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

BACKGROUND: In 1995 Clalit Health Services introduced a structured follow-up schedule, by primary care nurses, of diabetic patients. This was supplementary care, given in addition to the family physician's follow-up care. This article aims to describe the performance of diabetes follow-up and diabetes control in patients with additional structured nursing follow-up care, compared to those patients followed only by their family physician. METHODS: We randomly selected 2,024 type 2 diabetic subjects aged 40-76 years. For each calendar year, from 2005-2007, patients who were "under physician follow-up only" were compared to those who received additional structured nursing follow-up care. MAIN OUTCOMES: Complete diabetes follow-up parameters including: HbA1c, LDL cholesterol, microalbumin, blood pressure measurements and fundus examination. RESULTS: The average age of study participants was 60.7 years, 52% were females and 38% were from low socioeconomic status (SES). In 2005, 39.5% of the diabetic patients received structured nursing follow-up, and the comparable figures for 2006 and 2007 were 42.1% 49.6%, respectively. The intervention subjects tended to be older, from lower SES, suffered from more chronic diseases and visited their family physician more frequently than the control patients. Patients in the study group were more likely to perform a complete diabetes follow-up plan: 52.8% vs. 21.5% (2005; p < 0.001) 55.5% vs. 30.3% (2006; p < 0.001), 52.3% vs. 35.7% (2007; p < 0.001). LDL cholesterol levels were lower in the study group only in 2005: 103.7 vs. 110.0 p < 0.001. CONCLUSION: Subjects with supplementary structured nursing follow-up care were more likely to perform complete diabetes follow-up protocol. Our results reinforce the importance of teamwork in diabetic care. Further study is required to identify strategies for channeling the use of the limited resources to the patients who stand to benefit the most.

Low rate of non-attenders to primary care providers in Israel - a retrospective longitudinal study.

BACKGROUND: A model that combines reactive and anticipatory care within routine consultations has become recognized as a cost-effective means of providing preventive health care, challenging the need of the periodic health examination. As such, opportunistic screening may be preferable to organized screening. Provision of comprehensive preventive healthcare within the primary care system depends on regular attendance of the general population to primary care physicians (PCPs). OBJECTIVES: To assess the proportion of patients who do not visit a PCP even once during a four-year period, and to describe the characteristics of this population. METHODS: An observational study, based on electronic medical records of 421,012 individuals who were members of one district of Clalit Health Services, the largest health maintenance organization in Israel. RESULTS: The average annual number of visits to PCPs was 7.6 ± 8.7 to 8.3 ± 9.0 (median 5, 25%-75% interval 1-11) and 9.5 ± 10.0 to10.2 ± 10.4 (median 6, 25%-75% interval 1-14) including visits to direct access consultants) in the four years of the study. During the first year of the study 87.2% of the population visited a PCP. During the four year study period, only 1.5% did not visit a PCP even once. In a multivariate analysis having fewer chronic diseases (for each additional chronic disease the OR, 95% CI was 0.40 (0.38¬0.42)), being a new immigrant (OR, 95% CI 2.46 (2.32¬2.62)), and being male (OR, 95% CI 1.66 (1.58¬1.75)) were the strongest predictors of being a non-attender to a PCP for four consecutive years. CONCLUSIONS: The rate of nonattendance to PCPs in Israel is low. Other than new immigrant status, none of the characteristics identified for nonattendance suggest increased need for healthcare services.

Low clinical utility of folate determinations in primary care setting.

BACKGROUND: Fortification of cereal products with folic acid is not mandatory in Israel, yet folate deficiency remains rare and is usually associated with poor diet, malabsorption, alcoholism, or use of certain drugs. A retrospective review of all folate level determinations performed between January 2004 and January 2007 in the central district of Clalit Health Services in Israel revealed that only 4.3% of the 43,176 tests ordered were below the norm (5.6 nmol/L). OBJECTIVES: To determine parameters that identify folate-deficient patients without known risk factors and to establish principles that aid the physician in deciding when to order folate determinations. METHODS: Study population included 152 patients from 13 large primary care clinics with folate deficiency but without known risk factors for folate deficiency (37 with anemia). They were matched with 556 controls (141 with anemia).The medical records were reviewed for the indication of the test and treatment that followed the results. RESULTS: Hematologic indices, vitamin B12, ferritin, and transferrin saturation levels were similar in the study and control groups. Subgroup comparisons based on anemia status showed similar results. The clinical indications for folate determinations were similar in the folate-deficient patients and the control group. Only 68 of 152 patients (44.7%) were prescribed a folate supplement. CONCLUSIONS: Neither laboratory parameters nor clinical findings in patients' charts were capable of distinguishing folate-deficient patients from controls. It seems that folate determinations in patients without known risk factors for folate deficiency are of little clinical significance.

