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To compare the rates of schizophrenia among 1st and 2nd generation immigrants from two distinct backgrounds and across sequential periods of immigration.A 30-years retrospective cohort study (187,184 individuals) of 1st and 2nd generation East-African immigrants (EAIs) and former Soviet-Union immigrants (FSUIs) who migrated to Israel between 1980 and 2012. EAIs were further divided according to waves of immigration. Period prevalence was calculated between the years 2002-2012. Multivariate logistic regression models were used to examine the association between immigration-related factors and prevalence of schizophrenia (Native-Born Israelis serving as reference group).The prevalence of schizophrenia in 1st generation EAIs and FSUIs was 1.8% and 1.2%, respectively, compared to 1.0% among NBIs (p0.001). The prevalence of schizophrenia among 2nd generation EAIs and FSUIs was 1.3% and 0.8%, respectively, compared to 0.6% among NBIs (p0.001). Adjusted odds ratios for developing schizophrenia compared to NBIs were 1.6 (95%CI:1.4-1.8) and 2.1 (95%CI:1.6-2.7), among 1st and 2nd generation EAIs and 1.1 (95%CI:0.9-1.2) and 1.3 (95%CI:1.0-1.8) among 1st and 2nd generation FSUIs respectively. Among EAIs, we observed the highest rate of schizophrenia in the pioneer wave of immigrants with gradual decline across subsequent waves: 2.4%, 1.9% and 1.0% for the 1st, 2nd and 3rd waves of immigration, respectively (p0.001).The increased risk for developing schizophrenia among 2nd generation immigrants and among pioneer groups of immigrants emphasizes the importance of persistent investment in acculturation. Further studies elucidating the impact of country of origin and ethnic density on the risk for developing schizophrenia are warranted.

Israel, a young country that constantly absorbs immigrants from different cultures, has a unique social structure. The mosaic of culture and values that exist in it, the delicate balance that exists between religion and state, advanced legislative processes, the central place of the family in individual life, combined with the principles of autonomy in which the health system operates, require deliberate action to formulate solutions and meet current challenges. In this unique space the contribution of the palliative social workers is reflected through the application of models for individual and family assessment, clinical interventions implemented with cultural sensitivity and out of consideration for the family unit as an essential system for treatment planning. This coping occurs in the absence of recognition in the palliative care field as a unique area of expertise that requires specific training for palliative social workers, as exists for the nursing and medical professions. The field of palliative care provides social workers with space for meaningful interventions and channeling the challenges into the opportunity for professional growth, in coming to formulate professional responses to the needs emerging in the rich mosaic of patients and families in Israel.

Patients with advanced/chronic kidney disease (CKD) stage 5 face a high burden of comorbidity, physical and mental symptoms, and impaired quality of life (QOL). Dialysis, which has become a treatment of choice, cannot supply an optimal replacement of the kidney function. Old and fragile dialysis patients with multiple comorbidities often need expensive medical treatments, repeated hospitalizations, and their life expectancy is not longer than those who have chosen not to use dialysis. The WHO emphasizes the need of palliation for serious and incurable diseases, such as CKD stage 5. Among patients who suffer from under-diagnosis and under-treatment of symptoms, some regret having started dialysis. Conservative treatment is offered only in a few cases and only a small proportion of patients have signed an Advanced Care Directive. Patients wish to receive information about their prognosis and treatment choices, thus feeling in control of their treatment. More countries are adopting the ideas of palliative care for CKD patients in order to ensure their QOL and to encourage the patients and their families to be active partners in the decision-making process. Using a palliative care approach can prevent patients from suffering and will reduce treatment costs. This review presents the data published on the subject in world literature.

