Publications by authors named "Yochai Schonmann"

24 Publications

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The Burden of Coronavirus Disease 2019 and Its Complications in Patients With Atopic Dermatitis-A Nested Case-Control Study.

Dermatitis 2021 Jun 15. Epub 2021 Jun 15.

From the Lübeck Institute of Experimental Dermatology, University of Lübeck, Germany Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel Clalit Health Services, Tel Aviv Sial Research Center, Division of Community Health, Ben-Gurion University of the Negev, Be'er Sheva Department of Behavioral Sciences, Ariel University Shalvata Mental Health Center, Hod Hasharon Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel.

Background: The burden of coronavirus disease 2019 (COVID-19) among patients with atopic dermatitis (AD) is poorly understood.

Objectives: The aims of the study were to characterize a large cohort of COVID-19-positive adult patients with AD and to identify predictors of COVID-19-associated hospitalization and mortality.

Methods: A population-based nested case-control study was performed. Multivariable logistic regression was used to evaluate odds ratios and 95% confidence intervals of predictors for COVID-19-associated hospitalization and mortality.

Results: Of 78,073 adult patients with AD, 3618 (4.6%) tested positive for COVID-19. Subclinical COVID-19 infection occurred in 3368 (93.1%) of COVID-19-positive patients, whereas 123 (3.4%), 46 (1.3%), 55 (1.5%), and 26 (0.7%) patients developed a mild, moderate, severe, and critical disease, respectively. Altogether, 250 patients (6.0%) were hospitalized, and 40 patients (1.1%) died because of COVID-19 complications. Coronavirus disease 2019-associated hospitalization was independently associated with the intake of extended courses of systemic corticosteroids (adjusted odds ratio, 1.96; 95% confidence interval, 1.23-3.14; P = 0.005). None of AD-related variables independently predicted COVID-19-associated mortality. The presence of comorbid metabolic syndrome, chronic obstructive pulmonary disease, chronic renal failure, and depression projected both COVID-19-associated hospitalization and mortality.

Conclusions: Prolonged systemic corticosteroids during the pandemic are associated with increased odds of COVID-19-associated hospitalization and should be avoided in patients with AD.
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http://dx.doi.org/10.1097/DER.0000000000000772DOI Listing
June 2021

Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization and Mortality in Patients with Psoriasis: A Population-Based Study.

Am J Clin Dermatol 2021 May 31. Epub 2021 May 31.

Clalit Health Services, Tel-Aviv, Israel.

Background: The impact of immune-related conditions on the outcomes of coronavirus disease 2019 (COVID-19) is poorly understood. Determinants of COVID-19 outcomes among patients with psoriasis are yet to be established.

Objective: Th objective of this study was to characterize a large cohort of patients with psoriasis with COVID-19 and to identify predictors of COVID-19-associated hospitalization and mortality.

Methods: A population-based nested case-control study was performed using the computerized database of Clalit Health Services, Israel. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence (CIs) of predictors for COVID-19-associated hospitalization and mortality.

Results: The study population included 3151 patients with psoriasis who tested positive for COVID-19. Subclinical COVID-19 infection occurred in 2818 (89.4%) of the patients while 122 (3.9%), 71 (2.3%), 123 (3.9%), and 16 (0.5%) of the patients experienced a mild, moderate, severe, and critical disease, respectively. Overall, 332 (10.5%) patients were hospitalized and 50 (1.6%) patients died because of COVID-19 complications. Intake of methotrexate independently predicted COVID-19-associated hospitalization (adjusted OR 2.30; 95% CI 1.11-4.78; p = 0.025). Use of biologic agents was not associated with COVID-19-associated hospitalization (OR 0.75; 95% CI 0.32-1.73; p = 0.491) or mortality (OR 0.85; 95% CI 0.12-6.21; p = 0.870). Older age, the presence of comorbid cardiovascular diseases, metabolic syndrome, chronic obstructive pulmonary disease, and chronic renal failure independently predicted both COVID-19-associated hospitalization and mortality.

Conclusions: The use of oral methotrexate was associated with an increased odds of COVID-associated hospitalization, whereas the use of biologic drugs was not associated with worse outcomes of COVID-19 among patients with psoriasis.
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http://dx.doi.org/10.1007/s40257-021-00605-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166379PMC
May 2021

Tumor necrosis factor inhibitors are associated with a decreased risk of COVID-19-associated hospitalization in patients with psoriasis-A population-based cohort study.

