Publications by authors named "Michal Shani"

44 Publications

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

J Gen Intern Med 2021 May 6. Epub 2021 May 6.

Department of Quality Measurements and Research, Clalit Health Services, Tel Aviv, Israel.

Introduction: Good medication adherence is associated with decreased healthcare expenditure; however, adherence is usually assessed for single medication. We aim to explore the associations of adherence levels to 23 chronic medications with emergency room (ER) visits and hospitalizations. The primary endpoints are ER visits and hospitalizations in internal medicine and surgical wards.

Methods: Individuals aged 50-74 years, with a diagnosis of diabetes mellitus or hypertension, treated with at least one antihypertensive or antidiabetic medication during 2017 were included. We determined personal adherence rates by calculating the mean adherence rates of the medications prescribed to each individual. Adherence rates were stratified into categories. We retrieved information about all the ER visits, and hospitalizations in internal medicine and surgical wards during 2016-2018.

Results: Of 268,792 persons included in the study, 50.6% were men. The mean age was 63.7 years. Hypertension was recorded for 217,953 (81.1%), diabetes for 160,082 (59.5%), and both diabetes and hypertension for 109,225 (40.6%). The mean number of antihypertensive and antidiabetic medications used was 2.2 ± 1.1. In total, 51,301 (19.1%) of the cohort visited the ER at least once during 2017, 21,740 (8.1%) were hospitalized in internal medicine wards, and 10,167 (3.8%) in surgical wards during 2017. Comparing the highest adherence category to the lowest, adjusted odds ratios were 0.64 (0.61, 0.67) for ER visits, 0.56 (0.52, 0.60) for hospitalization in internal wards, and 0.63 (0.57, 0.70) for hospitalization in surgical wards. Odds ratios were similar for the three consecutive years 2016-2018.

Conclusion: Better medication adherence was associated with fewer ER visits and hospitalizations among persons with diabetes and hypertension. Investing in improving medication adherence may reduce health costs and improve patients' health.
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http://dx.doi.org/10.1007/s11606-021-06864-9DOI Listing
May 2021

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

Injury 2021 Apr 14;52(4):905-909. Epub 2020 Oct 14.

National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel-Hashomer 52621, Israel; Emergency and Disaster Management Department, Faculty of Medicine, School of Public Health, Tel-Aviv University, Israel.

Objective: To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients.

Background: Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival.

Methods: A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015-2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age.

Results: Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment.

Conclusions: Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account.
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http://dx.doi.org/10.1016/j.injury.2020.10.060DOI Listing
April 2021

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

J Thromb Thrombolysis 2021 May;51(4):1132-1137

Department of Family Medicine Central District, Clalit Health Service, Rehovot, Israel.

To investigate if patients treated with oral anticoagulants (OAC) have delayed surgical intervention (more than 48 h) compared to patients without OAC therapy, and if there is an impact to surgery timing on hospitalization length and mortality. A retrospective cohort study of all patients aged over 65 registered with a new diagnosis of hip fracture who underwent surgery in one of the general hospitals run by Clalit, Israel between 01/01/2014 and 31/12/2017. Data was retrieved for patient demographics, OAC treatment, and Charlson comorbidity index. 5828 patients were operated for hip fractures, mean age was 82.8 years (65-108), 4013 (68.8%) were female. 415 were treated with direct oral anticoagulants (DOACs) (7.1%) and 311 with warfarin (5.3%) prior to their hospitalization. Patients taking OAC were less likely to be operated within 48 h from arrival to the hospital compared to patients not receiving OAC. The 30 day mortality was 4.2% among patients not receiving OAC, 6.0% among patients taking DOACs and 10.0% among patients receiving warfarin (p < 0.001). Adjusted odds ratio for mortality at 30 day among patients taking DOACs was similar to patients who didn't take OAC. (OR 1.0, CI 0.7, 1.6). The 30 day mortality rate of patients who were receiving OAC (either DOACs or warfarin) was not significantly different whether patients were operated within 48 h or not. Mortality rate was highest among patients taking warfarin. For patients who received DOACs, operation within 48 h wasn't associated with lower mortality rate. In these patients it seemed reasonable to adjust surgery time according to patients' characteristics and needs.
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http://dx.doi.org/10.1007/s11239-020-02261-xDOI Listing
May 2021

Survival Benefit in Patients with Heart Failure Treated in Specialized Heart Failure Center within the Community.

Isr Med Assoc J 2020 Jan;22(1):8-12

Heart Failure Center, Heart Institute, Hadassah University Hospital, Jerusalem, Israel.

Background: Heart failure centers with specialized nurse-supervised management programs have been proposed to improve prognosis. The Heart Failure Center in Beit Shemesh, Israel, is located within a large primary care facility. The specialist team supervised the managememt of patients both within the frame of the center and while they were hospitalized.

Objectives: To evaluate the health services utilization by heart failure patients treated at a heart failure center and their clinical outcome.

Methods: In this retrospective study, we compared the clinical outcome of patients treated at a heart failure center to patients who received the standard care in 2013-2014. The clinical outcome included primary care visits, emergency room visits, hospitalizations, and death.

Results: The study comprised 430 heart failure patients; 82 were treated at the heart failure center and 348 under standard care. At baseline, no significant differences were seen in clinical parameters between the groups. Healthcare utilization was higher among the study group. No significant changes in healthcare utilization were found. During follow-up, patients treated in a heart failure center were more likely to get recommended heart failure medications. Mortality was significantly lower in patients treated in the heart failure center compared with those receiving standard care 3.6% vs. 24%, respectively (P = 0.001), hazard ratio 0.19, 95% confidence interval 0.06-0.62, P = 0.005.

Conclusions: Joint management of heart failure by primary clinics and a specialized community heart failure center reduced mortality. There was no decrease in healthcare utilizations among heart failure center patients, despite the reduction in mortality.
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January 2020

Letting Go.

