Search

To assess the prevalence of risk factors associated with cardiovascular disease (CVD) and CVD-related morbidity in a large Middle-Eastern psoriatic arthritis (PsA) cohort. A retrospective case control study was conducted using Israel’s largest health care provider’s patient database from 2000 to 2013. For each patient with PsA, 10 patients with no history of psoriasis or arthritis were matched for age and sex. Analysis of CVD-related risk factors and morbidity included hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus type 2 (DM-2), obesity, smoking, ischemic heart disease (IHD), congestive heart failure (CHF), cerebrovascular accident (CVA), carotid artery disease, peripheral vascular disease (PVD), aortic aneurism, valvular heart disease (VHD), and cardiomyopathy. Statistical analysis was conducted using t test and chi-square tests as appropriate. Univariate and multivariable logistic regression models assessed the association between PsA and CVD-related risk factors and morbidity. Three thousand one hundred sixty-one PsA patients were included, with average age 58 ± 15.0 years, of whom 53.4% were women. Increased prevalence of DM-2, HLD, HTN, and obesity (OR 1.7, 1.5, 1.5, 1.5 respectively) was noted in the PsA group. Increased prevalence of IHD (p

Objective.To assess the prevalence of systemic lupus erythematosus (SLE) in a psoriatic arthritis (PsA) cohort and to compare it to the general population using the database of a large healthcare provider.Methods.We analyzed the database of a PsA cohort (2002–2017), matched for age and sex, with randomly selected controls for demographics, clinical and laboratory manifestations, and dispensed medications. Statistical analysis used t test and chi-square test as appropriate. In the PsA group, incidence density sampling was performed matching PsA patients without SLE as controls to each case of PsA with SLE by age and follow-up time. Univariable and multivariable conditional logistic regression analyses were used to assess factors affecting SLE development.Results.The PsA and control groups consisted of 4836 and 24,180 subjects, respectively, with a median age of 56 ± 15 years, and of whom 53.8% were female. Eighteen patients (0.37%) in the PsA group and 36 patients (0.15%) in the control group were diagnosed with SLE (P = 0.001). SLE patients without PsA had higher anti-dsDNA and anticardiolipin antibodies. The usage of drugs with known potential to induce SLE was higher in the PsA than in the control group. Older age at PsA diagnosis, shorter PsA duration, and statin treatment were associated with SLE in PsA patients.Conclusion.A 2.3-fold increase in the prevalence of SLE in PsA relative to the control group was found. Risk factors for SLE development included older age at PsA diagnosis, shorter PsA duration, and statin treatment. The association between PsA and SLE may affect treatment choices and medication development.

Tracheal intubation is a vital and common procedure during surgical care. The tracheal tube may be inserted orally or trans-nasally. Nasal intubation enables a non-restricted approach for oral and oropharyngeal regions. Thus, nasotracheal intubation is more suitable for surgeries such as uvulopalatopharyngoplasty treating obstructive sleep apnea. Obstructive sleep apnea is an independent risk factor for postoperative cardiorespiratory complications. Thus, meticulous treatment during and post-operatively is needed keeping the upper airway open including the nasal cavity. In several studies, nasotracheal intubation resulted in disruption of the nasal mucosa.The objective of this study is evaluating the developing nasal resistance post nasotracheal intubation and comparing it to nasal resistance post-orotracheal intubation. To our knowledge, this is the first data on nasal obstruction following nasal intubation.Forty-four candidates, for elective non-head and neck procedures were randomized into two groups: oral intubation group and nasal intubation group. The nasal resistance of all participants was measured by anterior rhinomanometry upon the recommendation of the standardization committee on objective assessment of the nasal airway. Statistical analysis with paired T test, Chi square and McNemar's test was performed. Statistical significance was evaluated at P≤0.05.There were no differences between the study groups regarding nasal resistance before and after intubation. However, nasotracheal intubation was found to disrupt the normal nasal cycle of the nasal mucosa.Nasotracheal intubation does not negatively affect nasal resistance in the early postoperative period.Nasotracheal intubation does not affect nasal resistance and it seems to be safe for OSA patients. More research has to be conducted to evaluate the nasal resistance in patients who undergo oral and nasal surgeries.

Objective.To investigate endocrine comorbidities in patients with psoriatic arthritis (PsA).Methods.A retrospective, cross-sectional study was performed with the database of Clalit Health Services, the largest healthcare provider in Israel, between 2002 and 2014. Patients with PsA were identified and matched by age and sex to healthy controls. The following morbidities were analyzed: hypo/hyperthyroidism, hypo/hyperparathyroidism, hyperprolactinemia, Cushing disease, Addison disease, diabetes insipidus, diabetes mellitus (DM), pituitary adenoma, acromegaly, and osteoporosis. Descriptive statistics were applied. The associations between PsA and endocrine comorbidities were analyzed by univariable and multivariable analysis.Results.The study included 3161 patients with PsA, 53.4% women, mean age 58.4 ± 15.4 years, and 31,610 controls. Comparative analyses yielded higher proportion of hypothyroidism (12.7% vs 8.6%, p < 0.0001), Cushing disease (0.3% vs 0.1%, p < 0.0001), osteoporosis (13.2% vs 9.1%, p < 0.0001), and DM (27.9% vs 20.7%, p < 0.0001) in the PsA group compared with the control group. In the multivariable regression analysis, the following diseases were more frequent in the PsA group: hypothyroidism (OR 1.61, 95% CI 1.47–1.81), DM (OR 1.35, 95% CI 1.18–1.42), Cushing disease (OR 3.96, 95% CI 1.67–9.43), and osteoporosis (OR 1.56, 95% CI 1.37–1.78).Conclusion.PsA is associated with a high frequency of hypothyroidism, osteoporosis, DM, and Cushing disease. Awareness of these comorbidities may help physicians provide the optimal medical care to patients with PsA.