Dermatol Ther 2021 May 25:e15003. Epub 2021 May 25.

Clalit Health Services, Tel-Aviv, Israel.

The risk of coronavirus disease 2019 (COVID-19) and its complications among patients with psoriasis treated by tumor necrosis factor inhibitors (TNFis) remains to be decisively delineated. We aimed to assess the risk of COVID-19 infection, COVID-19-associated hospitalization, and mortality among Israeli patients with psoriasis treated by TNFi relative to other systemic agents. A population-based cohort study was conducted to compare psoriasis patients treated by TNFi (n = 1943), with those treated by methotrexate (n = 1929), ustekinumab (n = 348), and acitretin (n = 1892) regarding COVID-19 outcomes. Risk of investigated outcomes was assessed using uni- and multi-variate Cox regression analyses. The incidence rate of COVID-19, COVID-19-associated hospitalization, and mortality in the TNFi group was 35.8 (95% CI, 26.1-47.9), 0.8 (95% CI, 0.0-4.2), and 0.0 per 1000 person-years, respectively. Exposure to TNFi was associated with a comparable risk of COVID-19 infection [adjusted hazard ration (HR) for TNFi vs methotrexate: 1.07 (95% CI, 0.67-1.71); TNFi vs ustekinumab: 1.07 (95% CI, 0.48-2.40); TNFi vs acitretin: 0.98 (95% CI, 0.61-1.57)]. TNFi was associated with a decreased risk of COVID-19-associated hospitalization relative to methotrexate (adjusted HR, 0.10; 95% CI, 0.01-0.82) and ustekinumab (adjusted HR, 0.04; 95% CI, 0.00-0.64), but not to acitretin (adjusted HR, 1.00; 95% CI, 0.16-6.16). No significant difference in COVID-19-associated mortality was found between the four different groups. TNFi was associated with a decreased risk of admissions due to COVID-19. Our findings substantiate the continuation of TNFi treatment during the pandemic. TNFi may be positively considered in patients with moderate-to-severe psoriasis warranting systemic treatment during the pandemic.
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http://dx.doi.org/10.1111/dth.15003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8209905PMC
May 2021

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

Risk of COVID-19 Infection, Hospitalization, and Mortality in Patients with Psoriasis Treated by Interleukin-17 Inhibitors.

J Dermatolog Treat 2021 Mar 24:1-28. Epub 2021 Mar 24.

Clalit Health Services, Tel-Aviv, Israel.

Background: The risk of the infection and its complications under this drug class remains to be determined.

Objective: To evaluate the risk of COVID-19, COVID-19-associated hospitalization, and mortality among patients with psoriasis treated by IL-17I.

Methods: A population-based cohort study was performed to compare psoriasis patients treated by IL-17I (n = 680) with those treated by methotrexate (n = 2,153) and non-systemic/non-immunomodulatory treatments (n = 138,750) regarding the incidence of COVID-19 and its complications.

Results: The use of IL-17I was not associated with an increased risk of COVID-19 infection [adjusted HR for IL-17I vs. methotrexate: 0.91 (95% CI, 0.48-1.72); IL-17I vs. non-systemic/non-immunomodulatory treatments: 0.92 (95% CI, 0.54-1.59)]. IL-17I was associated with comparable risk of COVID-19-associated hospitalization [adjusted HR for IL-17I vs. methotrexate: 0.42 (95% CI, 0.05-3.39); IL-17I vs. non-systemic/non-immunomodulatory treatments: 0.65 (95% CI, 0.09-4.59)] and COVID-19-associated mortality [adjusted HR for IL-17I vs. methotrexate: 7.57 (95% CI, 0.36-157.36); IL-17I vs. non-systemic/non-immunomodulatory treatments: 7.05 (95% CI, 0.96-51.98)]. In a sensitivity analysis, neither secukinumab nor ixekizumab imposed an elevated risk of any of the outcomes of interests.

Conclusions: IL-17I treatment does not confer an increased risk of COVID-19 infection or its complications in patients with psoriasis. Our findings support the continuation of IL-17I treatment during the pandemic.
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http://dx.doi.org/10.1080/09546634.2021.1905766DOI Listing
March 2021

The risk of COVID-19 in patients with bullous pemphigoid and pemphigus: A population-based cohort study.