Authors:
Michal Shani

Fam Med 2020 01;52(1):70-71

Department of Family Medicine, Central District, Clalit Health Services, Israel.

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http://dx.doi.org/10.22454/FamMed.2020.272999DOI Listing
January 2020

Adherence to oral antihypertensive medications, are all medications equal?

J Clin Hypertens (Greenwich) 2019 02 7;21(2):243-248. Epub 2019 Feb 7.

Department of Family Medicine Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Good medication adherence is a key factor in chronic disease management. Poor adherence is associated with adverse outcomes and high costs. We aimed to explore adherence rates among oral antihypertensive medications. The study included members of the Central District of Clalit Health Services in Israel aged between 40 and 75 years, who were diagnosed with hypertension before 2012 and who filled at least one prescription per year during 2012-2014, for the following medications: hydrochlorothiazide, nifedipine, amlodipine, lercanidipine hydrochloride, atenolol, bisoprolol, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor antagonists (ARBs), and statins. Purchase of at least nine monthly prescriptions during 2013 was considered as "good medication adherence." We compared systolic blood pressure and LDL levels, according to medication adherence, for each medication and cross-adherence rates between medications. The study included 31 530 subjects. The rates of good medication adherence varied widely among the medications investigated, ranging from 53% for statins and hydrochlorothiazide to 71% for amlodipine. Mean systolic BP and LDL levels were statistically significantly lower among persons with good, compared to lower adherence, for each of the medications investigated. Both advanced age and more chronic medications were associated with higher adherence rates for all medications tested. Poor adherence to any single medication was found to be associated with lower adherence to other medications. Different antihypertensive medications have different adherence rates. Since adherence to one medication is related to adherence to other medications, investing in medication adherence may be highly beneficial.
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http://dx.doi.org/10.1111/jch.13475DOI Listing
February 2019

Healthcare Service Utilization by 116,816 Patients with Atopic Dermatitis in Israel.

Acta Derm Venereol 2019 Apr;99(4):370-374

Siaal Research Center for Family Medicine and Primary Care, Division of Community Health, Ben-Gurion University of the Negev, 8155211 Yavne, Israel.

Understanding of the epidemiology and healthcare service utilization related to atopic dermatitis is necessary to inform the use of new treatments. This cross-sectional study was based on a group of patients with atopic dermatitis and a matched control group comprised of age- and sex- matched enrolees without atopic dermatitis from a large medical database. Healthcare service utilization usage data were extracted and compared between groups. The study included 116,816 patients with atopic dermatitis and 116,812 controls. Atopic dermatitis was associated with an increased burden of healthcare utilization across the entire spectrum of healthcare services compared with controls. For patients severely affected by atopic dermatitis, the increased burden correlated with disease severity: a high-er frequency of emergency room visits (odd ratio (OR) 1.7; 95% confidence interval (CI) 1.6-1.9), dermatology wards hospitalizations (OR 315; 95% CI 0-7,342), and overall hospitalizations (OR 3.6; 95% CI 3.3-3.9). In conclusion, this study demonstrates an increased burden of healthcare utilization in atopic dermatitis.
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http://dx.doi.org/10.2340/00015555-3117DOI Listing
April 2019

Psoriasis and Hidradenitis Suppurativa: A Large-scale Population-based Study.

J Am Acad Dermatol 2018 Nov 28. Epub 2018 Nov 28.

Department of Quality Measurements and Research, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel; Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Background: The coexistence of psoriasis and hidradenitis suppurativa (HS) has been described, but the association between these conditions is yet to be firmly established.

Objectives: To study the association between psoriasis and HS using a large-scale real-life computerized database.

Methods: A cross-sectional study was conducted comparing the prevalence of HS among patients with psoriasis and among age-, sex- and ethnicity-matched control subjects.

Results: A total of 68,836 patients with psoriasis and 68,836 controls were included in the study. The prevalence of HS was increased in patients with psoriasis as compared to the control group (0.3% vs. 0.2%, respectively; OR, 1.8; 95% CI, 1.5-2.3; P<0.001). In a multivariate analysis adjusting for smoking, obesity, and other comorbidities, psoriasis was still associated with HS (OR, 1.8; 95% CI, 1.4-2.2; P<0.001). Patients with coexistent psoriasis and HS were significantly younger (39.0±15.7 vs. 42.6±21.2 years; P=0.015) and had a higher prevalence of obesity (35.1% vs. 25.3%; P=0.001) and smoking (58.5% vs. 37.3%; P<0.001) as compared to patients with psoriasis alone.

Limitations: Retrospective data collection.

Conclusions: A positive association was observed between HS and psoriasis. Further longitudinal observational studies are necessary to establish these findings in other study populations.
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http://dx.doi.org/10.1016/j.jaad.2018.11.036DOI Listing
November 2018

Diabetic Retinopathy -Incidence And Risk Factors In A Community Setting- A Longitudinal Study.

Scand J Prim Health Care 2018 Sep 27;36(3):237-241. Epub 2018 Jun 27.

b Department of Family Medicine, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel.

Aim: To evaluate the natural history of diabetic retinopathy (DR) in diabetic patients and to assess long term risk for other chronic diseases associated with DR.

Methods: Retrospective, community-based study. Diabetics who underwent their first fundoscopic examination during 2000-2002, and had at least one follow- up examination by the end of 2007 were included. The primary outcome was the development of DR (proliferative diabetic retinopathy (PDR), non PDR (NPDR) or macular edema. Patients were followed for another 9 years for documentation of new diagnosis of related diseases.