The trend of increasing numbers of terminally ill patients hospitalized in general wards requires nursing staff to be able to provide palliative care (PC). The self-efficacy (SE) to provide PC was found to be a leading factor predicting future professional behavior. There is no tool in the Hebrew language to evaluate SE for symptoms management and provision of psychosocial care within the PC.To validate a Hebrew version of the "Palliative Care Self-Efficacy Scale )PCSES)" among nursing staff employed in various hospital wards.A cross-sectional study was performed among nursing staff employed at four Israeli hospitals in oncology, internal medicine, surgical and emergency care wards.The PCSES questionnaire was translated into Hebrew and was completed by 588 nurses. Cronbach's alpha coefficients for the translated tool were high: 0.89 for the tool as a whole, 0.82 for the scale regarding ability to deal with questions regarding end-of-life care, and 0.85 for the symptoms management scale. As in the original tool, two factors that in combination explain 58.6% of the variance were found: ability to deal with questions regarding end-of-life care (46.43%) and symptoms management (12.2%).The psychometric characteristics of this tool demonstrate that it can be used to estimate SE in providing PC among nurses employed in various hospital wards.This tool should be used and evaluated among additional professionals involved in providing PC. It should also be tested as a method to identify changes in SE over time.

The epidemiological transition to non-communicable diseases in the 20th century necessitated the development of new public health approaches to address the problems of the new age. As understanding of the determinants of health became more sophisticated, so did public health practice. Thus, palliative care became an integral component of the health definition. It is an approach which improves quality of life of patients and their families facing chronic serious illness and life-threatening diseases. This is performed through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual. Palliative care is provided without giving up cure or slowing disease progression.

The American Society of Clinical Oncology has identified non-evidence-based chemotherapy as one of the 10 most prevalent examples of futile care and has identified chemotherapy at the last month of life as a quality indicator of oncology practice.To characterize chemotherapy treatment and the use of palliative and other healthcare services during the last year of life among cancer patients in an Israeli Health Maintenance Organization (HMO).A cross-sectional study was conducted of members of Leumit Health Services (LHS) who died of cancer between 2009 and 2013. Data captured from LHS databases included: diagnosis, target drugs prescribed, health services utilization, and demographic data. Patients were stratified by time that elapsed between their last chemotherapy treatment and the date of death. The groups were compared in terms of demographics, morbidity, health services utilization and palliative care referrals over the six months prior to death.The study included 2,617 patients who received chemotherapy during their last year of life. Of these patients, 18.8% received chemotherapy 0-14 days prior to death. Palliative care referrals were less frequent among patients who received their last chemotherapy treatment during the 14 days prior to death (15.8%) and highest among patients who received their last chemotherapy treatment ≥180 days prior to death (31.9%: P0.0001(.Survival and the probability of administering palliative care at the end of life are inversely associated with the probability of administering chemotherapy.Efforts should be made to increase awareness amongst oncologists that aggressive treatment during the last weeks of life may be futile.

Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life (EOL) care and with better quality of life near death. Despite that, these discussions do not always occur between oncologists and their patients.To evaluate oncologists' agendas concerning EOL discussions and advanced directive (AD), and to identify barriers to these discussions.The study included oncologists from Israeli hospitals who were asked to complete a questionnaire in order to assess barriers to EOL conversations. The questionnaire was adapted from Canadian research among clinicians in medical wards. Participants were asked to rank the importance of the various barriers.The questionnaires were completed by 84 physicians. Most physicians in this group (97%) thought it was important to have discussions on GOC with the patient, and 67% thought it was important that the patient would sign an AD form. Respondents perceived patient and family-related factors as the most important barriers. Of these, the most important were the patients' and patients' families difficulty accepting their poor prognosis, rated as important by 90% and 78% respectively, and the patients' difficulty understanding the limitations and complications of life-sustaining treatments, rated as an important by 81% of respondents. While physicians and system factors were ranked lower than patient-related factors, time limitations and desire to maintain hope were also considered important, 80% and 74% respectively.Oncologists ranked patient and family-related factors as the most important barriers to GOC discussions. Time limitations and the desire to maintain hope were also considered important.Further work is required to assess patient preferences and perceptions and to develop targeted interventions.