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

BACKGROUND: Immigrant populations moving from undeveloped countries with low asthma prevalence have shown increased asthma prevalence in their new Westernized environment. We compared the prevalence of asthma among Israeli born children of Ethiopian origin to that in non-Ethiopian children. METHODS: Cross sectional study. Data was retrieved for children aged 6-18 years in four clinics with a large proportion of patients of Ethiopian origin. For each Israeli born child from Ethiopian origin we matched an Israeli born child of any other origin of the same age and gender, receiving primary care from the same physician at the same clinic. Asthma was defined as any visit to a primary care physician, emergency room or hospitalization related to asthma symptoms or subsequent purchasing of any asthma medication during 2008. RESULTS: 1217 children of Ethiopian origin and 1217 matched controls were studied. More Ethiopian children came from families with a low socioeconomic status (23.9% vs. 17%, p < 0.001), and with significantly lower parental smoking (5.1% vs. 40.1%, p < 0.001). The prevalence of asthma was 92/1217 (7.5%) among children of Ethiopian origin, compared to 122/1217 (10.0%) among the control group (OR = 0.74, 95% CI: 0.56-0.98, p = 0.032). When adjusted for tobacco exposure, the OR for risk of asthma in the Ethiopian children was 0.80 (95% CI: 0.59-1.09, p = 0.16). CONCLUSION: Asthma prevalence in the second generation of Israeli born children of Ethiopian origin does not seem to differ from other children in their community. This observation supports the theory that environmental exposures, rather than genetic factors, dictated the increase in asthma in this immigrant population.

[Family physicians attitude towards quality indicator program].

BACKGROUND: Quality indicator programs for primary care are implanted throughout the world improving quality in health care. In this study, we have assessed family physicians attitudes towards the quality indicators program in Israel. METHODS: Questionnaires were distributed to family physicians in various continuing educational programs. The questionnaire addressed demographics, whether the physician dealt with quality indicators, time devoted by the physician to quality indicators, pressure placed on the physician related to quality indicators, and the working environment. RESULTS: A total of 140 questionnaires were distributed and 91 (65%) were completed. The average physician age was 49 years (range 33-65 years]; the average working experience as a family physician was 17.8 years (range 0.5-42); 58 physicians were family medicine specialist (65.9%). Quality indicators were part of the routine work of 94% of the physicians; 72% of the physicians noted the importance of quality indicators; 84% of the physicians noted that quality indicators demand better team work; 76% of the physicians noted that quality indicators have reduced their professional independence. Pressure to deal with quality indicators was noted by 72% of the family physicians. Pressure to deal with quality indicators was related to reduced loyalty to their employer (P = 0.001), reducing their interest to practice family medicine (p < 0.001), and increasing their burnout at work (p = 0.001). DISCUSSION: It is important that policy makers find the way to leverage the advantages of quality indicator programs, without creating a heavy burden on the work of family physicians.

Patient characteristics correlated with quality indicator outcomes in diabetes care.