Background Patients with psoriasis and psoriatic arthritis (PsA) can develop a variety of comorbidities including metabolic syndrome, diabetes, hypertension, cardiovascular diseases and depression. Comorbidities, in turn, may influence the therapeutic regimen and affect treatment results. Previous studies show a high incidence of coexistence of psoriasis and systemic lupus erythematosus (SLE). Unlike psoriasis, the coexistence of PsA and SLE has been reported only in case reports. Objectives To assess the prevalence of SLE in a PsA patient cohort and to compare it to the general population using the database of a large health care provider. Methods The study, which was conducted from 2002-2017, is a retrospective study on a PsA cohort consisting of 4,836 PsA patients matched for age and sex with 24,180 randomly selected control patients. Data on this cohort was derived from the database of more than 4.3 million people enrolled in the largest health care provider in Israel, Clalit Health Services. The database was used to extract demographic data, such as age, sex, ethnicity and socioeconomic status; clinical and laboratory manifestations of SLE; medication dispensed and SLE-inducing medications. T-test was used to compare continuous variables and a Chi-square test was used for categorical variables. All tests were 2-sided; p values of Results The PsA study group consisted of 4,836 subjects, at a median age of 56+/-15, 2603 (53.8%) of whom were females. The control group consisted of 24,180 subjects matched for age and sex. 18 patients (0.37%) in the PsA study group, and 39 patients (0.16%) in the control group where diagnosed with SLE (p=0.002). SLE patients without co-existing PsA had higher anti-double stranded DNA (anti-dsDNA) positivity (92.3% vs 66.7%, p=0.022) and positive anti-cardiolipin (ACL) antibodies (46.2% vs 16.7%, p=0.041). No other significant differences were observed between the two groups in terms of clinical and laboratory manifestations of SLE. PsA patients with concomitant SLE compare to PsA patients without SLE were more often female (100% vs 53.7%, p Conclusion A 2.3 fold increase in the prevalence of SLE in PsA patients than in the control group was found in our study population. There were no significant differences in the clinical and laboratory manifestations of SLE between these two groups. The positive correlates between SLE and PsA may point to common underlying pathogenetic pathways and may affect treatment choices and medication development. More research is needed for a better understanding of this diseases association. Disclosure of interests Danielle Korkus: None declared, Tal Gazitt: None declared, Ilan Feldhamer: None declared, Idit Lavi: None declared, amir Haddad: None declared, Erez Batat: None declared, Sari Greenberg-Dotan: None declared, arnon Cohen Grant/research support from: Prof. Arnon Cohen received research grants from Janssen, Novartis and abbVie and Sanofi, Consultant for: Prof. Arnon Cohen served as a consultant, advisor for abbVie; amgen; Boehringer ingelheim; Dexcel pharma; Janssen, Lilly; Neopharm; Novartis, Perrigo; Pfizer; Rafa; Sanofi, Speakers bureau: Prof. Arnon Cohen served as speaker for abbVie; amgen; Boehringer ingelheim; Dexcel pharma; Janssen, Lilly; Neopharm; Novartis, Perrigo; Pfizer; Rafa; Sanofi, Devy Zisman Grant/research support from: Dr D Zisman received research grants from Pfizer, Janssen, Consultant for: Dr D Zisman served as a consultant, for Pfizer, abbvie, Novartis, Ellie-Lilly, Sanofi, Speakers bureau: Dr D Zisman served as a speaker for abbVie, Janssen, Lilly, Novartis, Pfizer, Sanofi

Direct oral anticoagulants (DOACs) reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation but may result in serious bleeding complications. Off-label dose-reduced use of DOACs to mitigate bleeding is common in routine clinical practice although data about its consequences on patient outcomes are limited. Therefore, our objective was to evaluate the effectiveness and safety of off-label dose-reduced vs per-label standard-dose DOAC treatment.The study cohort included newly diagnosed patients with nonvalvular atrial fibrillation that had initiated DOAC therapy between 2011 and 2017 in Clalit Health Services (Tel Aviv, Israel). Effectiveness was defined as the composite outcome of all-cause mortality, stroke, or myocardial infarction. The safety outcome was defined as bleeding events requiring hospitalization. Patients were followed until March 30, 2018 or until occurrence of an outcome event. Hazard ratios (HR) were adjusted for 21 variables, including comorbidities, concomitant medications, and socioeconomic factors, using multivariate regression.A total of 8425 patients met the study criteria; 5140 (61%) patients were treated with DOACs at per-label dosing and 3285 (39%) patients were treated with off-label dose-reduced DOAC. Off-label dose-reduced treatment was associated with a higher rate of the composite effectiveness outcome: adjusted HR 1.57 (95% confidence interval, 1.34-1.83; P.001) and a higher rate of bleeding: adjusted HR 1.63 (95% confidence interval, 1.14-2.34; P = .008).Almost 4 of 10 patients were treated with off-label dose-reduced DOAC, which was associated with reduced effectiveness without a safety benefit. Compliance with per-label dosage may significantly improve outcomes of this population.

Background There is limited information on the epidemiology of psoriatic arthritis (PsA) in general and in Middle Eastern populations in particular. The aims of this study were to estimate the prevalence and incidence rates of PsA and their temporal trends in the general population in Israel. Methods In this study, a cohort of adult patients with PsA was derived from the database of Clalit Health Services (CHS), Israel’s largest health fund, with over 4.4 million members. The crude and age- and sex-standardized prevalence and incidence rates of PsA from 2006 to 2015 in the general population were calculated. The variation in PsA prevalence was assessed in relation to several demographic factors. Results Among the 2,931,199 individuals aged 18 years and older registered in the CHS database in 2015, 4490 patients had a diagnosis of PsA (322 incident cases), resulting in overall crude prevalence and incidence rates of 0.153% (95% CI 0.149%, 0.158%) and 10.9 (95% CI 9.8, 12.3) per 100,000 population, respectively. The reported prevalence of PsA in Israel has doubled between 2006 and 2015 (from 0.073% to 0.153%). In contrast, the global incidence rate remained stable, with a gradual increase in incidence among individuals aged 51 to 70 years. PsA is associated with Jewish ethnicity, high socioeconomic status, and higher body mass index. Conclusions The prevalence and incidence of PsA in Israel are within the range of previous estimates from Southern European populations. An increase in the reported prevalence of PsA was observed over the past decade in the general population in Israel.

Background The European Society for Medical Oncology published in 2015 its Magnitude of Clinical Benefit Scale (ESMO-MCBS) for cancer medicines. Our objective was to evaluate the association between Israel's national reimbursement decisions regarding novel cancer drugs, prior to the availability of ESMO-MCBS, and the later published ESMO-MCBS scores. Research design and methods ESMO-MCBS scores were obtained retrospectively for the cancer drugs that were candidates for reimbursement in Israel in 2013-2015 and were categorized to 'highest benefit' (ESMO-MCBS 4-5 or A) 'medium benefit' (3 or B) and 'lowest benefit' (0-2 or C). The reimbursement decisions were accessed and compared with the categorized ESMO scores. Results ESMO-MCBS score was available for 19/22 drugs approved for reimbursement and 15/16 non-approved drugs. 58% of the approved drugs gained a 'highest benefit' score and 37% were 'medium benefit'. 87% of the non-approved drugs had 'lowest benefit' scores. Median score for approved drugs was 4 vs. 1 for the non-approved (p Conclusions The Israeli decisions regarding reimbursement of novel cancer drugs, demonstrated concordance with ESMO-MCBS scores. Incorporation of ESMO-MCBS data in reimbursement deliberations could assist in framing the appropriate use of the limited resources to deliver effective and affordable cancer care.

