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

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

Incident gout and chronic Kidney Disease: healthcare utilization and survival

Background

Uncontrolled gout can cause significant joint and organ damage and has been associated with impairments in quality of life and high economic cost. Gout has also been associated with other comorbid diseases, such as chronic kidney disease. The current study explored if healthcare resource utilization (HRU) and survival differs between patients with incident gout in the presence or absence of chronic kidney disease (CKD).

Methods

Clalit Health Services (CHS) data were used to conduct a retrospective population-based cohort study of incident gout between 1/1/2006–31/12/2009. Incident cases of gout were identified and stratified by CKD status and by age group (< 55 and 55+ years). CKD status was defined as a pre-existing diagnosis of chronic kidney disease, chronic renal failure, kidney transplantation, or dialysis at index date. Demographic and clinical characteristics, as well as healthcare resource use, were reported.

Results

A total of 12,940 incident adult gout patients, with (n = 8286) and without (n = 4654) CKD, were followed for 55,206 person-years. Higher rates of HRU were observed for gout patients with CKD than without. Total annual hospital admissions for patients with gout and CKD were at least 3 times higher for adults < 55 (mean = 0.51 vs 0.13) and approximately 1.5 times higher for adults 55+ (mean = 0.46 vs 0.29) without CKD. Healthcare utilization rates from year 1 to year 5 remained similar for gout patients < 55 years irrespective of CKD status, however varied according to healthcare utilization by CKD status for gout patients 55+ years. The 5-year all-cause mortality was higher among those with CKD compared to those without CKD for both age groups (HR_{< 55 years} = 1.65; 95% CI 1.01–2.71; HR_{55+ years} = 1.50; 95% CI 1.37–1.65).

Conclusions

The current study suggests important differences exist in patient characteristics and outcomes among patients with gout and CKD. Healthcare utilization differed between sub-populations, age and comorbidities, over the study period and the 5-year mortality risk was higher for gout patients with CKD, regardless of age. Future work should explore factors associated with these outcomes and barriers to gout control in order to enhance patient management among this high-risk subgroup.

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

CONTEXT

Low serum calcidiol has been associated with multiple comorbidities and mortality but no "safe" range has been found for the upper concentration.

OBJECTIVE

We aim to establish the upper threshold of serum calcidiol, beyond which there is an increased risk for acute coronary syndrome and/or mortality.

DESIGN, SETTING, AND PARTICIPANTS

We extracted data for 1,282,822 Clalit Health Services members aged >45 between July 2007 and December 2011. Records of mortality or acute coronary syndrome were extracted during the follow-up period. Kaplan-Meier analysis calculated time to episode and Cox regression models generated adjusted hazard ratios for episode by calcidiol group (<10, 10.1-20, 20.1-36, and >36.1 ng/mL).

OUTCOME MEASURES

Acute coronary syndrome subsuming all-cause mortality.

RESULTS

During the 54-month study period, 422,822 Clalit Health Services members were tested for calcidiol, of which 12,280 died of any cause (905 with acute coronary syndrome) and 3933 were diagnosed with acute coronary syndrome. Compared to those with 20-36 ng/mL, the adjusted hazard ratios among those with levels of <10, 10-20, and >36 ng/mL were 1.88 (confidence interval [CI]: 1.80-1.96), 1.25 (CI: 1.21-1.30), and 1.13 (CI: 1.04-1.22) (P < .05), respectively.

LIMITATIONS

The study cohort comprised only 30% of the population, those tested for vitamin D. The small sample size of those with calcidiol >36 ng/mL prevented further analysis of this group.

CONCLUSIONS

Vitamin D in the 20-36 ng/mL range was associated with the lowest risk for mortality and morbidity. The hazard ratio below and above this range increases significantly.

Streptococcal pharyngitis: a prospective study of compliance and complications

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

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

BACKGROUND

Internet use by patients as a source of information on health and disease is expanding rapidly with obvious effects on the doctor-patient relationship. Many of these effects remain undocumented or are poorly understood.

OBJECTIVES

To assess the use of the internet for health information by patients in primary care in Israel and their perception of the effects of internet use on their relationship with their doctor.