BACKGROUND: Quality indicators were adopted to compare quality of care across health systems. AIM: To evaluate whether patient characteristics influence primary care physicians' diabetes quality indicators. DESIGN OF STUDY: Retrospective cohort study. SETTING: Primary care setting. METHOD: The study was conducted in the Central District of Clalit Health Service in Israel. The five measures of diabetes follow-up were: the percentage of patients with diabetes for whom glycosylated haemoglobin (HbA(1c)), microalbumin, low-density lipoprotein (LDL)-cholesterol, and blood pressure were measured at least once, and the percentage of patients who were seen by an ophthalmologist, during 2005. Three outcome measures were chosen: the percentage of patients with diabetes and HbA(1c) <7 mg%, the percentage of patients with diabetes and blood pressure <130/80 mmHg, and the percentage of patients with diabetes and LDL-cholesterol <100 mg/dl in 2005. Sociodemographic information was retrieved about all the physicians' patients with diabetes. RESULTS: One-hundred and seventy primary care physicians took care of 18 316 patients with diabetes. The average number of patients with diabetes per physician was 107 (range 10-203). A lower quality indicator score for HbA(1c) <7 mg% was correlated with a higher percentage of patients of low socioeconomic status (P<0.001) and new immigrants (P = 0.002), and correlated with borderline significance with higher mean patients' body mass index (P = 0.024); lower quality indicator score for blood pressure <130/80 mmHg was related to higher patients' age (P = 0.006). None of the diabetes follow-up measures were related to patients' characteristics. CONCLUSION: Achieving good glycaemic control is dependent on patient characteristics. New immigrants, patients of low socioeconomic status, and older patients need special attention to avoid disparities.

Patient attitudes to being treated by junior residents in the community.

OBJECTIVE: Understanding the attitudes of patients to being treated by residents in the community. METHODS: A questionnaire was administered to patients visiting community family medicine teaching clinics. The study methodology included statements to which they agree or disagree. RESULTS: Three hundred and four questionnaires were completed by patients; 94% had visited a resident in the past year; 78.9% agreed that residents were as skilled as senior doctors, but only 45.4% felt that they were as quick at diagnosis as the senior doctors; 73.0% felt that residents spent more time with them; 40.0% were not pleased by the constant change of the residents attending on them. Analysis by logistic regression showed that men had a more positive attitude to the competence of the residents as well as their professionalism (OR 2.73, 95% CI, 1.45-5.10). Frequent visitors to the clinic had a more negative attitude to the residents' professionalism (OR 0.91 (0.85-0.98)) and were more likely to agree with the statement "I would prefer to see the regular doctor and not a different resident each time" (OR 1.09 (1.01-1.18)). Those who were attended more by residents on their visits showed a positive attitude to the professionalism of residents (OR 1.14 (1.01-1.28)) and were less likely to agree with the statement "I would prefer to see the regular doctor and not a different resident each time" (OR 0.90 (0.84-0.98)). CONCLUSIONS: Patients have a positive attitude to being treated by residents in ambulatory clinics, which is associated with repeat exposure to care by residents. PRACTICAL IMPLICATIONS: Departments with ambulatory training should consider having constant presence of residents in their teaching clinics, and teaching staff in the clinics should develop ways to recommend patients to be seen by residents.

Suboptimal identification of obesity by family physicians.

OBJECTIVES: To examine how family physicians identify and document obesity. STUDY DESIGN: Prospective cross-sectional study of 289 patients in 7 family practice clinics of Clalit Health Services in Israel. METHODS: Two hundred eighty-nine patients from 7 family practice clinics had their body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) determined by the study staff and subsequently compared with the data retrieved from the family practices' database regarding physicians' BMI documentation and obesity diagnosis. Demographic variables, comorbidities, and medication use were also extracted. Multivariate odds ratios (ORs) and 95% confidence intervals (CIs) were obtained to determine the predictors of BMI documentation. RESULTS: Seventy-eight of 289 patients (27.0%) were obese (BMI, > or =30.0), and 126 (43.6%) were overweight (BMI range, 25.0 to < or =29.9). Body mass index was documented in 39 of 78 obese patients (50.0%) and in 49 of 126 overweight patients (38.9%) (P <.001). Diagnosis of obesity was recorded in 19 of 78 obese patients (24.4%). Older patients (OR, 2.77; 95% CI, 1.39-5.49) and obese patients (OR, 2.04; 95% CI, 1.04-3.99) were more likely to have their weight and height measured and BMI calculated by their physician. Patients with comorbid conditions such as diabetes mellitus (OR, 4.35; 95% CI, 2.20-8.62) and hypertension (OR, 3.20; 95% CI, 1.71-5.99) and patients taking chronic medications (OR, 3.44; 95% CI, 1.20-9.83) were also more likely to have their BMI documented. CONCLUSIONS: Family physicians failed to identify most obese and overweight patients, as seen by lack of BMI documentation and concordant diagnoses in the medical problem list. Determination of BMI by physicians in family practice is of utmost importance, and its incorporation into medical care should be optimized.