After a decade of extensive use, the actual contribution of bevacizumab in first-line treatment of metastatic colorectal cancer (mCRC) is still unclear.To evaluate 'real-life' outcomes of patients with mCRC before and after the introduction of bevacizumab to standard mCRC first-line practice.Using the computerized administrative database of Clalit Health Services' (CHS), Israel's largest health care provider, we retrospectively compared two cohorts (n = 1739): (A) all CHS' patients diagnosed with mCRC between January 2000 and December 2004 that received first-line irinotecan or oxaliplatin-based combination chemotherapy (before bevacizumab was introduced) (n = 1052), and (B) all patients that started first-line irinotecan or oxaliplatin combination chemotherapy together with bevacizumab between September 2006 and December 2009 (after bevacizumab was fully reimbursed in Israel for mCRC first-line therapy) (n = 687). The primary endpoint was overall survival (OS) and secondary endpoints were first-line progression-free survival (PFS) and metastatectomy rates.Median OS was longer in Cohort B than in Cohort A [23.0 months vs.15.0, adjusted hazard ratio (HR), 0.75]. Secondary outcomes were also better; PFS of 14.0 months vs. 9.8 in the earlier period (HR, 0.75) and metastatectomy rate of 8.1% versus 3.9%. The longer OS in Cohort B was preserved even after controlling for latter-line epidermal growth factor receptor (EGFR) inhibitor use (HR = 0.77).In this analysis, OS, PFS and metastatectomy rates of first-line treatment of mCRC were significantly higher in the later period of the study. These results, derived from 'real-life' practice, suggest that the use of bevacizumab, among other alterations in the clinical management of mCRC between the two periods, might have had a significant contribution to these outcomes, and may therefore support the current practice of adding bevacizumab to first-line treatment of mCRC.

Objectives To study the association between traditional disease-modifying antirheumatic drugs (c-DMARD) or anti-TNF-α agents and herpes zoster (HZ) in patients with psoriatic arthritis (PsA). Methods A retrospective cohort study was conducted in patients with PsA between 2002 and 2013. Patients were grouped as follows: no DMARDs (Group A); c-DMARDs (Group B); anti-TNF-α agents (Group C); anti-TNF-α agents in combination with c-DMARDs (Group D). Crude incidence rates (IR) were calculated as number of HZ episodes per 1000 patient-years. A Cox regression model was used to adjust for HZ risk factors (age, gender, steroid use, Charlson Comorbidity Index score, and previous treatment) in order to estimate their contribution to the risk of the first HZ event. Results The study included 3128 patients, mean age 50.26±14.54 years; 46.2% male. During a period of 20 096 person-years 182 HZ events were observed. The crude IR (95% CI) of HZ in the study population was 9.06 per 1000 patient-years, and in Groups A-D 7.36 (5.41 to 9.79), 9.21 (7.5 to 11.21), 8.64 (4.84 to 14.26), 17.86 (10.91 to 27.58), respectively. In a multivariate analysis, age (HR 1.01, 95% CI 1.00 to 1.02), treatment with steroids (HR 1.08, 95% CI 1.04 to 1.13), and a combination of anti-TNF-α agents and c-DMARDs (HR 2.37, 95% CI 1.32 to 4.22) were significantly associated with HZ events. Conclusions In our database, the risk of HZ was significantly increased with age, treatment with steroids, and combination of anti-TNF-α agents and c-DMARDs, but not with c-DMARDs or anti-TNF-α therapy alone. Time to HZ event was shorter in patients treated with anti -TNF-α agents.

6591 Background: Observational studies have shown an increased risk of BC with use of HRT. However, data on the prognosis of BC that develop in HRT users are inconsistent. The association between HRT use and results of the 21-gene Recurrence Score (RS) assay (Oncotype DX, Genomic Health Inc.) has not been investigated. We aimed to analyze this association, and examine the actual rate of distant recurrence or death in this population. Methods: Clalit Health Services (CHS) is the largest health maintenance organization (HMO) in Israel. We identified all CHS newly diagnosed ER+, N- breast-cancer patients, aged 45-60 that performed a RS assay between 01/2006-12/2012 and that were treated for at least three months with HRT during the eight years before BC diagnosis. A 1:4 matched-cohort analysis was performed, with matching made according to age and year of BC diagnosis. Clinical and demographic data were extracted from the CHS centralized registry for all patients. RS assay scores was grouped according to the TAILORX categorization and distribution was compared using Chi-square test. Kaplan-Meier analysis with log-rank test was performed in order to compare time to a combined outcome of distant-recurrence and mortality. Results: A cohort of 259 HRT-treated patients was identified and matched with 1001 controls, not treated with HRT. The proportions of low-risk patients (RS 0-25) and high-risk patients (RS 26-100) were 76.8% and 23.2%, respectively, within HRT-treated patients, and 80.4% and 19.6% within controls. Chi square test was not found significant (χ2= 1.634, p = 0.201). The mean follow-up time was 148.4 months for the cases and 146.9 months for controls, with log-rank test not showing a significant difference between groups. Conclusions: These data did not show significant association between HRT use and higher RS assay scores, and also did not find an association between HRT use and actual distant recurrence or death. Although the proportion of patients with high risk RS appeared to be slightly higher within HRT treated patients, this difference had not reached significance and further studies are required.

Comorbidities associated with psoriatic arthritis (PsA) include cardiovascular diseases, diabetes mellitus, and obesity. This study evaluated the association between PsA and common gastrointestinal (GI) diseases. A retrospective study was performed in Israel’s largest health care provider database between 2002 and 2013. 3161 PsA patients were matched for age and sex with 31610 randomly selected patients. We searched these patients’ records for the presence of peptic ulcer disease (PUD), reflux esophagitis, Crohn’s disease, ulcerative colitis, irritable bowel syndrome (IBS) and celiac disease. T-test was used to compare continuous variables and a Chi-square test was used for categorical variables. Multivariate logistic regression models were used to assess the association between PsA and GI comorbidities. PsA was associated with Crohn’s disease (OR 2.4, 95 %CI: 1.75–3.32, p

Backgound Randomized controlled trials (RCTs) have shown that dabigatran, rivaroxaban and warfarin cause similar bleeding rates. Methods We performed a retrospective population-based cohort study to determine the incidence of bleeding in patients with atrial fibrillation (AF) beginning dabigatran, rivaroxaban or warfarin. Consecutive patients initiating anticoagulation for AF during a 3 year period were identified using a computerized database. Patients who bled and required hospitalization underwent chart review. Bleeding incidences were calculated per 100 patient-years of treatment. Results 18,249 patients were included: 9564 (52.4%) received warfarin, 5976 (32.7%) dabigatran, and 2709 (14.8%) rivaroxaban. Bleeding incidences were 3.9 (95% CI, 3.6–4.4) in warfarin-treated patients, 4.2 (95% CI, 3.7–4.7) in dabigatran patients, and 4.1 (95% CI, 3.0–5.3) in rivaroxaban patients. Intracranial hemorrhage (ICH) rates were 0.71 (95% CI, 0.56–0.90) for warfarin, 0.4 (95% CI, 0.18–0.87) for dabigatran, and 0.27 (95%CI, 0.10–0.80) for rivaroxaban. GI hemorrhage rates were 1.88 (95%CI, 1.62–2.20) for warfarin, 2.98 (95% CI, 2.4–3.5) for dabigatran and 2.39 (95%CI, 1.6–3.5) for rivaroxaban. Conclusions We demonstrate similar bleeding rates with both dabigatran 150 mg and 110 mg and rivaroxaban compared to warfarin.

