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Stroke is the third most common cause of disability and the second most common cause of death worldwide. Greater levels of medication adherence after stroke or transient ischemic attack are associated with improved survival. Very few medication adherence prediction models are available and have not been validated using external data. The current study aimed to evaluate the predictive performance of previously published beta regression models for statin and antiplatelet adherence at 1 year in patients’ post-stroke or transient ischemic attack. The models use the first 90-day adherence data as a single predictor for 1-year adherence. Adherence was measured using the Proportion of Days Covered (PDC), which utilized prescription-filling data. Model performance was assessed using the following metrics: R² (proportion of variance explained), the difference between the mean observed and the mean predicted PDC, and the calibration slope, which ideally should be one. 2369 were included in the statin cohort, and 2147 patients were included in the antiplatelet cohort. R 2 was 0.67 and 0.56 for statin and antiplatelet models, respectively. The difference between the mean observed and the mean predicted PDC was −3.7% and −2.5% for statin and antiplatelet models, respectively. The calibration slopes were 1.06 and 0.96 for the statin and antiplatelet models, respectively. The model performed well on a new patient population comprised of post-stroke patients and may be used for early identification of patients at high risk for low 1-year adherence within 90 days post-stroke, enabling timely, targeted adherence-support interventions.

Immune protection following either vaccination or infection with SARS-CoV-2 is thought to decrease over time. We designed a retrospective study, conducted at Leumit Health Services in Israel, to determine the kinetics of SARS-CoV-2 IgG antibodies following administration of two doses of BNT162b2 vaccine, or SARS-CoV-2 infection in unvaccinated individuals. Antibody titers were measured between 31 January 2021, and 31 July 2021 in two mutually exclusive groups: (i) vaccinated individuals who received two doses of BNT162b2 vaccine and had no history of previous infection with COVID-19 and (ii) SARS-CoV-2 convalescents who had not received the vaccine. A total of 2653 individuals fully vaccinated by two doses of vaccine during the study period and 4361 convalescent patients were included. Higher SARS-CoV-2 IgG antibody titers were observed in vaccinated individuals (median 1581 AU/mL IQR [533.8–5644.6]) after the second vaccination than in convalescent individuals (median 355.3 AU/mL IQR [141.2–998.7]; p < 0.001). In vaccinated subjects, antibody titers decreased by up to 38% each subsequent month while in convalescents they decreased by less than 5% per month. Six months after BNT162b2 vaccination 16.1% subjects had antibody levels below the seropositivity threshold of <50 AU/mL, while only 10.8% of convalescent patients were below <50 AU/mL threshold after 9 months from SARS-CoV-2 infection. This study demonstrates individuals who received the Pfizer-BioNTech mRNA vaccine have different kinetics of antibody levels compared to patients who had been infected with the SARS-CoV-2 virus, with higher initial levels but a much faster exponential decrease in the first group.

Aims/hypothesis Not all people with type 2 diabetes who undergo bariatric surgery achieve diabetes remission. Thus it is critical to develop methods for predicting outcomes that are applicable for clinical practice. The DiaRem score is relevant for predicting diabetes remission post-Roux-en-Y gastric bypass (RYGB), but it is not accurate for all individuals across the entire spectrum of scores. We aimed to develop an improved scoring system for predicting diabetes remission following RYGB (the Advanced-DiaRem [Ad-DiaRem]). Methods We used a retrospective French cohort ( n  = 1866) that included 352 individuals with type 2 diabetes followed for 1 year post-RYGB. We developed the Ad-DiaRem in a test cohort ( n  = 213) and examined its accuracy in independent cohorts from France ( n  = 134) and Israel ( n  = 99). Results Adding two clinical variables (diabetes duration and number of glucose-lowering agents) to the original DiaRem and modifying the penalties for each category led to improved predictive performance for Ad-DiaRem. Ad-DiaRem displayed improved area under the receiver operating characteristic curve and predictive accuracy compared with DiaRem (0.911 vs 0.856 and 0.841 vs 0.789, respectively; p =  0.03); thus correcting classification for 8% of those initially misclassified with DiaRem. With Ad-DiaRem, there were also fewer misclassifications of individuals with mid-range scores. This improved predictive performance was confirmed in independent cohorts. Conclusions/interpretation We propose the Ad-DiaRem, which includes two additional clinical variables, as an optimised tool with improved accuracy to predict diabetes remission 1 year post-RYGB. This tool might be helpful for personalised management of individuals with diabetes when considering bariatric surgery in routine care, ultimately contributing to precision medicine.

