation.

BACKGROUND: The Internet has transformed the patient-physician relationship by empowering patients with information. Because physicians are no longer the primary gatekeepers of medical information, shared decision making is now emerging as the hallmark of the patient-physician relationship. OBJECTIVES: To assess the reactions of primary care physicians to encounters in which patients present information obtained from the Internet (e-patients) and to examine the influence of the physicians' personal and demographic characteristics on their degree of satisfaction with e-patients. METHODS: A questionnaire was developed to assess physicians' attitudes to e-patients, their knowledge and utilization of the Internet, and their personal and professional characteristics. Family physicians in central Israel were interviewed by telephone and in person at a continuing medical education course. RESULTS: Of the 100 physicians contacted by phone, 93 responded to the telephone interviews and 50 physicians responded to the questionnaire in person. There was an 85% response rate. The mean age of respondents was 49 years. Most physicians were born in Israel, with a mean seniority of 22 years. Most had graduated in Eastern Europe, were not board certified and were employees of one of the four health management organizations in Israel. Most physicians responded positively when data from the Internet were presented to them by patients (81%). A number of respondents expressed discomfort in such situations (23%). No association was found between physicians' satisfaction in relationships with patients and comfort with data from the Internet presented by patients. CONCLUSIONS: Physicians in this sample responded favorably to patients bringing information obtained online to the consultation. Though it may be difficult to generalize findings from a convenience sample, Israeli family physicians appear to have accepted internet use by patients.

Discriminatory behavior of family physicians toward a person with Alzheimer's disease.

BACKGROUND: It has been anecdotally suggested that health care professionals have stigmatic beliefs about persons with Alzheimer's disease (AD). However, the nature and prevalence of those beliefs have yet to be elucidated. The aim of the present study is to examine stigma towards a person with AD among primary care physicians. METHODS: A nationally representative sample of 501 family physicians (54.1% female, mean age = 49, mean years in the profession = 21) were interviewed using a computer-assisted telephone interview and a structured questionnaire based on an expanded version of attribution theory. RESULTS: The findings showed that physicians' discriminatory behavior was especially high in the dimension of avoidance and coercion, but low in the dimension of segregation. Two central emotions (anger-fear and pity) were found to affect participants' tendency to discriminate, as were attributions of dangerousness. CONCLUSIONS: Addressing these factors may require targeted education of health professionals as well as the enforcement of anti-discrimination policies.

Are people who use "natural drugs" aware of their potentially harmful side effects and reporting to family physician?

We studied the extent of patients' utilization of complementary medicine (CM), and their knowledge and attitude regarding it in 740 patients visiting 25 randomly family medicine practices. One-third reported using some kind of CM, usually a natural drug (67.6%), often together with conventional drugs. Among the users of natural drugs, 56.2% believed they caused no side effects, 44.7% never reported natural drug usage to their physician, and 11% did so only rarely. There was a significant correlation (P = 0.03) between the belief that natural drugs can cause adverse effects and the tendency to report their usage to the family physician. Compared to nonusers, the typical user of any kind of CM was older (with a 1.05-fold increase for every year of age), defined his/her health status as bad (8.6-fold higher incidence), visited the family doctor more often, and was of Eastern European origin. In conclusion, although the use of natural drugs is extensive, patients' knowledge of their potential adverse effects is poor. A public educational campaign, with inclusion of the need to report such usage to the family physician, should be implemented, and questions on the use of complementary medicine/natural drugs should be incorporated as an integral part of the history taking by primary care physicians.