OBJECTIVE: We aimed to examine the hypothesis that behavioral and neurocognitive functions of preschool children with Obstructive Sleep Apnea Syndrome (OSAS) are impaired compared to healthy children, and improve after adenotonsillectomy (TA). METHODS: A comprehensive assessment battery was used to assess cognitive and behavioral functions, and quality of life in children with OSAS compared to matched controls. RESULTS: 45 children (mean age 45.5 ± 9 months, 73% boys, BMI 15.7 ± 2) with OSAS were compared to 26 healthy children (mean age 48.6 ± 8 months, 46% boys, BMI 16.4 ± 2). Mean AHI in the OSAS group was 13.2 ± 10.7 (ranging from 1.2 to 57). Significantly impaired planning and fluency (executive function) were found in children with OSAS, as well as impaired attention and receptive vocabulary. Parents and teachers described the OSAS group as having significantly more behavior problems. Quality of life questionnaire in children with OSAS (mean 2.3, range 0.7-4.3) was significantly worse compared to controls (mean 0, range: 0-4), P Language: en

The role of health care organizations in reducing inequalities in health has recently drawn considerable interest from researchers and policy makers (McKee 2002; Smedley, Stith, and Nelson 2003;). It is clearly acknowledged that disparities in health are a result of interrelated factors external to the health care realm, such as socioeconomic status (SES), ethnicity, geography, and education (Chin et al. 2007; Starfield and Birn 2007; Benyamini et al. 2008; Riva et al. 2009;), yet health care organizations have an important role in reducing health disparities caused by these social factors, as well as by unequal access to quality medical care (Aaron and Clancy 2003). To address this need, the National Health Plan Collaborative was formed in 2004, aimed at reducing racial and ethnic disparities and improving the overall quality of care in the U.S. health care system. Early reports indicate that the plans have made significant headway in achieving coordination of disparities activities across the organization (Lurie et al. 2008). Yet data on programs' structures and the processes put in place, as well as achievements in disparity reduction, have not been reported to date. The means by which health care organizations can effectively achieve disparity reductions are yet to be unveiled (Fiscella 2007). Israeli society has a diverse demographic profile in terms of its ethnic, religious, immigrant, and socioeconomic makeup. Recent reports show widening inequalities in economic status, as attested by the higher Gini coefficient (a marker of income variance) in Israel than in all OECD countries (Shmueli and Gross 2001). Recent studies report considerable differences in the health status of the Israeli population (Epstein and Horev 2007): differences in life expectancy according to geographical areas, minority status (mainly between the largest minority of Arab Muslims and the general Israeli Jewish population), and level of education (Shuval 1990; Chernichovsky and Anson 2005; Israeli Bureau of Statistics 2009;); large differences in infant mortality rates according to geographical area and minority status (Tarabeia et al. 2004); and disparities in the prevalence of chronic diseases according to minority status and education level in a variety of conditions, including osteoporosis (Nitzan-Kaluski et al. 2003), obesity (Keinan-Boker et al. 2005), and coronary artery disease (Salameh et al. 2008). In Israel, all citizens, by law, are members of one of four health funds that serve as insurers and health care providers. Clalit Health Services is the largest health fund with over 3.8 million enrollees (53 percent market share), with

Background Direct oral anticoagulants (DOACs) are at least as effective as vitamin K antagonists (VKAs) for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). DOACs are associated with less intracranial hemorrhage and are easier to administer and therfore have become standard of care for stroke prevention in NVAF patients. Nevertheless, many eligible patients still receive no anticoagulation. The effect on overall mortality in routine practice of DOAC therapy compared to no anticoagulation in NVAF patients is unknown. Methods We identified all newly diagnosed, anticoagulant naive NVAF patients eligible for DOAC therapy from 2011 to 2016 in Clalit Health Services, the largest HMO in Israel. We created a matched cohort, using 1:1 propensity score matching of DOAC -treated versus non-anticoagulant treated NVAF patients. The primary outcome was overall mortality rate in the two cohorts. Secondary outcomes were rates of stroke, major cardiac and bleeding events. Results 28,195 newly diagnosed CHADS2 ≥2 NVAF patients were identified. Of these 8 298 received a DOAC and 10 603 received no anticaogulation. The remainder received a VKA and were not included in this study. Patients recieving DOAC therapy were younger (77.4 vs 78.0 years), had a higher socioeconomic status (5.6 vs. 5.3), had a female predominance (53.7% vs 52.0%), had a higher BMI (29.6 vs 28.3) and had a greater prevalance of accompanying cardiovascular morbidities namely congestive heart failure (CHF) (29% vs 27%) and stroke (33% vs 30%) (P Conclusions In this cohort of newly diagnosed NVAF patients treated in routine clinical practice, DOAC therapy was associated with a lower risk for death compared to no oral anticoagulation. Our findings provide further evidence for the importance of DOAC therapy in NVAF patients. Disclosures No relevant conflicts of interest to declare.

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) IS THE TREATMENT OF CHOICE FOR PATIENTS WITH OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS). IF used on a regular basis, CPAP can effectively reduce the apnea-hypopnea index (AHI), decrease daytime sleepiness,1,2 improve sleep quality and quality of life for both the patient and partner,3 and reduce the risk of cardiovascular events.4–6 Despite the increase in CPAP treatment options (i.e., bilevel positive airway pressure, autoadjusting CPAP), treatment acceptance and adherence are low. It has been estimated that 15% to 30% of patients do not accept CPAP treatment from the outset.7 The decision to embrace CPAP occurs during the first few days of treatment.3,8–10 The issues influencing CPAP acceptance (or non-acceptance) are complicated, involving behaviors by the physician, patient, and health care system. Currently, no single factor has been consistently identified as predictive of CPAP acceptance and adherence.1,10,11–17 CPAP support programs and patient education increase patient acceptance during treatment initiation,18–20 since they improve patients' symptoms and their perception about CPAP treatment, driving patients to seek therapy.19–21 Little is known about the role of socioeconomic status (SES), determined by income level,22–24 on the decision to accept CPAP treatment. Patients with OSAS25 and people with low SES have higher rates of obesity, glucose intolerance, and cigarette smoking.4,6,26,27 Health literacy among low SES patients was found to be a barrier to treating obesity and managing cardiovascular disease (CVD).22,24,28–30 Patients with lower SES have a greater likelihood of exposure to SES risk behaviors, including nonattendance for health checkups and poor compliance, resulting in increased CVD morbidity and mortality risk.24,27 Patients with OSAS recruited from hospitals serving low SES neighborhoods,28 compared with hospitals serving high SES populations, had a greater body mass index (BMI) and more comorbidity, despite similar demographics. Forty-two percent of patients with OSAS from hospitals serving minority groups failed to follow up for CPAP treatment, compared with 7% in the voluntary hospital group.28 This finding may be related to health literacy and low SES behavior. It is possible that the poor compliance with various interventions may impair treatment acceptance among low-SES OSA patients requiring CPAP. The aim of the study was to evaluate whether SES is an independent factor affecting CPAP acceptance to commence (purchase) treatment.