J Am Acad Dermatol 2021 07 17;85(1):79-87. Epub 2021 Mar 17.

Clalit Health Services, Tel-Aviv, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.

Background: The burden of COVID-19 in patients with bullous pemphigoid (BP) and pemphigus is yet to be evaluated.

Objective: To assess the risks of COVID-19 and COVID-19-associated hospitalization and mortality in patients with BP and pemphigus and to delineate determinants of severe COVID-19 illness among these patients.

Methods: A population-based cohort study compared COVID-19 and its complications in patients with BP (n = 1845) and pemphigus (n = 1236) with age-, sex-, and ethnicity-matched control subjects.

Results: The risks of COVID-19 (hazard rate [HR], 1.12; 95% confidence interval [CI], 0.72-1.73; P = .691) and COVID-19-associated hospitalization (HR, 1.58; 95% CI, 0.84-2.98; P = .160) was comparable between patients with BP and controls. The risk of COVID-19-associated mortality was higher among patients with BP (HR, 2.82; 95% CI, 1.15-6.92; P = .023). The risk of COVID-19 (HR, 0.81; 95% CI, 0.44-1.49; P = .496), COVID-19-associated hospitalization (HR, 1.41; 95% CI, 0.53-3.76; P = .499), and COVID-19-associated mortality (HR, 1.33; 95% CI, 0.15-11.92; P = .789) was similar in patients with pemphigus and their controls. Systemic corticosteroids and immunosuppressants did not predispose COVID-19-positive BP and pemphigus patients to a more severe illness.

Limitations: Retrospective data collection.

Conclusions: Patients with BP experience increased COVID-19-associated mortality and should be monitored closely. Maintaining systemic corticosteroids and immunosuppressive adjuvant agents during the pandemic is not associated with worse outcomes.
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http://dx.doi.org/10.1016/j.jaad.2021.02.087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968167PMC
July 2021

Cardiovascular risk assessment: baseline snapshots or accumulated burden?

Authors:
Yochai Schonmann

Eur J Prev Cardiol 2020 Nov 25. Epub 2020 Nov 25.

Department of Quality Measurements and Research, Clalit Health Services, 101 Arlozorov St., Tel Aviv 6209804, Israel.

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http://dx.doi.org/10.1093/eurjpc/zwaa092DOI Listing
November 2020

Reply to: "Assessment of hepatic fibrosis in MAFLD: a new player in the evaluation of residual cardiovascular risk?"

Dig Liver Dis 2021 Mar 25;53(3):385-386. Epub 2021 Jan 25.

Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States.

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http://dx.doi.org/10.1016/j.dld.2021.01.014DOI Listing
March 2021

Orthopaedic corticosteroid injections and risk of acute coronary syndrome: a cohort study.

Br J Gen Pract 2021 28;71(703):e128-e133. Epub 2021 Jan 28.

Healthcare Quality Indicators Program for Clalit Health Services Hospitals, Department of Quality Measurements and Research, Clalit Health Services, Tel Aviv; Sial Research Center, Division of Community Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Background: Corticosteroid injections (CSIs) are a common treatment for arthritis and other musculoskeletal conditions.

Aim: To determine whether there is an increased incidence of acute coronary syndrome (ACS) following intra-articular and soft-tissue CSI.

Design And Setting: Cohort study in an urban primary care orthopaedic clinic.

Method: Data were reviewed from all patients aged ≥50 years and seen by orthopaedic specialists between April 2012 and December 2015, including CSI, hospital admission in the week following the orthopaedic visit, and cardiovascular risk factors. The incidence of an ACS-associated hospital admission was compared between visits in which patients received CSIs and visits in which patients did not.

Results: A total of 60 856 orthopaedic visits were reviewed (22 131 individual patients). The mean age was 70.9 years (standard deviation [SD] = 10.8), and 66.5% were female. Injections were administered in 3068 visits (5.1%). In the week following the visit there were 25 ACS hospital admissions (41 per 100 000 visits); seven events were after visits with an injection, and 18 were after non-injection visits. Patients who had received an injection were more likely to experience a subsequent ACS. (227 versus 31 events per 100 000 visits, odds ratio [OR] = 7.3; 95% confidence interval [CI] = 2.8 to 19.1). The association between receiving a CSI and ACS remained similar when the analysis was restricted to subgroups defined by age, sex, and cardiovascular risk factors.