Results: 516 patients' (1,032 eyes) records were included and were followed first for an average of 4.15 ± 1.27 years. During follow-up, 28 (2.7%) of the total 1,032 eyes examined were diagnosed with PDR. An additional 194 (18.8%) eyes were diagnosed with new NPDR. The cumulative incidence of NPDR was 310/1,032 (30.0%). All the patients who developed PDR had prior NDPR. By the end of the 9 years extended follow up, patients with NPDR had a greater risk for developing chronic renal failure HR = 1.71 (1.14-2.56), ischemic heart disease HR = 1.57 (1.17-2.09), and had an increased mortality rate HR = 1.26 (1.02-1.57) Conclusion: DR is associated with a higher rate of diabetes complications. Patients with DR should be followed more closely. Key points During a mean follow-up of 4.5 years, the cumulative incidence of diabetic retinopathy in a community cohort was 18.8%. NDPR (non-proliferative diabetic retinopathy) is a predictor of PDR (proliferative diabetic retinopathy). In a real life setting NPDR is a marker of a poorer prognosis. Patients with NDPR should be monitored more closely.
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http://dx.doi.org/10.1080/02813432.2018.1487524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381535PMC
September 2018

Cancer Screening of Older Adults in Israel According to Life Expectancy: Cross Sectional Study.

J Am Geriatr Soc 2017 Nov 5;65(11):2539-2544. Epub 2017 Sep 5.

Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objectives: To examine over-screening of older Israelis for colon and breast cancer.

Design: Cross sectional.

Setting: Clalit Health Services (CHS), Israel's largest health maintenance organization (HMO), provides care for more than half of the country's population and operates a national age-based programs for cancer screening.

Participants: All community-dwelling members aged 65 to 79 in 2014 (N = 370,876).

Measurements: We used CHS data warehouse to evaluate cancer screening during 2014. Life expectancy (LE) was estimated using the validated Schonberg index.

Results: Almost one-quarter (23.1%; 15.6% of adults aged 65-74, 42.7% of adults aged 75-79) of the study population had an estimated LE of less than 10 years. Annual fecal occult blood test and biannual mammography rates among adults aged 65 to 74 with a LE of 10 years or longer were 37.1% and 70.0%, respectively. Rates dropped after age 75 (4.0%, 19.5%) and to a lesser extent with a LE of less than 10 years (31.6%, 56.4%). Prostate-specific antigen testing is not part of the national screening program, and the proportion of people tested (42.6%), did not vary similarly with age of 75 and older (43.2%) or LE of less than 10 years (38.1%).

Conclusion: The cancer screening inclusion criteria of the national referral system have a strong effect on receipt of screening; LE considerations are less influential. Some method of estimating LE could be incorporated into algorithms to improve individualized cancer screening to reduce over- and underscreening of older adults.
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http://dx.doi.org/10.1111/jgs.15035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734912PMC
November 2017

Diabetes medication persistence, different medications have different persistence rates.

Prim Care Diabetes 2017 08 15;11(4):360-364. Epub 2017 Apr 15.

Department of Family Medicine Sackler Faculty of Medicine, Tel Aviv University, Israel.

Aim: To assess the persistence of diabetic patients to oral medications.

Methods: The study included all type 2 diabetic patients over 40 years, members of one District of Clalit Health Services Israel, who were diagnosed with diabetes mellitus before 2008 and who filled at least one prescription per year during 2008-2010, for the following medications: metformin, glibenclamide, acarbose, statins, angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor antagonists (ARBs). Purchase of at least 9 monthly prescriptions during 2009 was considered "good medication persistence". We compared HbA1c and LDL levels, according to medication persistence, for each medication; and cross persistence rates between medications.

Results: 21,357 patients were included. Average age was 67.0±11.0years, 48.9% were men, and 35.8% were from low SES. Good medication persistence rates for ARBs were 78.8%, ACEI 69.0%, statins 66.6%, acarbose 67.8%, metformin 58.6%, and glibenclamide 55.3%. Good persistence to any of the medications tested was associated with a higher rate of good persistence to other medications. Patients who took more medications had better persistence rates.

Conclusions: Different oral medications used by diabetic patients have different persistence rates. Good persistence for any one medication is an indicator of good persistence to other medications. Investment in enhancing medication persistence in persons with diabetes may improve persistence to other medications, as well as improve glycemic control.
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http://dx.doi.org/10.1016/j.pcd.2017.03.006DOI Listing
August 2017

End-stage renal disease and adherence to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers among patients with diabetes.

J Clin Hypertens (Greenwich) 2017 Jun 8;19(6):627-631. Epub 2017 Feb 8.

Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have become standards of care for diabetic nephropathy. The authors assessed the association between treatment adherence to ACEIs and ARBs and the development of end-stage renal disease (ESRD). The cohort comprised the 9895 members of the Central District of Clalit Health Services aged 40 to 70 years, diagnosed with diabetes before 2002, who filled at least four ACEI or ARB monthly prescriptions during 2002-2011. Forty-six percent of patients made 10 or more purchases a year. Hazard ratios for ESRD development and death decreased as adherence increased, with no evidence of a cutoff threshold or plateau. For both outcomes, hazard ratios were significantly lower among patients who purchased at least 10 monthly prescriptions (83% adherence), after adjusting for age, sex, and a number of clinically relevant factors. While ACEIs/ARBs have become standards of care in diabetes, treatment adherence is essential to achieve full benefit.
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http://dx.doi.org/10.1111/jch.12976DOI Listing
June 2017

High Normal Uric Acid Levels Are Associated with an Increased Risk of Diabetes in Lean, Normoglycemic Healthy Women.

J Clin Endocrinol Metab 2016 10 17;101(10):3772-3778. Epub 2016 Aug 17.