OBJECTIVES: To determine whether elderly subjects with obstructive sleep apnea (OSA) had different morbidity and health care utilization than elderly subjects without OSA and middle-aged patients with OSA 2 years before diagnosis. DESIGN: Case-control study between January 2001 and April 2003. SETTING: Two sleep–wake disorders centers. PARTICIPANTS: One hundred fifty-eight elderly and 1,166 middle-aged (aged 67–89 and 40–64, respectively) patients with OSA were matched 1:1 with healthy controls according to age, sex, geographic area, and primary physician. MEASUREMENTS: Polysomnography, medical diagnoses, and healthcare utilization. RESULTS: Healthcare costs 2 years before diagnosis were more than 1.8 times as high for elderly and middle-aged patients with OSA as for controls (P

Health care use, a reliable measure of morbidity, is noticeably higher 1 yr before obstructive sleep apnea syndrome (OSAS) diagnosis in preschool children. It is not clear at what age OSAS-related morbidity becomes expressed.To explore morbidity and health care use among children with OSAS starting from first year of life.Case-control study, starting from the first year of life to date of OSAS diagnosis, among 156 patients (age range, 3-5 yr) and their pair-matched healthy control subjects, by age, sex, primary care physician, and geographic location.Patients with OSAS underwent nocturnal polysomnography studies. Medical records during hospital visits were reviewed for diagnosis. Variables of health care use were obtained from computerized databases of Clalit Health Care Services, the largest health maintenance organization in Israel.From the first year of life to date of OSAS diagnosis, children with OSAS had 40% more (p = 0.048) hospital visits, 20% more repeated (two or more) visits (p0.0001), and higher consumption of antiinfective and respiratory system drugs (p0.0001). Referrals of children with OSAS to otolaryngology surgeons and pediatric pulmonologists were higher from Year 1 (p0.0001) to date of OSAS diagnosis, especially in Year 4 (odds ratio, 9.4; 95% confidence interval, 4.2-21.1). The 215% elevation (p0.0001) in health care use of the OSAS group was due mainly to higher occurrence of respiratory tract morbidity (p0.0001).Practitioners should be aware that starting in Year 1 until date of diagnosis, children with OSAS have higher health care use, mostly related to respiratory diseases.

Drug survival has recently become an important clinical issue in psoriasis. However, there has been little research into factors associated with drug survival of methotrexate and acitretin. The aim of this study was to investigate factors associated with drug survival of methotrexate and acitretin treatment for psoriasis. Survival analysis was performed in patients who received methotrexate or acitretin for the treatment of psoriasis, drawn from the Clalit Health Services database. Investigated factors included demographic variables, obesity, metabolic syndrome, psoriatic arthritis, administration route and folic acid supplementation. Among 6,256 patients, factors associated with treatment drop-out were: younger age (p

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

Background The relative efficacy of lapatinib vs. continuing trastuzumab beyond progression (TBP) in HER2-positive metastatic breast cancer (MBC) patients, who progressed on first-line trastuzumab, is still unclear. The objective of this population based cohort study was to compare outcomes of lapatinib vs. TBP in daily practice. Methods All HER2-positive MBC patients who began second-line anti HER2 therapy between 1st January 2010 and 30th August 2013 were selected from Clalit Health Services’ (CHS) electronic database. Available data on patient and disease characteristics and treatments were analyzed. The primary endpoint was overall survival (OS). Outcomes were compared using the Kaplan-Meier (log-rank) method and Cox proportional hazards model. Results 64 patients received second-line lapatinib and 93 TBP. The two treatment groups were similar in age and co-morbidity rates, but differed in proportion of prior adjuvant trastuzumab (lapatinib: 29.7%, TBP: 16.1%, P = 0.043) and rates of prior brain metastases (lapatinib: 32.8%, TBP: 10.8%, P = 0.01). Lapatinib median OS was 13.0 months (95% CI: 9.5–16.5) vs. 31.0 for TBP (95% CI: 20.6–41.4), P

e12512 Background: Tumors with HER2 overexpression usually respond to HER2-targeted therapies. Since the CLEOPATRA and EMILIA trials, a taxane plus trastuzumab and pertuzumab (TTP) are the first-line standard for the management of HER2 + metastatic breast cancer (MBC) and trastuzumab emtansine (TDM-1) is the second-line standard. Intrinsic subtypes existing within HER2+ tumors may impact the degree of a patient’s response to anti HER2 therapy; however HER2 subtyping for predicting response is still experimental and not in routine clinical use. In this retrospective population-based study, we aimed to assess whether duration of treatment (DOT) of second-line TDM1 is associated with the DOT of first-line TTP, and might serve as a hint for a HER2 subtype. Methods: Clalit Health Services (CHS) manages health care of 52% of the Israeli population. We identified 113 HER2+ CHS MBC patients, treated with TTP as first-line treatment that initiated TDM1 as second-line, until Dec. 31, 2016. Patient's (pts) demography, HER2 and HR status were recorded. A Cox proportional hazard model, stratified by HR status, adjusted for age and prior adjuvant trastuzumab, was used to explore the association between second-line and first-line DOT in HR positive and negative pts. Results: Pts baseline characteristics and DOT in first- and second-line treatment are presented in the table. A statistically significant association between DOT of both treatment lines was found in HR positive pts with a trend also in HR negative pts. Conclusions: The observed association between first- and second-line DOT, unrelated to hormonal status, may result from a primary characteristic of the intrinsic tumor subtype, that impacts acquired resistance. Longer observations in larger patient cohorts are required to confirm this observation. [Table: see text]

Background. Obstructive sleep apnea (OSA) is associated with growth impairment that usually improves following effective treatment. In this study we investigated the mechanisms underlying the growth processes in young children diagnosed with OSA, before and after adenotonsillectomy (T&A).Methods. Young children (6–36 months old) were enrolled and evaluated before and several months after T&A surgery for height, weight, circulating high sensitive C-reactive protein (CRP), and insulin-like growth factor 1 (IGF-1) levels. Caloric intake was assessed by a validated Short Food Frequency Questionnaire (SFFQ).Results. Following T&A, children added 4.81 cm and 1.88 kg to their height and weight, respectively (P<0.001for both) and had a significant increase in BMI Z score (P=0.002). Increased caloric intake of 377 kcal/day was noted (P<0.001), with increased protein and decreased fat intake. The decrease in CRP levels correlated with the increase in body weight in boys (P<0.05, adjusted for caloric intake).Conclusions. Adenotonsillectomy results in enhanced somatic growth in young children that correlates with a decrease in systemic inflammation and caloric intake increment. Our findings imply that systemic inflammation may have an important role in this OSA-related morbidity.