Conclusion: CSI for musculoskeletal conditions may substantially increase the risk of ACS in the week following the injection. Although the absolute risk of ACS is small, the effect size appears to be clinically significant.
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http://dx.doi.org/10.3399/bjgp20X713945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805411PMC
January 2021

Risk factors for mental illness in adults with atopic eczema or psoriasis: protocol for a systematic review.

BMJ Open 2020 12 28;10(12):e038324. Epub 2020 Dec 28.

Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.

Introduction: Evidence indicates that people with the common inflammatory skin diseases atopic eczema or psoriasis are at increased risk of mental illness. However, the reasons for the relationship between skin disease and common mental disorders (ie, depression and anxiety) or severe mental illnesses (ie, schizophrenia, bipolar disorder and other psychoses) are unclear. Therefore, we aim to synthesise the available evidence regarding the risk factors for mental illness in adults with atopic eczema or psoriasis.

Methods And Analysis: We will conduct a systematic review of randomised controlled trials, cohort, case-control and cross-sectional studies. We will search the following databases from inception to March 2020: Medline, Embase, Global Health, Scopus, the Cochrane Library, Web of Science, Base, PsycInfo, the Global Resource of Eczema Trials, and the grey literature databases Open Grey, PsycExtra and the New York Academy of Medicine Grey Literature Report. We will also search the bibliographies of eligible studies and relevant systematic reviews to identify additional relevant studies. Citation searching of large summary papers will be used to further identify relevant publications. Two reviewers will initially review study titles and abstracts for eligibility, followed by full text screening. We will extract data using a standardised data extraction form. We will assess the risk of bias of included studies using the Quality in Prognosis Studies tool. We will synthesise data narratively, and if studies are sufficiently homogenous, we will consider a meta-analysis. We will assess the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation framework.

Ethics And Dissemination: Ethical approval is not required for a systematic review. Results of the review will be published in a peer-reviewed journal and disseminated through conferences.

Prospero Registration Number: CRD42020163941.
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http://dx.doi.org/10.1136/bmjopen-2020-038324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772326PMC
December 2020

Acne keloidalis nuchae and thyroid diseases: a population-based cohort study.

Int J Dermatol 2021 Apr 10;60(4):466-470. Epub 2020 Dec 10.

Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.

Background: The association between acne keloidalis nuchae (AKN) and thyroid diseases is yet to be investigated.

Objective: To evaluate the risk of developing hypothyroidism and hyperthyroidism among patients with AKN and to characterize the patients who have AKN and thyroid comorbidities.

Methods: A population-based cohort study was conducted comparing AKN patients (n = 2,677) with age-, gender-, and ethnicity-matched control subjects (n = 13,190) with regard to incident cases of hypothyroidism and hyperthyroidism. Adjusted hazard ratios (HRs) were estimated by Cox regression analysis.

Results: The incidence rates of hypothyroidism among patients with AKN and controls were estimated at 2.15 (95% CI, 1.49-2.99) and 0.82 (95% CI, 0.66-1.00) cases/1000 person-years, respectively. The crude risk of developing incident hypothyroidism was 1.85-fold greater in patients with AKN (HR, 1.85; 95% CI, 1.24-2.78; P = 0.003). The elevated risk persisted following the adjustment for putative confounders (adjusted HR, 1.72; 95% CI, 1.03-2.89; P = 0.040). The risk of hyperthyroidism was comparable in patients with AKN and controls both in the crude (HR, 1.55; 95% CI, 0.57-4.22) and adjusted (adjusted HR, 1.92; 95% CI, 0.59-6.21) analyses. Patients with coexistent AKN and thyroid diseases were significantly older at the onset of AKN, had more prominent female preponderance, and had a higher burden of comorbidity.

Conclusions: Patients with AKN are at an increased risk of hypothyroidism. Screening for hypothyroidism should be considered in AKN patients with a compatible clinical picture.
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http://dx.doi.org/10.1111/ijd.15331DOI Listing
April 2021

Liver fibrosis marker is an independent predictor of cardiovascular morbidity and mortality in the general population.