Chief Physician's Office and Department of Family Medicine Central District (M.S., S.V.), Clalit Health Services, Israel; Sackler School of Medicine (M.S., S.V., M.L.), Tel Aviv University, Tel Aviv, Israel; Nephrology and Hypertension Institute (D.D., E.J.H., A.L.), Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel 52653; Department of Medicine B, The Dr Pinchas Bornstein Talpiot Medical Leadership Program (G.T.), Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Israel Defense Forces Medical Corps, Military Track of Medicine, The Hebrew University Faculty of Medicine (G.T., A.L.), Ein Kerem Campus, Jerusalem, Israel; and Department of Medicine and Medical Education (A.L.), Mt Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts 02115.

Context: The risk associated with serum uric acid (SUA) levels within the normal range is unknown, especially among lean and apparently healthy adults.

Objective: Evaluating whether high-normal SUA levels, 6.8 mg/dL and below, are associated with an increased diabetes risk, compared with low-normal SUA.

Design And Setting: This was a cohort study with 10 years of followup involving all clinics of the largest nationally distributed Health Maintenance Organization in Israel.

Participants: Participants included 469,947 examinees, 40-70 years old at baseline, who had their SUA measured during 2002. We excluded examinees who had hyperuricemia (SUA > 6.8 mg/dL), impaired fasting glucose, overweight or obesity and chronic cardiovascular or renal disorders. The final cohort was composed of 30 302 participants.

Interventions: Participants were followed up to a new diagnosis of diabetes during the study period.

Main Outcome Measures: Odds ratio of developing diabetes among participants with high-normal baseline SUA were compared with low-normal (2 ≤ uric acid < 3 and 3 ≤ uric acid < 4 in women and men, respectively).

Results: In a logistic regression model adjusted for age, body mass index, socioeconomic status, smoking, baseline estimated glomerular filtration rate, and baseline glucose, SUA levels of 4-5 mg/dL for women were associated with 61% increased risk for incident diabetes (95% confidence interval, 1.1-2.3). At the highest normal levels for women (SUA, 5-6 mg/dL) the odds ratio was 2.7 (1.8-4.0), whereas men had comparable diabetes risk at values of 6-6.8 mg/dL (hazard ratio, 1.35; 95% confidence interval, 0.9-2.1).

Conclusions: SUA levels within the normal range are associated with an increased risk for new-onset diabetes among healthy lean women when compared with those with low-normal values.
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http://dx.doi.org/10.1210/jc.2016-2107DOI Listing
October 2016

Amlodipine treatment of hypertension associates with a decreased dementia risk.

Clin Exp Hypertens 2016;38(6):545-9. Epub 2016 Jul 8.

b Clalit Health Services , Family Medicine Department , Central District , Rishon LeZion , Israel.

Hypertension has been shown to be a risk factor for development of dementia. However, medical treatment of hypertension failed to reduce consistently the risk of dementia. Experimental study pointed to the possibility of difference between different calcium channel blockers (CCB) in their neuro-protective effect. The aim of our study was to evaluate the risk of dementia during treatment of hypertension with different CCBs. This is a retrospective cohort study based on electronic database of a large public health care organization. Study period was 11 years and it included patients aged 40-75 years old, having diagnosis of hypertension without diagnosis of dementia at the starting point, treated with either single specific CCB (study group) or with other than CCBs antihypertensive medications (control group) for at least 30 months during the study period. A total of 15,664 patients that satisfied these criteria were identified: 3,884 were treated with amlodipine, 2,062 were treated with nifedipine, 609 were treated with lercanidipine, and 9,109 never received CCBs. Dementia developed in 765 (4.9%) patients. Adjusted hazard ratio (HR) for dementia in patients treated with amlodipine, nifedipine, and lercanidipine was 0.60 (p < 0.001), 0.89 (NS), and 0.90 (NS). Decreased adjusted HR of dementia with amlodipine was demonstrated in the patients aged 60 or more (HR 0.61 [0.49-0.77], p < 0.001), but not in the patients aged less than 60 years old. This study shows that amlodipine therapy may be associated with a decreased dementia risk in hypertensive individuals older than 60 years, compared to those treated without CCBs.
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http://dx.doi.org/10.3109/10641963.2016.1174249DOI Listing
December 2016

Family physicians prescribing lifestyle medicine: feasibility of a national training programme.

Postgrad Med J 2016 Jun 21;92(1088):312-7. Epub 2016 Jan 21.

Israeli Society of Lifestyle Medicine, Israeli Association of Family Physicians, Tel Aviv, Israel.

Background: The actual causes of the preponderance of non-communicable chronic diseases are related to unhealthy behaviours, such as poor nutrition, physical inactivity and tobacco use. Our goal was to evaluate the feasibility of training in lifestyle medicine (LM) for family physicians, which could be included in 'Healthy Israel 2020', a national initiative created to enhance the health of Israelis.

Methods: Twenty-six providers participated in a 1-year certificate of completion in LM. A control group included 21 providers who participated in a similar musculoskeletal training programme. Pre/post data were collected in both groups of participants' attitudes and self-efficacy to prescribe LM and personal health behaviours. Mid/post feedback was collected in the study group participants.

Results: Physicians in the LM training represented a nationwide distribution and attended >80% of the programmes' meetings. They reported positive outcomes in most areas after the intervention compared with baseline. Five variables reached statistical significance: potential to motivate patients to improve exercise behaviours (p<0.05), confidence in one's knowledge about LM (p=0.01) and counselling (p<0.01), particularly related to exercise (p=0.02) and smoking cessation (p<0.05). The control group demonstrated one significant change: potential to motivate patients to change behaviours to lose weight (p<0.05).

Conclusions: A training programme in LM appears feasible and could have a positive impact on interested family physicians' attitudes and confidence in prescribing LM. Thus, 'Healthy Israel 2020' and other programmes worldwide, which aim to improve health behaviours and decrease the impact of chronic diseases, might consider including family physicians training.
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http://dx.doi.org/10.1136/postgradmedj-2015-133586DOI Listing
June 2016

White Nights.