Context Pain is a common complaint in maintenance hemodialysis (MHD) patients, and it is often inadequately assessed and inappropriately treated. Objectives The study goal was to preliminarily evaluate pain management in MHD patients. Methods The study was a cross-sectional study conducted in 2013–2015. A sample of 277 MHD patients who reported pain within the last 24 hours from five hospital hemodialysis units in Israel were interviewed and evaluated. Study tools included the Brief Pain Inventory, the Pain Management Index (PMI), demographic and clinical characteristics. Pharmacy computerized data were reviewed to identify the type of analgesics used. Results Mean pain level was 7.2 ± 2.2 (median: 8). Pain level was mild in 17 (6.1%), moderate in 120 (43.3%) and severe in 140 (50.5%) of patients. Only 185 participants (66.8%) were treated with analgesics during the year prior to the interview. Of these, 99 (53.5%) received opioids. Using the PMI to preliminarily assess the appropriateness of the treatment, 214 (77.3%) of patients with pain in the last 24 hours were undertreated, and 52 patients (18.8%) were appropriately treated. In a multivariable analysis, factors associated with inappropriate treatment were severe pain intensity and a higher Functional Independent Measure (FIM). A lower FIM was associated with opioid use in a multivariable analysis. Conclusions According to the PMI, most dialysis patients were found to be inappropriately treated. About one third received opioids, but even among them, inappropriate treatment was common. Pain management in MHD patients needs to be improved.

To characterize the practice of subcutaneous hydration provision in the Beer-Sheva home care hospice unit. We also explore the potential connection between the provision of subcutaneous hydration and the incidence of death rattle. This was a prospective observational study involving 120 hospice patients. During the 6 days before death, hospice staff recorded whether or not fluids were administered orally and/or subcutaneously; the duration, timing, and quantity of fluid administration; the incidence, timing, and duration of death rattle; and whether medications that can affect death rattle were given. Fifty-three percent of the patients received subcutaneous hydration. The mean daily volume administered in the hydration group was 434 ml. There was a significant association between the duration of treatment in the hospice unit and provision of subcutaneous hydration (mean of 51 days in hydration group vs. 31 days in non-hydration group, p = 0.03). Although not statistically significant, males were more likely to receive subcutaneous hydration than females (62% of males vs. 46% of females, p = 0.09). There was a higher incidence of death rattle in men compared to women (54.7% in men vs. 32.8% in women, p = 0.025). A statistically significant association between death rattle and the provision of subcutaneous hydration wasn’t demonstrated. The decision of whether to provide subcutaneous hydration is individualized taking into consideration the values of the patients and their families. The provision of 500 ml per day of subcutaneous saline during the last 6 days of life does not significantly increase the incidence of death rattle.

Previous studies reported low prevalence of cardiovascular disease (CVD) despite an increasing prevalence of metabolic abnormalities in immigrants who moved from low CVD-risk regions to Western countries. Nevertheless, little is known about hospital admissions due to CVD in immigrants.A retrospective cohort study of East Africa immigrants (EAI), Former Soviet Union immigrants (FSUI) and native-born Israelis (NBI) over 11-year period. Associations between ethnicity, age, sex, CVD, and hospital admission were assessed using logistic and Poisson regression models. Incidence density rates per person-years were calculated.The age-adjusted prevalence rates of ischemic heart disease in EAI, FSUI and NBI, respectively, were 1.8%, 8.2%, and 5.8%, respectively (p 0.001). The corresponding rates for stroke were 2.6%, 3.5%, and 2.5%, respectively. Multivariate odds ratios for all CVD were found to be significantly lower in EAI for both sexes. Hospitalizations rate due to CVD were 9, 17, and 6 per 1000 person-years in EAI, FSUI and NBI, respectively (p 0.001). EAI were more likely to be hospitalized due to hypertensive disease, cerebral vascular diseases and heart disease, in comparison to NBI and FSUI. However, when controlling for CVD risk factors profile, EAI had similar admission rates to NBI. EAI were more likely to be hospitalized in internal medicine, geriatrics, and neurology departments, and less likely to be admitted to intensive care units or surgical department.EAI had low rates of all types of CVD, and low risk of hospitalization after controlling for CVD risk factors profile.