Dig Liver Dis 2021 Jan 2;53(1):79-85. Epub 2020 Nov 2.

School of Public Health, University of Haifa, Haifa 3498838, Israel; Department of Gastroenterology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel. Electronic address:

Background: A growing body of evidence suggests that Non-alcoholic fatty liver disease (NAFLD) and liver fibrosis are associated with cardiovascular disease (CVD). However, the independent role of liver fibrosis markers in the prediction of CVD in the general population is seldom tested.

Aims: To assess whether a marker of liver fibrosis predicts the first occurrence of a CVD event in a large sample of community-based general population.

Methods: Historical cohort using data from a large health provider that operates a centralized computerized medical record. The level of liver fibrosis was measured by the fibrosis-4 (FIB-4) score, and the association with CVD was adjusted for the European Systematic Coronary Risk Evaluation calculator (SCORE).

Results: The study included 8,511 individuals, 3,292 with inconclusive fibrosis and 195 with advanced fibrosis (FIB-4 ≥ 2.67). People with advanced fibrosis had higher risk for CVD, after adjustment for sociodemographic characteristics, the SCORE, use of statins and aspirin (HR [95%CI], 1.63 [1.29-2.06]). The association persisted in both women and men. Using age-specific cut-offs, there was a dose-response association between inconclusive and advanced fibrosis and CVD (HR [95%CI], 1.15 [1.01-1.31]) and HR [95%CI], 1.60 [1.27-2.01], respectively, P for trend<0.001).

Conclusions: A simple fibrosis score is independently associated with CVD, suggesting that fibrosis markers should be considered in primary-care risk assessment.
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http://dx.doi.org/10.1016/j.dld.2020.10.014DOI Listing
January 2021

Training Family Doctors and Primary Care Nurses in Evidence-based Prevention, Screening and Management of Cardiovascular Risks in Western Ukraine: A Longitudinal Study.

Zdr Varst 2020 Dec 18;59(4):227-235. Epub 2020 Oct 18.

Institute of General Practice and Family Medicine, Medical Faculty, Martin Luther-University Halle-Wittenberg, 06112 Halle / Saale, Germany.

Introduction: The Ukrainian primary healthcare programme of preventive and screening recommendations has not been evidence-based. The traditional system of continuous medical education in Ukraine places participants in the role of passive listeners. This study explored the effects of an interactive training course on evidence-based prevention and screening of cardiovascular risks, on changes in Ukrainian family doctors' (FDs) and primary care nurses' (PCNs) knowledge and readiness to change practice over time.

Methods: Three hundred and seven FDs and PCNs participated in the study. Changes in participants' knowledge were assessed with 20 multiple choice questions, and their readiness to change practice with a five-item questionnaire. These were administered before, immediately after, three and twelve months after training.

Results: The mean pre-course knowledge score was 6.1 (SD 1.8) out of 20, increasing to 14.9 (SD 2.3) immediately afterwards (p<0.001). Three months later it was 10.2 (SD 3.2) and at one year it was 10.4 (SD 3.3), both of which were significantly higher than the pre-training level (p<0.005). The percentage of participants that were highly motivated to change their practice increased from 18.4% before the training to 62.3% immediately afterwards (p<0.001). Three months later, this fell to 40.4%. At 12 months it further reduced to 27.4%, but was still significantly higher than the baseline level (p<0.001).

Conclusions: The interactive training was effective in increasing both participants' knowledge and their readiness to change their clinical practice. The impact of the training diminished over time, but was still evident a year later.
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http://dx.doi.org/10.2478/sjph-2020-0029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583428PMC
December 2020

The Bidirectional Association Between Bullous Pemphigoid and Psoriasis: A Population-Based Cohort Study.

Front Med (Lausanne) 2020 31;7:511. Epub 2020 Aug 31.