INTRODUCTION Recent large randomized controlled trials have shown that direct oral anticoagulants (DOACs) are at least as effective as vitamin K antagonists (VKAs) for prevention of stroke or systemic embolism in patients with non-valvular atrial fibrillation (AF) and are associated with similar or lower rates of bleeding. The results for bleeding seen in Phase 3 trials might not be applicable to real world practice. Population-based studies suggest that the bleeding risk for DOACs and VKA is similar however neither the risk of bleeding associated with different doses of DOACs nor that associated with apixaban in routine clinical practice is well established. We performed a large population-based study to determine the incidence of bleeding in patients with AF beginning treatment with different doses of dabigatran, rivaroxaban, apixaban or a VKA. METHODS From the computerized database of the 4.5 million member Israeli Clalit Health Services health care provider, consecutive patients initiating a VKA or DOAC for AF between January 1, 2011 and December 31, 2014 were studied. Bleeding patients who required hospitalization were identified and key clinical and laboratory data were recorded. Incidence of bleeding was calculated during the first 20 months of treatment which was the minimum duration of treatment for all of the drugs. Adjusted hazard ratios for overall bleeding, intracranial hemorrhage (ICH) and gastrointestinal (GI) bleeding and all-cause mortality within 30 days were recorded and case fatality rates were calculated as the proportions of bleeding patients who died within 30 days. RESULTS 26184 patients initiated anticoagulants for AF: 14258 received VKA, 214 -received dabigatran 75 mg, 3563 received dabigatran 110 mg , 1410 received dabigatran 150 mg, 2570 received rivaroxaban 15 mg, 2140 received rivaroxaban 20 mg, 1227 received apixaban 2.5 mg and 802 received apixaban 5 mg. Key patient demographics and the overall and site-specific bleeding rates are shown in table 1. Hazard ratios for any bleeding, ICH and GI bleeding adjusted for age, renal failure, CHADS2 score, aspirin use and Charlson comorbidity score favored dabigatran 150 mg versus VKA (P CONCLUSIONS The results of our population-based non-randomized study of unselected AF patients demonstrate a decreased bleeding rate for dabigatran 150mg and an increased bleeding rate for apixaban 2.5 mg compared to VKA. There was a consistent tendency for increased bleeding in patients receiving lower versus higher doses of the NOACs which probably reflects physician tendency to select lower doses of DOACs for patients at greater risk for bleeding. Disclosures Ellis: Boehringer Ingelheim: Speakers Bureau; Bayer: Speakers Bureau; Pfizer: Speakers Bureau. Eikelboom:Pfizer: Honoraria, Research Funding; Eli Lilly: Honoraria, Research Funding; Boehringer Ingelheim: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria, Research Funding; Bayer: Honoraria, Research Funding; Astra Zeneca: Honoraria, Research Funding; Bristol Myer Squibb: Honoraria, Research Funding; Sanofi-Aventis: Honoraria, Research Funding; Janssen: Honoraria, Research Funding.

e18258Background: The Israeli Health Insurance Law stipulates a National List of Health Services (NLHS) which all residents are entitled to. Every year, the government allocates an additional budge...

ObjectivesTo determine whether an altered hypothalamic-pituitary-thyroid axis is inherent to Down's syndrome or if a high level of thyroid-stimulating hormone (TSH) is a feature in a subset of patients with Down's syndrome.DesignComparative analysis.SettingMajor health maintenance organisation (3.8 million insured).PatientsA data warehouse search identified all subjects with Down's syndrome who attended Clalit Health Services in 2006 and were tested for TSH and free thyroxine (T4) level on the day of diagnosis (intention-to-treat population). The study group consisted of patients who were not diagnosed with thyroid disease or did not receive thyroid-modulating medication (n=428). Their findings were compared with a control group of healthy age- and sex-matched subjects who were randomly selected from the general population.Main outcome measuresDistribution of free T4, TSH and total T3 levels.ResultsThe distribution plot for TSH showed a significant shift of the curve to higher values in the study group compared with the controls (p≤0.0001). This finding held true on further analysis of the whole intention-to-treat population (pConclusionsDown's syndrome is associated with higher TSH levels. The results suggest that hyperthyrotropinaemia is an innate attribute of chromosome 21 trisomy. Therefore, T4 treatment should not be contemplated in Down's Syndrome unless the TSH is >95th centile in the presence of normal-range free T4 levels.

This study aims to determine whether there is an increased prevalence of obstructive lung diseases (OLDs) in patients with obstructive sleep apnea (OSA). We also determined whether among the OLD patients there is a difference in the prevalences of specific chronic disease co-morbidities between patients with and without OSA. The prevalences of COPD, asthma, and COPD combined with asthma (ICD-9 coding) were compared between 1,497 adult OSA patients and 1,489 control patients, who were matched for age, gender, geographic location, and primary care physician. The prevalences of specific co-morbidities were measured in the OLD groups between patients with OSA and the matched control group. COPD, asthma, and COPD combined with asthma were found to be more prevalent among OSA patients compared to the matched controls. Prevalences among patients with and without OSA, respectively, were COPD—7.6 and 3.7 % (P

We aimed to examine the hypothesis that behavioral and neurocognitive functions of preschool children with Obstructive Sleep Apnea Syndrome (OSAS) are impaired compared to healthy children, and improve after adenotonsillectomy (TA).A comprehensive assessment battery was used to assess cognitive and behavioral functions, and quality of life in children with OSAS compared to matched controls.45 children (mean age 45.5 ± 9 months, 73% boys, BMI 15.7 ± 2) with OSAS were compared to 26 healthy children (mean age 48.6 ± 8 months, 46% boys, BMI 16.4 ± 2). Mean AHI in the OSAS group was 13.2 ± 10.7 (ranging from 1.2 to 57). Significantly impaired planning and fluency (executive function) were found in children with OSAS, as well as impaired attention and receptive vocabulary. Parents and teachers described the OSAS group as having significantly more behavior problems. Quality of life questionnaire in children with OSAS (mean 2.3, range 0.7-4.3) was significantly worse compared to controls (mean 0, range: 0-4), P 0.004. One year following TA, 23 children with OSAS and 18 controls were re-evaluated. Significant improvement was documented in verbal and motor fluency, sustained attention, and vocabulary. After TA, fewer behavioral problems were seen.Preschool children with OSAS present significantly impaired executive functions, impaired attention and receptive vocabulary, and more behavior problems. One year after TA, the prominent improvements were in behavior and quality of life. These findings suggest that the impact of OSAS on behavioral and cognitive functions begins in early childhood.

To describe an organization-wide disparity reduction strategy and to assess its success in quality improvement and reduction of gaps in health and health care.Clalit Health Services, Israel's largest non-for-profit insurer and provider serving 3.8 million persons.Before and after design: quality assessment before and 12-month postinitiation of the strategic plan. A composite weighted score of seven quality indicators, measuring attainment of diabetes, blood pressure, and lipid control, lack of anemia in infants, and performance of mammography, occult blood tests, and influenza vaccinations.Quality indicator scores, derived from Clalit's central data warehouse, based on data from electronic medical records.Low-performing clinics, of low-socioeconomic and minority populations, were targeted for intervention. Twelve months after the initiation of the project continuous improvement was observed coupled with a reduction of 40 percent of the gap between disadvantaged clinics, serving ~10 percent of enrollees, and all other medium-large clinics.The comprehensive strategy, following a quality improvement framework, with a top-down top-management incentives and monitoring, and a bottom-up locally tailored interventions, approach, is showing promising results of overall quality improvement coupled with disparity reduction in key health and health care indicators.