[Attitudes of family physicians to influenza vaccination after a cluster of deaths that were initially attributed to the vaccination].

BACKGROUND: The influenza vaccination rates in high risk populations decreased in 2006, in part, perhaps, as a reaction to a cluster of deaths that were initially attributed to the vaccine. We postulated that this event affected family physicians who usually recommend vaccination, and caused a change in their prescribing behavior. OBJECTIVES: To survey family physicians as to their recommendation of the influenza vaccine in 2006 as opposed to the previous year. METHODS: After the 2006 influenza vaccination season an anonymous questionnaire was distributed in various settings to family physicians. The questions related to prescribing behavior in various target populations and whether they vaccinate themselves and their families. RESULTS: A total of 122 physicians responded; 74.5% thought that there was minimal or no connection between the vaccine and the deaths, 75.8% also denied any change in their recommendation behavior. However, there was a significant decrease in the recommendation strength as seen in the percentage of physicians who reported very strong recommendations to the elderly (57.4% vs. 32.3%, p < 0.05) and chronically ill patients (64.8% vs. 39%, p < 0.05). No difference was seen in their reported personal vaccination behavior. A multivariate regression model did not find any correlations between characteristics of the responding physicians and their attitudes or changes in attitudes to the influenza vaccine. CONCLUSIONS: The family physicians were more hesitant in recommending the influenza vaccine in 2006, and this may have affected vaccination rates. Improved availability of information and guidance to family physicians after the cluster of deaths may have prevented this.

[Has the time come to adopt consultation time as a new technology for "the basket"? A literature review of the relations between consultation duration and consultation quality in primary care].

Consultation time is an important resource in primary care, and it is important to understand whether a longer consultation results in better outcomes in morbidity and mortality, and patients' and physicians' satisfaction. Patients' visits may last from 2-3 minutes up to 30 minutes for similar medical problems. The increasing demands from the primary care physician in preventive medicine, complicated care and mental health, have led physicians to feel that the length of time for consultations were insufficient to fulfill these demands. The literature review conducted revealed two forms of research: observational studies where the research examined the relation between consultation length and various outcomes, and intervention studies where different consultation length were compared in order to assess their outcome. The studies are presented in this review according to the parameters that were examined: patients' and doctors' satisfaction, physician stress during the consultation, patients' recurrent visits, diagnosis of depression and psychological problems by the physician, preventive medicine and life style recommendation during consultation, diagnosis and treatment of acute and chronic diseases by the physician, utilization of resources such as prescription number, lab tests and referral to specialists by the physician.

Transition to insulin in Type 2 diabetes: family physicians' misconception of patients' fears contributes to existing barriers.

BACKGROUND: Many patients with Type 2 diabetes require treatment with insulin but do not receive it. AIM: To examine the barriers that hinder the transition to insulin from the point of view of patients and family physicians. PATIENTS: Study group (SG)-92 patients who need insulin (maximum oral medications and HbA(1c)>8.5%). Control group (CG)-101 patients who had begun insulin medication recently. PATIENTS were interviewed about attitudes and beliefs regarding their illness and insulin treatment. Physicians: 157 family physicians completed a questionnaire regarding barriers to insulin treatment and answered an open-ended question about the criteria for starting insulin. RESULTS: In comparing between barriers of SG patients and perspectives of the CG patients, SG patients perceived their illness as not very serious (46.7% vs. 7%, P<.0001), had more fear of addiction to insulin (39% vs. 20.8%, P<.01) and hypoglycemia (12% vs. 4%, P=.05), and perceived the quality of their treatment worse (P<.001). Pain associated with injection and blood tests ranked low. Only 44.3% of physicians specified two criteria or more for treatment with insulin. Physicians' main barriers for commencing insulin medication were as follows: patients' compliance (92.3%), hypoglycemia (79.9%), coping with pain associated with blood tests (53.9%), and pain associated with injections (47.4%). CONCLUSION: Physicians' knowledge was relatively low, and they assign much more importance to the physical fears of patients and are not sufficiently aware of patients' misconceptions regarding the seriousness of their condition and concerns of addiction. This gap apparently contributes to the delay or even the prevention of commencing insulin medication.