Authors:
Michal Shani

Ann Fam Med 2016 Jan-Feb;14(1):79-80

Department of Family Medicine, Central District, Clalit Health Service, Rehovot, Israel Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Israel

"How can you sleep at night after you ruined my life?" Arthur, a veteran patient of mine, implored after receiving his test results. This essay recounts my experience as a physician in coping with an extremely anxious patient, its influence on me, and some of my reflections on the ensuing white nights.
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http://dx.doi.org/10.1370/afm.1884DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709160PMC
October 2016

Uric acid levels within the normal range predict increased risk of hypertension: a cohort study.

J Am Soc Hypertens 2015 Aug 16;9(8):600-9. Epub 2015 May 16.

Chief Physician's Office and Department of Family Medicine, Central District Clalit Health Services, Tel Aviv, Israel.

There are data describing that cardiovascular risks related to serum uric acid (SUA) levels may begin below the current diagnostic level for hyperuricemia. Values from 5.2 to 6.0 mg/dL were positively associated with higher cardiovascular risk. The risk associated with lower SUA levels has not been fully assessed in healthy adults. The purpose of this study was to evaluate whether normal SUA levels, even below 5-6 mg/dL, might be related to an increased risk of hypertension, compared with low-normal SUA. This cohort study was conducted in an outpatient setting: all clinics of the largest Health Maintenance Organization in Israel, in a national distribution. A total of 118,920 healthy adults (40-70 years old), who had SUA levels screened during 2002, were eligible for the study. They were stratified according to baseline SUA, and were followed for 10 years. The study endpoint was any new diagnosis of hypertension during the study period (until December 31, 2011). During 10 years of follow-up (2002-2011), 28,436 examinees developed hypertension (23.9%). Compared with the pre-defined SUA reference values (2-3 mg/dL), women with SUA within the normal range had a gradual, increased risk of developing new-onset hypertension, starting at values as low as 3-4 mg/dL (adjusted odds ratio, 1.15; 95% confidence interval, 1.01-1.30). Women with SUA 5-6 mg/dL, still accepted as normouricemia, had a 66% increased risk of developing hypertension. Younger women (ages 40-50 years at baseline) in a similar SUA subgroup (5-6 mg/dL) had an even higher risk (odds ratio, 2.25; 95% confidence interval, 1.96-2.60). Similar results were seen among men. The possibility of subtle confounders exists, despite extensive adjustment. SUA within the normal range is associated with new-onset hypertension among healthy adults, compared with once very common low-normal range values. Further study is warranted to determine new cutoffs of hypo-, normo-, and hyperuricemia, which might be far lower than current scales.
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http://dx.doi.org/10.1016/j.jash.2015.05.010DOI Listing
August 2015

International primary care snapshots: Israel and China.

Br J Gen Pract 2015 May;65(634):250-1

Centre for Global Health, JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong.

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http://dx.doi.org/10.3399/bjgp15X684913DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408515PMC
May 2015

Structured nursing follow-up: does it help in diabetes care?

Isr J Health Policy Res 2014 29;3:27. Epub 2014 Aug 29.

Department of Family Medicine Central District, Clalit Health Service, Rehovot, Israel ; Department of Family Medicine Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: In 1995 Clalit Health Services introduced a structured follow-up schedule, by primary care nurses, of diabetic patients. This was supplementary care, given in addition to the family physician's follow-up care. This article aims to describe the performance of diabetes follow-up and diabetes control in patients with additional structured nursing follow-up care, compared to those patients followed only by their family physician.

Methods: We randomly selected 2,024 type 2 diabetic subjects aged 40-76 years. For each calendar year, from 2005-2007, patients who were "under physician follow-up only" were compared to those who received additional structured nursing follow-up care.

Main Outcomes: Complete diabetes follow-up parameters including: HbA1c, LDL cholesterol, microalbumin, blood pressure measurements and fundus examination.

Results: The average age of study participants was 60.7 years, 52% were females and 38% were from low socioeconomic status (SES). In 2005, 39.5% of the diabetic patients received structured nursing follow-up, and the comparable figures for 2006 and 2007 were 42.1% 49.6%, respectively. The intervention subjects tended to be older, from lower SES, suffered from more chronic diseases and visited their family physician more frequently than the control patients. Patients in the study group were more likely to perform a complete diabetes follow-up plan: 52.8% vs. 21.5% (2005; p < 0.001) 55.5% vs. 30.3% (2006; p < 0.001), 52.3% vs. 35.7% (2007; p < 0.001). LDL cholesterol levels were lower in the study group only in 2005: 103.7 vs. 110.0 p < 0.001.

Conclusion: Subjects with supplementary structured nursing follow-up care were more likely to perform complete diabetes follow-up protocol. Our results reinforce the importance of teamwork in diabetic care. Further study is required to identify strategies for channeling the use of the limited resources to the patients who stand to benefit the most.
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http://dx.doi.org/10.1186/2045-4015-3-27DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4150555PMC
September 2014

Obstructive sleep apnea and cardiovascular comorbidities: a large epidemiologic study.

Medicine (Baltimore) 2014 Aug;93(9):e45

Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petach Tikva (HG, IB, ES, GB); Sackler Faculty of Medicine (HG, IB, GB); Department of Family Medicine, Sackler School of Medicine (SV, MS), Tel Aviv University; Chief Physician Office, Clalit Health Services (SV), Tel Aviv; and Department of Family Medicine, Central District, Clalit Health Services, Rishon Le-Zion (MS), Israel.