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

The risk of developing psoriasis during the course of bullous pemphigoid (BP) is yet to be investigated. We aimed to assess the risk of psoriasis among patients with BP and the risk of BP in individuals with a history of psoriasis. A population-based retrospective cohort study was conducted comparing BP patients ( = 3,924) with age-, sex-, and ethnicity-matched control subjects ( = 19,280) with regard to incident cases of psoriasis. A case-control design was additionally followed to estimate the risk of BP in those with a preceding diagnosis of psoriasis. Adjusted hazard ratios (HRs) and adjusted odds ratios (ORs) were estimated by Cox regression and logistic regression, respectively. The incidence of psoriasis was 1.78 (95% CI, 1.25-2.48) and 0.67 (95%CI, 0.53-0.83) per 1,000 person-years among patients with BP and controls, respectively. Patients with BP were 2.6-fold more likely to develop psoriasis (HR, 2.60; 95%CI, 1.59-4.27) compared to controls. Furthermore, the prevalence of preexisting psoriasis was higher in patients with BP than in control subjects (1.7 vs. 1.1%, respectively; < 0.001). A history of psoriasis was associated with a 50% increase in the risk of BP (OR, 1.53; 95%CI, 1.17-2.02). Patients with a dual diagnosis of BP and psoriasis were younger, had higher prevalence of smoking and hypertension, and were treated more frequently with prolonged systemic and topical corticosteroids when compared to the remaining patients with BP. To conclude, a bidirectional association exists between BP and psoriasis. Awareness of this association may be of great importance for physicians managing patients with BP and psoriasis.
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http://dx.doi.org/10.3389/fmed.2020.00511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489270PMC
August 2020

Reply to: Adding a US Perspective for Stroke Risk in Noncompliant Older Adults.

J Am Geriatr Soc 2019 12 1;67(12):2665-2666. Epub 2019 Oct 1.

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

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http://dx.doi.org/10.1111/jgs.16172DOI Listing
December 2019

Atopic Eczema in Adulthood and Risk of Depression and Anxiety: A Population-Based Cohort Study.

J Allergy Clin Immunol Pract 2020 01 31;8(1):248-257.e16. Epub 2019 Aug 31.

Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; St John's Institute of Dermatology, Guy's & St Thomas' Hospital National Health Service (NHS) Foundation Trust and King's College London, London, United Kingdom; Health Data Research UK, London, United Kingdom.

Background: Atopic eczema is a common and debilitating condition associated with depression and anxiety, but the nature of this association remains unclear.

Objective: To explore the temporal relationship between atopic eczema and new depression/anxiety.

Methods: This matched cohort study used routinely collected data from the UK Clinical Practice Research Datalink, linked to hospital admissions data. We identified adults with atopic eczema (1998-2016) using a validated algorithm, and up to 5 individuals without atopic eczema matched on date of diagnosis, age, sex, and general practice. We estimated the hazard ratio (HR) for new depression/anxiety using stratified Cox regression to account for age, sex, calendar period, Index of Multiple Deprivation, glucocorticoid treatment, obesity, smoking, and harmful alcohol use.

Results: We identified 526,808 adults with atopic eczema who were matched to 2,569,030 without. Atopic eczema was associated with increased incidence of new depression (HR, 1.14; 99% CI, 1.12-1.16) and anxiety (HR, 1.17; 99% CI, 1.14-1.19). We observed a stronger effect of atopic eczema on depression with increasing atopic eczema severity (HR [99% CI] compared with no atopic eczema: mild, 1.10 [1.08-1.13]; moderate, 1.19 [1.15-1.23]; and severe, 1.26 [1.17-1.37]). A dose-response association, however, was less apparent for new anxiety diagnosis (HR [99% CI] compared with no atopic eczema: mild, 1.14 [1.11-1.18]; moderate, 1.21 [1.17-1.26]; and severe, 1.15; [1.05-1.25]).

Conclusions: Adults with atopic eczema are more likely to develop new depression and anxiety. For depression, we observed a dose-response relationship with atopic eczema severity.
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http://dx.doi.org/10.1016/j.jaip.2019.08.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947493PMC
January 2020

Statin Use Over 65 Years of Age and All-Cause Mortality: A 10-Year Follow-Up of 19 518 People.

J Am Geriatr Soc 2019 10 9;67(10):2038-2044. Epub 2019 Jul 9.

Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Objectives: As life expectancy continues to rise, the burden of cardiovascular disease among older people is expected to increase, making cardiovascular prevention in older people an issue of growing interest and public health importance. We aimed to explore the long-term effects of adherence to statins on mortality and cardiovascular morbidity among older adults.

Design: A historical population-based cohort study using routinely collected data.