Attitudes and knowledge on breastfeeding among paediatricians, family physicians, and gynaecologists in Israel.

OBJECTIVES: Many women in Western countries fail to breastfeed long enough. The aim of this study was to examine the attitudes and knowledge of Israeli family physicians (FPs), gynaecologists and paediatricians towards breastfeeding. DESIGN AND PARTICIPANTS: A questionnaire examined Physicians' attitudes towards breastfeeding and their role in encouraging it, their sources of information and adequacy of knowledge. RESULTS: Four hundred and seventy-eight physicians responded to the survey: 123 FPs, 134 gynaecologists and 221 paediatricians. Ninety to -hundred per cent of physicians agreed that breastfeeding is the best feeding method for infants and agree that physicians should encourage it. Less than 20% of physicians discuss breastfeeding with pregnant women, and less than 30% discuss it with women 3 months or more postnatally. On average, physicians correctly answered 3.5 +/- 1.7 out of seven questions examining knowledge. Physicians state their main sources of information as their own experience and reading. One hundred and ninety physicians specified how they encourage breastfeeding--of those, 75.3% speak only of the advantages of breastfeeding. CONCLUSION: Physicians have a positive disposition towards breastfeeding but their knowledge is somewhat low. It seems awareness is lacking to the importance of continuous support and practical guidance beginning before birth and continuing until 3 months or more postnatal.

Anti-beta2-glycoprotein I in Sjogren's syndrome is associated with parkinsonism.

The nervous system may be involved in up to 30% of patients with Sjogren's syndrome (SS). We describe three patients with Sjogren's syndrome and a concomitant parkinsonian syndrome. Elevated titers of anti-beta2-glycoprotein I IgG were found in the serum of all three patients. This autoantibody is strongly associated with anticardiolipin (aCL) antibodies, antiphospholipid syndrome (APS), and thromboembolic phenomena, but its role in the pathogenesis of the parkinsonian disorder in SS is unclear. These patients may present a subtype of SS patients in which the presence of aCL antibodies is associated with central nervous system involvement predominantly in the basal ganglia.

The role of periodic mortality case review sessions in a primary care teaching clinic.

BACKGROUND: Maintaining a death register and holding staff discussions about patients who died can aid the physician in audit and research, which will lead to improved care of the terminally ill and the bereaved and to the development of prevention strategies. These issues are important for students and residents as well. OBJECTIVES: To review the value of mortality-case discussions in primary care clinics, particularly teaching clinics. METHODS: The clinic death register, instituted in 1998, includes age, gender, cause of death, place of death, relevant illnesses, and support provided to the patient before the death. In the half-yearly sessions, the data are reviewed, and individual cases that had an emotional impact on the staff, or information that can bring about changes in future care are discussed by the clinic staff and trainees. RESULTS: In our clinic 233 deaths occurred during a 6 year period (1998-2003). The crude all-cause mortality rate was 7.1/1000. The median age was 80 years old. Neoplastic causes were slightly more frequent than cardiovascular causes of death. Only 15% died at home; 20% lived alone and 70% lived with a spouse or family members before the death. Topics discussed in the mortality review meetings include identifying pre-suicidal patients, when to hospitalize the sick elderly, dealing with the anger of bereaved families, and ensuring proper home care for terminal patients. CONCLUSIONS: We recommend keeping a death register and conducting mortality review sessions in order to improve the quality of care, emotional support of the staff, and training students and residents about the complex issues surrounding the death of patients.

Quality of diabetes care in the community: a cross-sectional study in central Israel.