Obstructive sleep apnea (OSA) is a common disorder, characterized by cyclic cessation of airflow for 10 seconds or more. There is growing awareness that OSA is related to the development and progression of cardiovascular disease. However, only a few studies have associated OSA directly to major cardiovascular events. The aim of this study was to evaluate the relationship between OSA and cardiovascular morbidity in a well defined population of patients.The electronic database of the central district of a major health management organization was searched for all patients diagnosed with OSA in 2002-2010. For each patient identified, an age- and sex-matched patient was randomly selected from the members of the same health management organization who did not have OSA. Data on demographics, socioeconomic status, and relevant medical parameters were collected as well.The study population included 2797 patients, average age 58.1, in which 76.6% were males. There was a significant correlation between OSA and the presence of ischemic heart disease (P < 0.001), pulmonary hypertension (P < 0.001), congestive heart failure (P < 0.001), cardiomyopathy (P = 0.003), and arrhythmia (P < 0.001). OSA was also significantly correlated with low socioeconomic status (P < 0.001).OSA and cardiovascular disease were strongly correlated. As such, early diagnosis and treatment of OSA may change the course of both diseases. We suggest that sleep disordered breathing should be routinely assessed in patients with cardiovascular problems. An ear-nose-throat evaluation may also be important to rule out anatomic disorders that cause upper airway obstruction.
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http://dx.doi.org/10.1097/MD.0000000000000045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4602425PMC
August 2014

Effect of arteriovenous hemodialysis shunt location on cardiac events in patients having coronary artery bypass graft using an internal thoracic artery.

Ther Apher Dial 2014 Oct 14;18(5):450-4. Epub 2014 Jan 14.

Nephrology Department, Internal Medicine Department, Vascular Surgery Department, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.

The possibility of developing coronary steal in patients having coronary artery bypass graft (CABG) using internal thoracic artery (ITA) and ipsilateral upper extremity arteriovenous (AV) hemodialysis shunt has been reported. The impact of this phenomenon on clinical outcomes is uncertain. The aim of this study was to investigate an association between the AV dialysis shunt location regarding the side of the ITA CABG and clinical outcomes. This retrospective cohort study included chronic hemodialysis patients having ITA CABG and upper extremity AV shunt. The patients were divided into two groups: those with ipsilateral and those with contralateral location of ITA CABG and AV shunt. The outcomes were: death from any cause, cardiac death and a first cardiac event. In a group of 112 chronic hemodialysis patients having CABG, 32 had an ipsilateral and 25 had a contralateral location of ITA CABG and an upper extremity AV shunt. Significantly more cardiac events occurred in the group with an ipsilateral compared to a contralateral location of ITA CABGs and dialysis AV shunts (hazard ratio, 2.16 [95% CI, 1.11 to 4.19], P = 0.023). There was no difference between the groups in the all cause mortality risk (hazard ratio, 1.005 [95% CI, 0.43 to 2.37], P = 0.990) or the risk of cardiac death (hazard ratio, 2.43 [95% CI, 0.64 to 9.17], P = 0.191). The ipsilateral location of a CABG with the use of ITA and upper extremity AV hemodialysis shunt may be associated with increased risk of cardiac events.
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http://dx.doi.org/10.1111/1744-9987.12158DOI Listing
October 2014

Predicting type 2 diabetes mellitus using haemoglobin A1c: a community-based historic cohort study.

Eur J Gen Pract 2014 Jun 29;20(2):100-6. Epub 2013 Nov 29.

Department of Family Medicine, Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel.

Background: The ADA 2010 guidelines added HbA1c ≥ 6.5% as a criterion for diagnosing diabetes mellitus type 2.

Objective: To evaluate the HbA1c test in predicting type 2 diabetes in a high risk population.

Methods: A community-based historic cohort study was conducted including 10 201 patients, who had not been diagnosed with diabetes, and who underwent HbA1c test during the years 2002-2005. Data was retrieved on diabetes risk factors and the onset of diabetes (according to the ADA 2003 criteria), during a follow-up period of five-to-eight years.

Results: Mean age was 58.25 ± 15.58 years; mean HbA1c level was 5.59 ± 0.55% and 76.8% had a BMI > 25 kg/m(2) (mean: 30.74 ± 8.30). In a Cox proportional hazards regression model, the risk of developing type 2 diabetes was 2.49 (95% CI: 1.29-3.71) for 5.5% ≤ HbA1c < 6% at baseline, 4.82 (95% CI: 2.83-8.20) for 6% ≤ HbA1c < 6.5% at baseline and 7.57 (95% CI: 4.43-12.93) for 6.5% ≤ HbA1c < 7% at baseline, compared to HbA1c < 4.5%. The risk of developing diabetes was 1.14 (95% CI: 1.05-1.25) for male gender, 1.16 (95% CI: 1.04-1.28) for cardiovascular diseases and 2.06 (95% CI: 1.80-2.35) for overweight (BMI > 25 kg/m(2)) at baseline. Neither age nor low socio-economic status was associated with increased risk of diabetes.

Conclusion: Levels of HbA1c ≥ 5.5% were associated with increased risk of type 2 diabetes during a five-to-eight-year follow-up period. Findings support the use of HbA1c testing as a screening tool in populations at risk of developing diabetes.
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http://dx.doi.org/10.3109/13814788.2013.826642DOI Listing
June 2014

Effect of timing of thrombectomy on survival of thrombosed arteriovenous hemodialysis grafts.

Vasc Endovascular Surg 2013 Jul 30;47(5):342-5. Epub 2013 Apr 30.

Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel.

Background: The use of an arteriovenous (AV) graft for hemodialysis is associated with a relatively high rate of thrombosis. Unfortunately, the urgent thrombectomy is not always readily available. Our aim was to investigate a possible association between the timing of thrombectomy and the patency rates of AV grafts.

Methods: A retrospective single-center study on patients who underwent thrombectomy of clotted AV grafts was conducted. According to the time of thrombectomy, all patients were divided into 4 groups.

Results: Primary graft patency at 6 months after thrombectomy was 28.3%, with no significant difference between the study groups (P = .161). Secondary graft patency at 6 months was significantly worse in the group that underwent thrombectomy between the third and fifth days than in the whole cohort: 15.4% versus 45.6% (P = .038).