Direct Oral Anti-Coagulants (DOACs) are the primary treatment for the long-term prevention of stroke in patients with atrial fibrillation. Strict adherence to DOAC therapy is crucial and must be maintained over the long term. Therefore, predicting long-term adherence is valuable for identifying patients at risk of non-adherence. We developed a novel method for predicting long-term adherence using first-order Markov models to assess adherence in new DOAC users during years 2–5. The prediction utilized age, CHA2DS2-VASc score, and first-year adherence data as predictors. Adherence was measured by calculating the proportion of days covered within consecutive 90-day windows, which were then stratified into deciles. We subsequently calculated the probability of a patient being in a specific adherence decile. The developed model demonstrated good calibration. We discovered that missing even 1 day of treatment per month in the first year was predictive of a lower likelihood of achieving the highest adherence decile in years 2–5. Additionally, we noted a non-linear relationship between age and adherence; adherence increased linearly with age but plateaued around age 75. This innovative approach to modelling and predicting adherence to DOACs for long-term therapy can help identify patients at risk of low adherence and may be applicable to other chronic medications.

Out of hospital cardiac arrest (OHCA) remains a major cause of morbidity and mortality. The survival rates are poor and even more frustrating are the rates of neurologically favorable outcomes at hospital discharge. In a recent IJHPR article, Einav et al. concluded that many primary care clinics are underequipped and the physicians underprepared to initiate life-saving services. The chance of having an OHCA in a primary care clinic is very low. But although the impact is small, primary care teams as well as other out-of-hospital healthcare personal should be familiar with the telephone number for summoning emergency medical services (EMS), be aware of the location of the defibrillator in their clinic, and know how to use it. The literature about effective ways to keep long-standing competencies in cardiopulmonary resuscitation among medical personnel outside the hospital is scarce. It is very difficult to evaluate the actual effectiveness of interventions on better outcome; the events are rare and unique in their nature and it hard to generalize the conclusions. The “chain of survival” concept involves a series of steps that should be taken at the scene in the community: early recognition of symptoms and activation of an emergency response system; early bystander cardiopulmonary resuscitation; rapid defibrillation, if needed; early advanced cardiac life support and integrated post-resuscitation care. In this “chain” there is an important role for healthcare personal in the community via improving their own skills and performance and via a deeper involvement in the education of the public. We should take all the needed steps so that community clinic personnel can be role models for effective and successful out of hospital cardiac resuscitation (OHCR).

Proton pump inhibitors (PPIs) are widely used for acid-related disorders, but observational studies have raised concerns about a possible association between long-term PPI use and upper gastrointestinal (GI) cancers. These associations may reflect confounding by indication and reverse causation. We aimed to evaluate the association between PPI use and upper GI cancer while explicitly addressing these biases. We conducted a matched case-control study using electronic health records from a national health organization in Israel. Cases were 875 adults (age 63.0 ± 11.9 years, 62.5% male) with incident upper GI cancer (esophageal, gastric, or duodenal) diagnosed between 2003 and 2024; each case was matched to 10 cancer-free controls (n = 8,750). Matching was performed on age, sex, ethnic sector (general, Jewish ultra-orthodox, and Arab), socioeconomic status, and year of enrollment. PPI exposure was ascertained from pharmacy records and modeled in discrete pre-diagnosis windows (0-6 months, 6-12 months, 1-3 years, and 3-10 years). Multivariable conditional logistic regression estimated adjusted odds ratios (aORs) and confidence intervals (CIs), with covariates including age, smoking, body mass index, socioeconomic status, healthcare utilization, pregnancy history (in women), alcohol use, Helicobacter pylori diagnosis, and upper GI symptom-related diagnoses (e.g., gastroesophageal reflux, gastritis, peptic ulcer disease). In models without adjustment for symptom-related diagnoses, PPI use was associated with increased odds of cancer (e.g., esomeprazole aOR 4.01, 95% CI 3.20, 5.03, p < 0.001; omeprazole aOR 2.38, 95% CI 1.99, 2.85, p < 0.001). When exposure was modeled by time window, associations diminished for exposures >1 year before diagnosis. After excluding the final year before diagnosis and adjusting for symptom-related diagnoses, we did not detect a harmful association between PPI use and upper GI cancer. Remote use (>3 years) was instead associated with lower odds (e.g., omeprazole aOR 0.62, 95% CI 0.51, 0.75, p < 0.001), with similar patterns in a gastric-only subgroup (701 cases, 7,010 controls). Key limitations include potential residual confounding, lack of direct dietary and family-history data, and incomplete capture of over-the-counter PPI use. Apparent harmful associations between PPI use and upper GI cancer were concentrated in the months immediately preceding diagnosis and disappeared after adjusting for diagnostic context and excluding the final year before diagnosis. In these adjusted analyses, we found no evidence of increased odds with long-term PPI use, and remote use (>3 years before diagnosis) was associated with reduced cancer odds for omeprazole and lansoprazole. These findings underscore the importance of investigating new-onset upper GI symptoms rather than attributing malignancy risk to acid-suppressive therapy.