N-terminal pro-B-type natriuretic peptide (NT-proBNP), a marker of ventricular strain, and C-reactive protein (CRP), a marker of inflammation, are reportedly elevated in school-aged children with obstructive sleep apnea (OSA). We hypothesized that cardiovascular morbidity affects circulating markers and their echocardiographic and polysomnographic (PSG) correlates in young children with OSA.We assessed young children undergoing adenotonsillectomy (TA) for OSA by polysomnography, echocardiography, and serum CRP and NT-proBNP levels.A total of 90 children with OSA (mean age 19 +/- 7 months; 71.2% male; BMI, z = 0.62 +/- 1.04) and 45 age- and sex-matched controls were included. Three months following TA, 72 children were reassessed for NT-proBNP and CRP. NT-proBNP level (pg/mL) was higher in subjects with OSA (189.1 +/- 112.7) vs control subjects (104.8 +/- 49.5; P = .006). Both NT-proBNP (187.8 +/- 114 vs 86 +/- 32.6; P = .002) and CRP levels (mg %) (0.49 +/- 0.41 vs 0.1 +/- 0.17; P.05) decreased following TA. Doppler pulse wave measuring tricuspid regurgitation (TR), a reflection of pulmonary hypertension, correlated with CRP (r = 0.61, P.01) but not NT-proBNP (r = -0.14, P = .53) levels. Left ventricle end-diastolic diameter (LVEDD) was at the maximal normal range (0.91 +/- 0.11), but did not correlate with CRP or NT-proBNP levels. Both CRP level and TR correlated with PSG variables reflecting nocturnal hypoxemia, whereas NT-proBNP level and LVEDD did not. Echocardiography in 40 children (out of 90) showed a decline in TR that was abnormal before TA and correlated with the decrease in CRP following TA.NT-proBNP levels are increased in children with OSA and decrease following TA. Echocardiographic parameters suggesting increased pulmonary pressure in young children with OSA are related to nocturnal hypoxemia and systemic inflammation, which also decrease following therapy.

Image-free computer navigation systems build a frame of reference of a patient's knee from anatomical landmarks entered by the surgeon during the initial stage of total knee arthroplasty. We performed tibial cuts on 70 sawbones using computer navigation. All landmarks were marked identically except for the tibial mechanical entry point, which was marked correctly in 10 bones and with offsets of 5, 10, and 15 mm medially and laterally in the others. The actual coronal angle of the tibial cuts was measured directly and compared to the final angle given by the navigation system. Significant deviations of the coronal angle were observed in the trial groups. Landmarking errors during navigated TKA can lead to inaccurate tibial bone cuts. This navigation system did not have an iterative software method to verify landmarking errors that can lead to inaccurate tibia bone cuts.

The aim of this study was to evaluate demographic and polysomnographic characteristics of positional (PPJ) and non-positional obstructive (NPP) sleep apnea (OSA) patients in 2077 OSA patients diagnosed in our Sleep Disorders Unit during a period of 10 years. An OSA patient is defined as positional if he has twice as many or more breathing abnormalities (apnea and hypopneas) while he sleeps in his supine posture compared to the lateral ones. Of the 2077 OSA patients, 1118 (53.8%) were positional and 959 (46.2%) were non-positional. No age differences were found between these two groups of patients. However, NPP were heavier and thus had a higher BMI than PP. PP had fewer and Less severe breathing abnormalities during sleep compared to NPP and thus, they enjoyed better sleep quality expressed by higher percentages of stage 2, 4 and 3+4 as well as a lower amount of short arousals than NPP. Also, PP patients are less sleepy during daytime hours than NPP. During the Multiple Sleep Latency Test (MSLT), NPP fall asleep faster in every nap than PP patients. No differences between these two patient groups were found for any parameter of Periodic Limb Movement Disorders. AHI and BMI are independently but inversely related to positional dependency. As AHI and BMI increase, the Likelihood to be a positional patient decreases. NPP have breathing abnormalities in the supine and lateral postures, thus, for them without question, CPAP is the treatment of choice. Since avoiding the supine posture during sleep may significantly improve the sleep quality and daytime alertness of many positional patients, it is imperative to carry out a high-quality study to evaluate if this is a real therapeutic alternative for many positional patients.

To determine whether elderly subjects with obstructive sleep apnea (OSA) had different morbidity and health care utilization than elderly subjects without OSA and middle-aged patients with OSA 2 years before diagnosis.Case-control study between January 2001 and April 2003.Two sleep-wake disorders centers.One hundred fifty-eight elderly and 1,166 middle-aged (aged 67-89 and 40-64, respectively) patients with OSA were matched 1:1 with healthy controls according to age, sex, geographic area, and primary physician.Polysomnography, medical diagnoses, and healthcare utilization.Healthcare costs 2 years before diagnosis were more than 1.8 times as high for elderly and middle-aged patients with OSA as for controls (P.001). Expenditures of elderly patients with OSA were 1.9 times as high as for middle-aged patients with OSA (P.001). Multiple logistic regression analysis (adjusting for age, body mass index, and apnea hypopnea index) revealed that cardiovascular disease (CVD) (odds ratio (OR)=4.1, 95% confidence interval (CI)=1.8-9.3) and use of psychoactive drugs (OR=3.8, 95% CI=1.5-10.1) are independent determinants for the top-third most-costly elderly patients with OSA.Elderly patients with OSA have high healthcare utilization because of CVD morbidity and use of psychoactive medications. Therefore, OSA has clinical significance in elderly people.

The aim of the present study was to explore morbidity and healthcare utilisation among young adult males with obstructive sleep apnoea (OSA) compared with middle-aged OSA patients over the 5-yr period preceding diagnosis. A prospective case–control study was performed; 117 young (22–39-yr-old) males with OSA were matched with 117 middle-aged (40–64-yr-old) OSA males for body mass index, apnoea/hypopnoea index, arterial oxygen saturation, arousal and awakening index, and Epworth Sleepiness Scale score. Each OSA patient was matched with controls by age, geographic area and physician. Young adult males with OSA showed no increase in specific comorbidity compared with controls. Middle-aged OSA patients exhibited increased risk of cardiovascular disease. Healthcare utilisation for the 5-yr period was ≥1.9 times higher among young and middle-aged male OSA patients than among controls. Multiple logistic regression analysis revealed that hyperlipidaemia in young adults and a body mass index of >37 kg·m −2 and cardiovascular disease in middle-aged adults are the only independent determinants of the upper third, most costly, OSA patients. Compared with middle-aged males with obstructive sleep apnoea, in whom increased expenditure was related to cardiovascular disease and body mass index, utilisation was not related to any specific disease in younger cases.