BACKGROUND: Good care of the diabetic patient reduces the incidence of long-term complications. Treatment should be interdisciplinary; in the last decade a debate has raged over how to optimize treatment and how to use the various services efficiently. OBJECTIVES: To evaluate the quality of care of diabetic patients in primary care and diabetes clinics in the community in central Israel. METHODS: We conducted a retrospective cross-sectional study of a random sample of 209 diabetic patients in a district of the largest health management organization in Israel. Patients were divided into two groups - those treated only by their family physician and those who had attended diabetes clinics. Data included social demographics, medications, risk factors, quality of follow-up, laboratory tests, quality of diabetes and blood pressure control, and complications of diabetes. RESULTS: Of the 209 patients 38% were followed by a diabetes clinic and 62% by a family physician. Patients attending the specialist clinic tended to be younger (P= 0.01) and more educated (P= 0.017). The duration of their diabetes was longer (P < 0.01) and they had more diabetic microvascular complications (P= 0.001). The percentage of patients treated with insulin was higher among the diabetes clinic patients (75% vs. 14%, P= 0.0001). More patients with nephropathy received angiotensin-converting enzyme inhibitors in the diabetes clinic (94% vs. 68%, P= 0.02). Follow-up in the specialist clinic as compared to by the family physician was better in the areas of foot examination (P< 0.01), fundus examination (P= 0.0001), and hemoglobin A1c testing (P= 0.01). On a regression model only fundus examination, foot examination and documentation of smoking status were significantly better in the diabetes clinic (P< 0.05). CONCLUSION: There is still a large gap between clinical guidelines and clinical practice. Joint treatment of diabetic patients between the family physician and the diabetes specialist may be a proposed model to improve follow-up and diabetes control. This model of treatment should be checked in a prospective study.

Herpetic eye disease in diabetic patients.

PURPOSE: To study the incidence of herpetic eye disease (HED) of the ocular surface in diabetics. DESIGN: Observational historical cohort study. SETTING: A district of the largest health maintenance organization in Israel (the Central District of Clalit Health Services). PARTICIPANTS: We reviewed the electronic medical records of all patients older than 50 years (159634 patients) in the district, and of these, 22382 (14.0%) patients had diabetes mellitus. METHODS: All filled prescriptions for acyclovir eye ointment between January 1, 2001 and December 31, 2003 (1483 tubes) and all hemoglobin A1c laboratory tests during 2003 (41910 tests) were documented. An ocular surface HED event was defined when a patient consumed at least 1 tube of topical acyclovir per month, whereas no acyclovir use was documented 3 months before and 3 months after that event. MAIN OUTCOME MEASURES: Incidence of ocular surface HED events in diabetics compared with nondiabetics adjusted for age and gender. RESULTS: After age and gender adjustment, significantly more diabetics had ocular surface HED (5.21 per thousand) compared with nondiabetics (4.27 per thousand; P<0.0001). Stratification by age revealed a significantly higher prevalence of HED in diabetics, aged 60 to 79 years. Recurrent herpetic events occurred during the study period in 25.2% of HED-affected diabetics, and in 16.6% of HED-affected nondiabetics (P = 0.05). Diabetics with poor glycemic control (mean annual hemoglobin A1c > 9%) consumed significantly more ocular acyclovir (P = 0.01). Multivariate analysis revealed this effect to be independent of age, gender, place of birth, or place of residency. CONCLUSIONS: Ocular surface HED is significantly more common among patients with diabetes mellitus. Poor glycemic control correlates with increased consumption of ocular acyclovir in diabetic patients.

[Intervention project to improve control of hypertension among diabetic patients--experience in a primary care clinic].