Setting: Clalit Health Services Northern District.

Participants: We followed members of Clalit Health Services aged 65 years or older who were eligible for primary cardiovascular prevention for a period of 10 years.

Measurements: We fitted Cox regression models to assess the association between the adherence to statin therapy and all-cause mortality and cardiovascular morbidity, adjusting for cardiovascular risk factors and associated morbidity as time-updated variables.

Results: The analysis included 19 518 older adults followed during 10 years (median = 9.7 y). All-cause mortality rates were 34% lower among those who had adhered to statin treatment, compared with those who had not (hazard ratio [HR] = .66; 95% confidence interval [CI] = .56-.79). Adherence to statins was also associated with fewer atherosclerotic cardiovascular disease events (HR = .80; 95% CI = .71-.81). The benefit of statin use did not diminish among beyond age 75 and was evident for both women and men.

Conclusion: Adherence to statins may be associated with reduced mortality and cardiovascular morbidity among older adults, regardless of age and sex. J Am Geriatr Soc 67:2038-2044, 2019.
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http://dx.doi.org/10.1111/jgs.16060DOI Listing
October 2019

Make quotations great again: a proposal to reduce false-knowledge.

BMJ Evid Based Med 2020 02 25;25(1):12-14. Epub 2019 Feb 25.

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

The last decades saw remarkable change in the way healthcare professionals generate and consume medical knowledge. Information management technologies have evolved considerably, yet medical publications continue to use a referencing system that has changed very little since the turn of the 20th century. Research suggests that up to one in five referenced claims quotes the original text inaccurately. Many authors, perhaps inadvertently, contribute to this process by citing non-primary data and amplifying the errors of their predecessors. Erroneous claims are propagated, accumulate into false belief systems and generate inaccurate knowledge. Updating the referencing system to provide additional information to support each referenced claim (eg, the location of the referenced statement in the original text and the nature of that text) could, perhaps, address this cycle of inaccuracy. We believe such changes in the referencing system would prompt authors to rigorously verify referenced claims and provide readers with context to inform a critical evaluation of the text. We detail our proposal for changes in the notations used for referencing, as well as in the information provided within reference lists. We also discuss some barriers and solutions to the adoption of our proposal.
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http://dx.doi.org/10.1136/bmjebm-2018-111109DOI Listing
February 2020

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

Chronic hypnotic use at 10 years-does the brand matter?

Eur J Clin Pharmacol 2018 Dec 8;74(12):1623-1631. Epub 2018 Aug 8.

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

Purpose: Chronic use of sedative-hypnotics is very common, although not guideline-endorsed. The incidence among new users is not well studied, and there are currently no recommendations favoring any specific agent. We quantified the risk for chronic use in first-time hypnotic users, and the association of the initial choice of hypnotic with later usage patterns.

Methods: We used the computerized database of Israel's largest healthcare provider. All 236,597 new users of sedative-hypnotics between the years 2000-2005 were followed for 10 years. Filled prescriptions in the second, fifth, and tenth years were recorded. The association of the first hypnotic choice (benzodiazepine/Z-drug) with chronic consumption was assessed using multivariate logistic regression.

Results: Average age on first use was 63.7 (SD ± 16.4) years. 58.6% were women. Benzodiazepines were initiated in 154,929 (65.5%) of the cases. Benzodiazepine users were older and of lower socioeconomic status, compared to Z-drug users (p < 0.001). On the tenth year, 103,912 (66.8%) of new users claimed ≤ 30 DDDs of hypnotics, 3,1724 (20.4%) were long-term users (≥ 180 DDD/year), and 828 (0.5%) used excessively (≥ 720 DDD/year). Z-drugs were associated with an increased risk of long-term use on the second year [17.3% vs. 12.4%, RR = 1.40 (1.37-1.43)] as well as on the fifth [21.9% vs. 13.9%, RR = 1.58 (1.55-1.61)] and tenth year [25.1% vs. 17.7%, RR = 1.42 (1.39-1.45)], p < 0.0001. Similar results were also observed for daily and excessive use (p < 0.001).

Conclusions: One in five new users of sedative-hypnotics will become a long-term user, but only 0.5% will become excessive users. Z-drugs were associated with an increased risk of chronic use.
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http://dx.doi.org/10.1007/s00228-018-2531-4DOI Listing
December 2018

Psoriasis in Israel: demographic, epidemiology, and healthcare services utilization.