Conclusions: Timing of thrombectomy of a clotted AV graft may have a significant impact on the graft survival.
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http://dx.doi.org/10.1177/1538574413487442DOI Listing
July 2013

The association between physicians' and patients' preventive health practices.

CMAJ 2013 May 8;185(8):649-53. Epub 2013 Apr 8.

School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC.

Background: Although much has been written about the potential power of the association between physicians' personal health practices and those of their patients, objective studies of this relationship are lacking. We investigated this association using objectively measured health care indicators.

Methods: We assessed 8 indicators of quality of health care (screening and vaccination practices) for primary care physicians (n = 1488) and their adult patients (n = 1,886,791) in Israel's largest health maintenance organization; the physicians were also patients in this health care system.

Results: For all 8 indicators, patients whose physicians were compliant with the preventive practices were more likely (p < 0.05) to also have undergone these preventive measures than patients with noncompliant physicians. We also found that more similar preventive practices showed somewhat stronger relations. For example, among patients whose physician had received the influenza vaccine, 49.1% of eligible patients received flu vaccines compared with 43.2% of patients whose physicians did not receive the vaccine (5.9% absolute difference, 13.7% relative difference). This is twice the relative difference (7.2%) shown for pneumococcal vaccine-eligible patients of influenza-vaccinated versus nonvaccinated physicians (60.9% v. 56.8%). When we examined the rates of unrelated practices, we found that, for example, mammography rates were identical for patients whose physicians did and did not receive the influenza vaccine.

Interpretation: We found a consistent, positive relation between physicians' and patients' preventive health practices. Objectively establishing this healthy doctor-healthy patient relation should encourage prevention-oriented health care systems to better support and evaluate the effects on patients of improving the physical health of medical students and physicians.
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http://dx.doi.org/10.1503/cmaj.121028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652935PMC
May 2013

Low clinical utility of folate determinations in primary care setting.

Am J Manag Care 2013 Mar 1;19(3):e100-5. Epub 2013 Mar 1.

Family Medicine, Tel Aviv University, P.O. 14238, Ashdod, 77042, Israel.

Background: Fortification of cereal products with folic acid is not mandatory in Israel, yet folate deficiency remains rare and is usually associated with poor diet, malabsorption, alcoholism, or use of certain drugs. A retrospective review of all folate level determinations performed between January 2004 and January 2007 in the central district of Clalit Health Services in Israel revealed that only 4.3% of the 43,176 tests ordered were below the norm (5.6 nmol/L).

Objectives: To determine parameters that identify folate-deficient patients without known risk factors and to establish principles that aid the physician in deciding when to order folate determinations.

Methods: Study population included 152 patients from 13 large primary care clinics with folate deficiency but without known risk factors for folate deficiency (37 with anemia). They were matched with 556 controls (141 with anemia).The medical records were reviewed for the indication of the test and treatment that followed the results.

Results: Hematologic indices, vitamin B12, ferritin, and transferrin saturation levels were similar in the study and control groups. Subgroup comparisons based on anemia status showed similar results. The clinical indications for folate determinations were similar in the folate-deficient patients and the control group. Only 68 of 152 patients (44.7%) were prescribed a folate supplement.

Conclusions: Neither laboratory parameters nor clinical findings in patients' charts were capable of distinguishing folate-deficient patients from controls. It seems that folate determinations in patients without known risk factors for folate deficiency are of little clinical significance.
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March 2013

Effect of timing of the first cannulation on survival of arteriovenous hemodialysis grafts.

Ther Apher Dial 2013 Feb 30;17(1):60-4. Epub 2012 Oct 30.

Nephrology Department, Assaf Harofeh Medical Center, Zerifin, Israel.

The use of an arteriovenous graft as vascular access for hemodialysis is associated with a high rate of patency loss. The influence of timing of the first cannulation of the graft on graft survival has not been sufficiently studied. The purpose of this study was to investigate an association between the timing of the first cannulation of the polytetrafluoroethylene arteriovenous graft and the incidence of 12-month failure. This is a retrospective study on a cohort of chronic hemodialysis patients treated in a single center. According to the time, in weeks, between graft construction and its first successful cannulation, the grafts were divided into six groups: 2nd, 3rd, 4th, 5th, 6th and 7th or more week after surgery. The primary outcome was primary graft failure at 12 months, defined as the first occurrence of graft thrombosis or any invasive access procedure. The secondary outcome was cumulative graft failure at 12 months, defined as complete loss of the access site for dialysis. Fifty-eight patients with 64 newly-created arteriovenous grafts were included in the study. In the whole cohort, the incidence of primary graft failure at 12 months was 72.2%, and the incidence of cumulative graft failure at 12 months was 40.7%. The incidences of primary graft failure and cumulative graft failure at 12 months did not differ significantly between the study groups. In our study, timing of the first cannulation of a new arteriovenous polytetrafluoroethylene graft had no significant impact on graft survival.
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http://dx.doi.org/10.1111/j.1744-9987.2012.01134.xDOI Listing
February 2013

The second generation and asthma: Prevalence of asthma among Israeli born children of Ethiopian origin.

Respir Med 2013 Apr 18;107(4):519-23. Epub 2013 Jan 18.

Department of Family Medicine Central District, Clalit Health Service, Israel.

Background: Immigrant populations moving from undeveloped countries with low asthma prevalence have shown increased asthma prevalence in their new Westernized environment. We compared the prevalence of asthma among Israeli born children of Ethiopian origin to that in non-Ethiopian children.

Methods: Cross sectional study. Data was retrieved for children aged 6-18 years in four clinics with a large proportion of patients of Ethiopian origin. For each Israeli born child from Ethiopian origin we matched an Israeli born child of any other origin of the same age and gender, receiving primary care from the same physician at the same clinic. Asthma was defined as any visit to a primary care physician, emergency room or hospitalization related to asthma symptoms or subsequent purchasing of any asthma medication during 2008.