Toxoplasma gondii establishes latent infection in a substantial proportion of the global population, yet the long-term health consequences of this infection remain incompletely characterized. We conducted a retrospective observational matched cohort study using longitudinal electronic health record data from a nationwide integrated healthcare provider, including members aged 18–45 years who underwent routine Toxoplasma serologic screening, typically performed in obstetric evaluation, excluding patients with clinical toxoplasmosis, immunosuppression, or HIV. Seropositive individuals were matched 1:1 without replacement to seronegative controls to align demographic, temporal, and socioeconomic variables. Time-to-event associations with predefined medical conditions were evaluated using Cox proportional hazards models with false discovery rate correction. The final cohort included 19,443 seropositive individuals and 19,443 matched controls (96.7% female), with a tight baseline balance of demographic and temporal characteristics. During follow-up, seropositivity was associated with increased risks of tobacco dependence (aHR 1.65), alcohol dependence (2.32), suicide attempt (1.82), motor vehicle accidents (1.22), and work accidents (1.27), as well as multiple infectious conditions, including hepatitis B (1.55), hepatitis C (2.15), and syphilis (2.43), with an overall trend toward increased all-cause mortality (1.32, 95% CI [1.00–1.74]). These findings suggest that asymptomatic Toxoplasma infection in young adults is associated with increased long-term behavioral and medical comorbidity.

Aim: To evaluate the natural history of diabetic retinopathy (DR) in diabetic patients and to assess long term risk for other chronic diseases associated with DR. Methods: Retrospective, community-based study. Diabetics who underwent their first fundoscopic examination during 2000-2002, and had at least one follow- up examination by the end of 2007 were included. The primary outcome was the development of DR (proliferative diabetic retinopathy (PDR), non PDR (NPDR) or macular edema. Patients were followed for another 9 years for documentation of new diagnosis of related diseases. Results: 516 patients' (1,032 eyes) records were included and were followed first for an average of 4.15 ± 1.27 years. During follow-up, 28 (2.7%) of the total 1,032 eyes examined were diagnosed with PDR. An additional 194 (18.8%) eyes were diagnosed with new NPDR. The cumulative incidence of NPDR was 310/1,032 (30.0%). All the patients who developed PDR had prior NDPR. By the end of the 9 years extended follow up, patients with NPDR had a greater risk for developing chronic renal failure HR = 1.71 (1.14-2.56), ischemic heart disease HR = 1.57 (1.17-2.09), and had an increased mortality rate HR = 1.26 (1.02-1.57) Conclusion: DR is associated with a higher rate of diabetes complications. Patients with DR should be followed more closely. Key points During a mean follow-up of 4.5 years, the cumulative incidence of diabetic retinopathy in a community cohort was 18.8%. NDPR (non-proliferative diabetic retinopathy) is a predictor of PDR (proliferative diabetic retinopathy). In a real life setting NPDR is a marker of a poorer prognosis. Patients with NDPR should be monitored more closely.

Background Previous studies have shown that more temporally regular primary care visits are associated with improved patient outcomes. Objective To examine the association of temporal regularity (TR) of primary care with hospitalizations and mortality in patients with chronic illnesses. Also, to identify threshold values for TR for predicting outcomes. Design Retrospective cohort study. Participants We used data from the electronic health record of a health maintenance organization in Israel to study primary care visits of 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease). Main measures We calculated TR for each patient during a two-year period (2016–2017), and divided patients into quintiles based on TR. Outcomes (hospitalization, death) were observed in 2018–2019. Covariates included the Bice-Boxerman continuity of care score, demographics, and comorbidities. We used multivariable logistic regression to examine TR’s association with hospitalization and death, controlling for covariates. Key results Compared to patients receiving the most regular care, patients receiving less regular care had increased odds of hospitalization and mortality, with a dose–response curve observed across quintiles ( p for linear trend < 0.001). For example, patients with the least regular care had an adjusted odds ratio of 1.40 for all-cause mortality, compared to patients with the most regular care. Analyses stratified by age, sex, ethnic group, area-level SES, and certain comorbid conditions did not show strong differential associations of TR across groups. Conclusions We found an association between more temporally regular care in antecedent years and reduced hospitalization and mortality of patients with chronic illness in subsequent years, after controlling for covariates. There was no clear threshold value for temporal regularity; rather, more regular primary care appeared to be better across the entire range of the variable.