To explore gender differences in morbidity and total health care utilization 5 years prior to diagnosis of obstructive sleep apnea (OSA).Case-control study; patients were recruited between January 2001 and April 2003.Two university-affiliated sleep laboratories.289 women (22-81 years) with OSA were matched with 289 men with OSA for age, body mass index (BMI), and apnea-hypopnea index (AHI). All OSA patients were matched 1:1 with healthy controls by age, geographic area, and primary physician.Women with OSA compared to men with OSA have lower perceived health status and Functional Outcomes of Sleep Questionnaire score (54.5% vs. 28.4%, P0.05 and 67.5+/-21.4 vs. 76+/-20.1, P0.05, respectively). Compared to men with OSA, women with OSA have higher risk of hypothyroidism (OR 4.7; 95% CI, 2.3-10) and arthropathy (OR 1.6, 95% CI, 1.1-2.2) and lower risk for CVD (OR 0.7; 95% CI, 0.5-0.91). Compared to controls, both women and men with OSA had 1.8 times higher 5-year total costs (P0.0001). Compared to men with OSA, expenditures for women with OSA are 1.3 times higher (P0.0001). The multiple logistic regression (adjusting for BMI, AHI) revealed that age (OR 1.04; 95% CI, 1.01-1.07), antipsychotic and anxiolytic drugs (OR 2.3; 95% CI, 1.2-4.4), and asthma (OR 2.4; 95% CI, 1.1-5.6) are independent determinants for "most costly" OSA women.Compared to men with similar OSA severity, women are heavier users of health care resources. Low FOSQ score and poor perceived health status in addition to overuse of psychoactive drugs are associated with high health care utilization among women with OSA.

10538 Background: Imatinib (IM) revolutionized the outcome of patients with advanced GISTs; however, disease progression eventually occurs due to IM resistance or intolerance. Sunitinib (SU) is an ...

Study objective To evaluate the possible role of low socioeconomic status (SES) as a risk factor for cardiovascular disease (CVD) among obstructive sleep apnea syndrome (OSAS) patients requiring treatment. Design Polysomnographic and demographic characteristics and associated morbidity were measured in 686 prospectively recruited adult OSAS patients from two regions in Israel. Setting Two university-affiliated sleep laboratories. Measurements and results The multiple logistic regression (after adjusting for gender, body mass index [BMI], and smoking) revealed that the following are independent determinants for CVD in OSAS patients requiring treatment: each decrease in income level category (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1 to 1.7), age ≥ 1 year (OR, 1.07; 95% CI, 1.04 to 1.1), hypertension (OR, 2.0; 95% CI, 1.3 to 3.1), and hyperlipidemia (OR, 3.7; 95% CI, 2.4 to 5.8); area under the receiver operating characteristic (ROC) = 81.9%. The multivariate determinants describing the low-SES OSAS patients included: minorities and immigrants combined (OR, 6.0; 95% CI, 2.9 to 12), female gender (OR, 2.4; 95% CI, 1.6 to 3.9), increased BMI (OR, 1.9; 95% CI, 1.3 to 2.9), unmarried status (OR, 1.9; 95% CI, 1.2 to 3.1), and years of education (≥ 1 year) [OR, 0.8; 95% CI, 0.7 to 0.8]; area under the ROC = 78.1%. Conclusion In addition to the already known traditional risk factors, low SES was found to be a novel independent risk factor for CVD among adult OSAS patients requiring treatment.

To investigate determinants of health-care utilization in patients with obstructive sleep apnea syndrome (OSAS).Case-control prospective study with OSAS patients and a control group. We compared 218 patients with OSAS to those of age-, gender-, geographically-, and family physician-matched control subjects from the general population, matched 1:1 (chi2 = 0.999).All participants were members of Clalit Health Care Services, a health maintenance organization in the southern region of Israel. All OSAS patients underwent nocturnal polysomnography studies. Indexes of health-care utilization 2 years prior to the polysomnography were analyzed.Health-care utilization was 1.7-fold higher (p0.001) in the OSAS patients due to more hospitalization days (p0.001), consultations (p0.001), and cost for drugs (p0.05), particularly those for the cardiovascular system. In comparison to men, women consumed significantly more health-care resources (p0.001). OSAS patientsor = 65 of age years consumed 2.2-fold more health-care resources than control subjects (p0.001). Polysomnography findings and OSAS severity and body mass index (BMI) did not predict health-care utilization, using multivariate logistic regression analysis. Age65 (odds ratio [OR], 2.2; p0.04) and female gender (OR, 2.0; p0.05) were the leading elements predicting the most costly OSAS patients. Arbitrarily dividing the OSAS group by cost of health-care utilization, the upper 25% (n = 55) of patients who were the "most costly" consumed sevenfold more health-care resources than the lower 75% of the patients. This was due to higher comorbidity, ie, 10 to 30% more hypertension, ischemic heart disease, diabetes mellitus, and pulmonary disease.OSAS patients are heavy users of health-care resources. Age65 years and female gender were the leading elements predicting the most costly OSAS patients, and not necessarily patients with a high BMI and classic OSAS severity indexes.

Background Psoriatic arthritis (PsA) is associated with higher prevalence and risk for cardiovascular morbidities [1,2]. Objectives The aim of the study is to substantiate these findings in our population and to examine additional aspects of cardiovascular morbidities, including congestive heart failure and cardiomyopathy. Methods A retrospective, longitudinal, cohort case control study was performed on records of patients with PsA between 2000 and 2013 from the database of Israel9s largest health care provider, Clalit Health Services. For each patient with PsA, 5 control patients without history of psoriasis or rheumatoid arthritis were chosen, matched for age and gender. The following morbidities were analyzed: ischemic heart disease (IHD), valvular heart disease excluding mitral valve prolapse, congestive heart failure (CHF), cardiomyopathy, idiopathic hypertrophic subaortic stenosis (IHSS), cerebrovascular accident (CVA), carotid artery disease, peripheral vascular disease (PVD), and aortic aneurism. T-test was used to compare continuous variables and Chi square test was used for categorical variables. Age, gender, socioeconomic status and ethnicity were entered into a multivariate regression model. Results The study included 3161 patients with PsA, 1474 males (46.6%) and 1687 (53.4%) females with a mean age of 58.29±15.44 years, and 15,805 controls. Comparative analysis demonstrated higher prevalence of the following in the case cohort: IHD (18.95% vs. 14.49%) p Conclusions A high prevalence of cardiovascular co-morbidities was found in this cohort of PsA patients. The spectrum of cardiac involvement was not limited to IHD, carotid artery disease and PVD, and included also increased risk of CHF, cardiomiopathies and valvular heart disease. A high index of suspicion, and close monitoring and treatment of cardiovascular risk factors are recommended. References Husni ME, Mease PJ. Managing comorbid disease in patients with psoriatic arthritis. Curr Rheumatol Rep 2010;12:281–287. Horreau C, Pouplard C, Brenaut E, Barnetche T, Misery L, Cribier B, et a l. Cardiovascular morbidity and mortality in psoriasis and psoriatic arthritis: a systematic literature review. J Eur Acad Dermatol Venereol 2013;27(Suppl. 3):12–29. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3830