METHODS

A cross-sectional survey was conducted among a convenience sample of patients visiting 10 primary care clinics in central Israel using a questionnaire developed for this survey. The survey examined attitudes to using the internet for health-related information and attitudes to sharing this information with doctors. Associations between demographic variables, internet use and patient satisfaction with the doctor's response were tested using the chi-square statistic and t-tests.

RESULTS

Completed questionnaires were received from 138 patients; the response rate was 69%. Patients in the study sample had a high rate of internet access (87%), with many using the internet as a source of health information (41%) although most patients using the internet never share this information with their doctor (81%). Among those who share information with the doctor, most felt that this has a positive effect on the relationship (870/%). Few patients reported being referred to websites by the doctor (28%).

CONCLUSIONS

Internet use is prevalent in this population, though physicians may be unaware of this. Future study could examine the effects of doctors who ask patients actively about their internet use and inform them of relevant health information sources online.

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

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

A survey of primary care physicians’ perceptions of their patients’ use of complementary medicine

PURPOSE

To study the perceptions and attitudes of primary care physicians concerning their patients' use of complementary medicine.

METHODS

A questionnaire was distributed to all 165 primary care physicians attending a routine continuing-medicine education program. Items included physicians' estimated rates of patient utilization of complementary medicine or herbal remedies and of patient reportage of such use; physicians' knowledge about side effects and interactions of herbal remedies; and frequency with which physicians questioned their patients on the use of complementary medicine and herbal remedies.

RESULTS

The compliance rate was 90.0% (n=150). Sixty-eight percent of physicians estimated that up to 15% of their patients use complementary medicine; 58% always or often asked their patients about it; 50% estimated that 10% of patients report use of complementary medicine, and 60% estimated the same rate for herbal remedies; 51% believed that herbal remedies have no or only mild side effects; more than 70% claimed that they had little or no knowledge about what herbal remedies are; 24% never referred patients for complementary medicine, and 69% did so occasionally. Twenty-five percent had some training in complementary medicine, and 31% practiced some kind of complementary medicine. Most of the physicians believed that people turn to alternative methods when they are dissatisfied with conventional medicine.

CONCLUSIONS

Physicians underestimate the rate of complementary medicine use by patients, suggesting that many patients do not report such use to their physician. Since alternative treatments are potentially harmful and may interact with conventional medications, physicians should be encouraged to communicate with patients about complementary medicine in general and herbal remedies in particular, and they should regularly include questions about their use when taking histories. They should also inform themselves about risks of alternative treatments particularly with herbal remedies, and have access to appropriate information systems.

Behavior of patients with flu-like symptoms: consultation with physician versus self-treatment

BACKGROUND

The reasons that patients consult the clinic physician for common minor symptoms are not clearly defined. For seasonal epidemic events such as flu-like symptoms this characterization is relevant.

OBJECTIVES

To identify the factors that prompt patients to seek medical attention, and correlate patient behavior with different demographic and disease variables.

METHODS

A random sample of 2,000 enrolled people aged 18-65 years and registered with eight primary care clinics located throughout Israel were asked to report whether they had had flu-like symptoms within the previous 3 months. Those who responded affirmatively (n = 346) were requested to complete an ad hoc questionnaire evaluating their treatment-seeking behavior.

RESULTS

A total of 318 patients completed the questionnaire (92% response rate), of whom 271 (85%) consulted a physician and 47 (15%) did not. Those who sought medical assistance had more serious symptoms as perceived by them (cough, headache and arthralgia) (P < 0.05), and their main reason for visiting the doctor was "to rule out serious disease." Self-employed patients were more likely than salaried workers to visit the clinic to rule out serious disease (rather than to obtain a prescription or sick note or to reassure family). They also delayed longer before seeking treatment (P = 0.01).

CONCLUSION

In our study the majority of individuals with flu symptoms tended to consult a physician, though there were significant variations in the reasons for doing so, based on a combination of sociodemographic variables. We believe these findings will help primary care physicians to characterize their practices and to program the expected demand of flu-like symptoms.