Int J Dermatol 2018 Sep 6;57(9):1068-1074. Epub 2018 Jul 6.

Chief Physician's Office, Department of Quality Measurements and Research, Clalit Health Services, Tel Aviv, Israel.

Background: Updated data regarding the epidemiology of psoriasis and related healthcare utilization are lacking.

Objective: To investigate the epidemiology, comorbidities, healthcare services utilization, and drug use in a large group of patients with psoriasis from Clalit Health Services (CHS) database.

Methods: A controlled cross-sectional study was performed. Case patients were defined when there was at least one documented diagnosis of psoriasis registered by a CHS dermatologist between the years 1998-2016. The extracted data included metabolic, cardiovascular and psychiatric comorbidities; community clinic visits; in- and outpatient services utilization profiles and drug use data, which included pharmacy claims of topical and systemic treatments, including phototherapy and climatotherapy. Comparative analysis was performed by a univariate and multivariate analysis, adjusting for age, gender, obesity, and smoking.

Results: The study included 118,680 patients with psoriasis (prevalence of 2.69%) and 118,680 age- and gender-matched controls. Patients with psoriasis had increased prevalence of metabolic, cardiovascular, and psychiatric illnesses. Psoriasis was significantly associated with an increased healthcare utilization. The mean (SD) number of annual dermatologist clinic visits and emergency room visits was 7.2 ± 12.4 and 2.9 ± 7.7 in psoriasis patients as compared to 2.9 ± 7.9 and 2.7 ± 7.4 in the control group (P < 0.001). Topical steroids were the most applied treatment in psoriasis patients (15.5%), and topical vitamin D analogs were second in use (14.6%). Traditional systemic treatment for psoriasis was used in 3.8% of the patients, and biologic treatments were used in 1.6% of the patients.

Conclusions: Our study quantifies healthcare services utilization and drug use in patients with psoriasis.
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http://dx.doi.org/10.1111/ijd.14130DOI Listing
September 2018

Validation of the 2016 USPSTF recommendations for primary cardiovascular prevention in a large contemporary cohort.

Eur J Prev Cardiol 2018 05 8;25(8):870-880. Epub 2018 Mar 8.

1 Clalit Health Services, Tel Aviv District, Israel.

Aims The aim of this study was to evaluate the performance of the US Preventive Services Task Force (USPSTF) cholesterol recommendations in a contemporary non-US cohort. Methods and results This is a historical cohort analysis of electronic records from Israel's largest health provider. All patients in the Tel Aviv district eligible for primary cardiovascular prevention were followed between January 2005 and December 2015. Risk was estimated by the pooled cohort equations. Statin eligibility was determined by USPSTF and American College of Cardiology and American Heart Association (ACC/AHA) recommendations. Atherosclerotic cardiovascular disease events were retrieved from electronic registration. The mean ± standard deviation age of the 10,889 (98,258 person-years) participants was 60.3 ± 9.4 years, and 69.1% were women. Outcome events were recorded for 1351 patients (12.4%). Treatment recommendations were discordant in 901 patients (8.3%) whose treatment was indicated only by the ACC/AHA guidelines, implying a 26% reduction in newly eligible patients for statin treatment had the USPSTF recommendations been implemented. Among the statin-naive patients, the pooled cohort equations underestimated the risk, with a predicted-to-observed event ratio of 0.88. The recommended treatment thresholds provided excellent calibration, with ratios of 1.0 for USPSTF and 0.98 for ACC/AHA-eligible patients. Both models showed similar discrimination (Harrel's C = 0.63 (0.62-0.65) for USPSTF vs. 0.64 (0.63-0.66) for ACC/AHA, P = 0.26). The USPSTF recommendations were less sensitive and more specific for the detection of outcome events than the ACC/AHA recommendations (61% vs. 75% and 68% vs. 55%, respectively). The net reclassification index was -0.01. Conclusions Calibration, discrimination and net reclassifications were very similar for USPSTF and ACC/AHA recommendations. Applying the USPSTF recommendations could reduce over-treatment.
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http://dx.doi.org/10.1177/2047487318763825DOI Listing
May 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