Results: 1217 children of Ethiopian origin and 1217 matched controls were studied. More Ethiopian children came from families with a low socioeconomic status (23.9% vs. 17%, p < 0.001), and with significantly lower parental smoking (5.1% vs. 40.1%, p < 0.001). The prevalence of asthma was 92/1217 (7.5%) among children of Ethiopian origin, compared to 122/1217 (10.0%) among the control group (OR = 0.74, 95% CI: 0.56-0.98, p = 0.032). When adjusted for tobacco exposure, the OR for risk of asthma in the Ethiopian children was 0.80 (95% CI: 0.59-1.09, p = 0.16).

Conclusion: Asthma prevalence in the second generation of Israeli born children of Ethiopian origin does not seem to differ from other children in their community. This observation supports the theory that environmental exposures, rather than genetic factors, dictated the increase in asthma in this immigrant population.
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http://dx.doi.org/10.1016/j.rmed.2012.12.024DOI Listing
April 2013

[Family physicians attitude towards quality indicator program].

Harefuah 2012 Oct;151(10):589-91, 604

Department of Family Medicine Central District, Clalit Health Services, Israel.

Background: Quality indicator programs for primary care are implanted throughout the world improving quality in health care. In this study, we have assessed family physicians attitudes towards the quality indicators program in Israel.

Methods: Questionnaires were distributed to family physicians in various continuing educational programs. The questionnaire addressed demographics, whether the physician dealt with quality indicators, time devoted by the physician to quality indicators, pressure placed on the physician related to quality indicators, and the working environment.

Results: A total of 140 questionnaires were distributed and 91 (65%) were completed. The average physician age was 49 years (range 33-65 years]; the average working experience as a family physician was 17.8 years (range 0.5-42); 58 physicians were family medicine specialist (65.9%). Quality indicators were part of the routine work of 94% of the physicians; 72% of the physicians noted the importance of quality indicators; 84% of the physicians noted that quality indicators demand better team work; 76% of the physicians noted that quality indicators have reduced their professional independence. Pressure to deal with quality indicators was noted by 72% of the family physicians. Pressure to deal with quality indicators was related to reduced loyalty to their employer (P = 0.001), reducing their interest to practice family medicine (p < 0.001), and increasing their burnout at work (p = 0.001).

Discussion: It is important that policy makers find the way to leverage the advantages of quality indicator programs, without creating a heavy burden on the work of family physicians.
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October 2012

Effect of N-acetylcysteine on residual renal function in chronic haemodialysis patients treated with high-flux synthetic dialysis membranes: a pilot study.

ISRN Nephrol 2013 26;2013:636208. Epub 2012 Nov 26.

Family Medicine Department, Clalit Health Services and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 97904, Israel.

Background. Preservation of residual renal function in chronic dialysis patients has proven to be a major predictor of survival. The aim of the present study was to investigate an ability of the combined use of N-acetylcysteine and high-flux biocompatible haemodialysis membranes to improve residual renal function in haemodialysis patients. Patients and Methods. Chronic haemodialysis patients with a residual urine output of at least 100 mL/24 h were administered oral an N-acetylcysteine 1200 mg twice daily for 2 weeks. Treatment group included patients treated with dialysers using high-flux synthetic biocompatible membranes. Control group included patients treated with dialysers using low-flux semisyntetic triacetate haemodialysis membranes. Results. Eighteen patients participated in the study. The residual glomerular filtration rate showed a nonsignificant trend for increase in both groups. The magnitude of GFR improvement after N-acetylcysteine administration was less pronounced in the group treated with high-flux biocompatible membranes: +0.17 ± 0.56 mL/min/1.73 m(2) in treatment group and +0.65 ± 0.53 mL/min/1.73 m(2) in control group (P < 0.05). Conclusion. In this study of favorable effect of N-acetylcysteine on residual renal function in chronic haemodialysis patients may be less pronounced when using high-flux biocompatible, rather than low-flux semisyntetic, HD membranes.
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http://dx.doi.org/10.5402/2013/636208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4045415PMC
June 2014

N-acetylcysteine may improve residual renal function in hemodialysis patients: a pilot study.

Hemodial Int 2012 Oct 30;16(4):512-6. Epub 2012 Apr 30.

Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Israel.

Clinical outcomes in chronic dialysis patients are highly dependent on preservation of residual renal function (RRF). N-acetylcysteine (NAC) may have a positive effect on renal function in the setting of nephrotoxic contrast media administration. In our recent study, we showed that NAC may improve RRF in peritoneal dialysis patients. The aim of the present study was to investigate the effect of NAC on RRF in patients treated with chronic hemodialysis. Prevalent chronic hemodialysis patients with a residual urine output of at least 100 mL/24 hours were included. The patients were administered oral NAC 1200 mg twice daily for 2 weeks. Residual renal function was assessed at baseline and at the end of treatment using a midweek interdialytic urine collection for measurement of urine output and calculation of residual renal Kt/V and glomerular filtration rate (GFR). Residual GFR was measured as the mean of urea and creatinine residual renal clearance. Each patient served as his own control. Twenty patients were prospectively enrolled in the study. Administration of NAC 1200 mg twice daily for 2 weeks resulted in significant improvement in RRF: urine volume increased from 320 ± 199 to 430 ± 232 mL/24 hours (P < 0.01), residual renal Kt/V increased from 0.19 ± 0.12 to 0.29 ± 0.14 (P < 0.01), and residual GFR increased from 1.6 ± 1.6 to 2.4 ± 2.3 mL/minute/1.73 m(2) (P < 0.01). N-acetylcysteine may improve RRF in patients treated with chronic hemodialysis.
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http://dx.doi.org/10.1111/j.1542-4758.2012.00702.xDOI Listing
October 2012