BACKGROUND: Hypertension in diabetics is a recognised risk factor for vascular disease, both of large and small vessels. Tight control of blood pressure (BP), aiming at 130/80, reduces both morbidity and mortality from vascular disease. OBJECTIVE: Tight control of BP in diabetics aiming at 130/80. TARGET POPULATION: Type 2 diabetics with BP over 130/80, whether undergoing treatment or not, in the Shoham primary care clinic. METHODS: Patients meeting the above criteria were identified by scanning their files. Their compliance to treatment and dose adjustment was followed. Preferred first line drugs were ACE inhibitors and diuretics. RESULTS: A total of 91 of the 115 (79%) diabetics were identified as also being hypertensive. The objective of BP 130/80 or less was achieved in 26% of cases at the beginning of the research and in 53% after 6 months (p<0.001). Prior to the intervention, the average BP in the hypertensives was 142.1+/-17.6/80.6+/-8.3 and they were being treated with an average of 1.5+/-1.2 drugs. Twenty-one patients (23%) were receiving no drug treatment. After 6 months the average BP in these patients was 132.2+/-14.2/77.6+/-6.1 and they were being treated with an average of 2.0+/-1.2 drugs. Six (6.5%) patients were without drug treatment. The average diastolic and systolic pressure was significantly lower after the intervention (p<0.001 and p=0.001 respectively) and more anti-hypertensive drugs were being used (p=0.001) CONCLUSION: Through good clinical team co-operation it is possible to successfully treat hypertension in diabetics. It is important to implement the guidelines of treating hypertensive diabetics.

[Lag Ba-Omer bonfires--is there any association between the tradition and asthma and COPD exacerbations].

BACKGROUND: Air pollution is a potential cause of asthma and COPD exacerbations. On the evening of Lag Ba-Omer, when there were bonfire parties throughout the country, significant air pollution was reported. OBJECTIVES: To evaluate the association of the air pollution caused by Lag Ba-Omer bonfires party (8th May 2004) and asthma and COPD exacerbations in the Rehovot area. METHODS: Data on air quality and pollution levels was retrieved from the monitoring system of the Ministry of the Environment for the period of Lag Ba-Omer (May 2004). All visits to the Kaplan Medical Center Emergency Department, local after-hours first aid clinics and hospital admissions in May 2004 were evaluated. The daily rate of visits and admissions with the diagnosis of asthma or COPD exacerbation was recorded. RESULTS: Data from the Rehovot monitoring station revealed worsening in the air pollution indices in the two days after Lag Ba-Omer. On the same days of the week, a week earlier and a week later, the air quality was good. There was no increase in asthma or COPD visits to after-hours first aid clinics and no increase in hospitalizations. An increase in the rate of visits due to asthma and COPD to the emergency department was noted in the days after Lag Ba-Omer in comparison to the control days (15/277 (5.4%) vs. 14/593 (2.4%), p < 0.05). CONCLUSION: There was an increase in emergency department visits due to asthma and COPD without an increase in hospital admissions in the days of air pollution after Lag Ba-Omer. Further studies should focus on a possible increase in self medication and family physician visits in the period around Lag Ba-Omer.

Dry eye in diabetic patients.

PURPOSE: To compare the prevalence of keratoconjunctivitis sicca (KCS) in a prospective cohort of 22,382 diabetic patients with that in the general population. DESIGN: Prospective, observational, cohort study. SETTING: A district of israel's largest health maintenance organization. STUDY POPULATION: We followed the electronic medical records of all patients in the district older than 50 years (159,634 patients) between January 1 and December 31, 2003. Of those, 22,382 (14.0%) had diabetes. OBSERVATION PROCEDURE: The proportion of ocular lubrication consumers was compared among diabetic and nondiabetic patients. All HbA1c laboratory tests performed by the diabetic patients were documented (41,910 tests), and glycemic control was correlated with the consumption of ocular lubrication. MAIN OUTCOME MEASURES: Ocular lubrication use by diabetic patients compared with the general population and the relationship between glycemic control and ocular lubrication use. RESULTS: After age and gender adjustment, a significantly higher percentage of diabetic patients (20.6%) received ocular lubrication, compared with nondiabetic patients (13.8%, P < .001). The difference was significant for all age groups and for both sexes (P < .001). A similar significant difference was prominent between diabetic and nondiabetic patients aged 60 to 89 years who were frequent users of ocular lubrication. Ocular lubrication consumption increased with poorer glycemic control (mean annual HbA1c levels). Multivariate analysis revealed this effect to be independent of age, sex, place of birth, or place of residence. CONCLUSIONS: KCS is significantly more common among diabetic patients. Poor glycemic control correlates with increased artificial tear use in diabetic patients.