Type 2 Diabetes Mellitus (T2DM) is disproportionally prevalent among the Bedouin minority in Israel, with especially poor treatment outcomes compared to other indigenous groups. This study uses the perspective of the Bedouins themselves to explore the distinct challenges they face, as well as their coping strategies. The study is based on an interpretive interactionist analysis of 49 semi-structured interviews with Bedouin men and women. The findings of the analysis include three themes. First, physical inequality: the Bedouin community’s way of coping is mediated by the transition to a semi-urban lifestyle under stressful conditions that include the experience of land dispossession and the rupture of caring relationships. Second, social inequality: they experience an inaccessibility to healthcare due to economic problems and a lack of suitable informational resources. Third, unique resources for coping with T2DM: interviewees use elements of local culture, such as religious practices or small enclaves of traditional lifestyles, to actively cope with T2DM. This study suggests that there is a need to expand the concept of active coping to include indigenous culture-based ways of coping (successfully) with chronic illness.

Type 2 Diabetes Mellitus (T2DM) is disproportionally prevalent among the Bedouin minority in Israel, with especially poor treatment outcomes compared to other indigenous groups. This study uses the perspective of the Bedouins themselves to explore the distinct challenges they face, as well as their coping strategies. The study is based on an interpretive interactionist analysis of 49 semi-structured interviews with Bedouin men and women. The findings of the analysis include three themes. First, physical inequality: the Bedouin community’s way of coping is mediated by the transition to a semi-urban lifestyle under stressful conditions that include the experience of land dispossession and the rupture of caring relationships. Second, social inequality: they experience an inaccessibility to healthcare due to economic problems and a lack of suitable informational resources. Third, unique resources for coping with T2DM: interviewees use elements of local culture, such as religious practices or small enclaves of traditional lifestyles, to actively cope with T2DM. This study suggests that there is a need to expand the concept of active coping to include indigenous culture-based ways of coping (successfully) with chronic illness.

Oxygen enriched air may increase oxygen pressure in brain tissue and have biochemical effects even in subjects without lung disease. Consistently, several studies demonstrated that normobaric oxygen treatment has clinical benefits in some neurological conditions. This study examined the efficacy of normobaric oxygen treatment in subjects with depression. In a randomized, double-blind trial, 55 participants aged 18–65 years with mild to moderate depression (had a Hamilton Rating Scale for Depression [HRSD] score of ≥ 8) were recruited to the study from the Southern district in Israel. Participants underwent a psychiatric inclusion assessment at baseline and then were randomly assigned to either normobaric oxygen treatment of 35% fraction of inspired oxygen or 21% fraction of inspired oxygen (room air) through a nasal tube, for 4 weeks, during the night. Evaluations were performed at baseline, 2 and 4 weeks after commencement of study interventions, using the following tools: HRSD; Clinical Global Impression (CGI) questionnaire; World Health Organization-5 questionnaire for the estimation of Quality of Life (WHO-5-QOL); Sense of Coherence (SOC) 13-item questionnaire; and, Sheehan Disability Scale (SDS). A multivariate regression analysis showed that the mean ± standard deviation [SD] changes in the HRSD scores from baseline to week four were − 4.2 ± 0.3 points in the oxygen-treated group and − 0.7 ± 0.6 in the control group, for a between-group difference of 3.5 points (95% confidence interval [CI] − 5.95 to − 1.0; P = 0.007). Similarly, at week four there was a between-group difference of 0.71 points in the CGI score (95% CI − 1.00 to − 0.29; P = 0.001). On the other hand, the analysis revealed that there were no significant differences in WHO-5-QOL, SOC-13 or SDS scores between the groups. This study showed a significant beneficial effect of oxygen treatment on some symptoms of depression.Trial registration: NCT02149563 (29/05/2014).

Findings from clinical trials of mindfulness-based interventions (MBI) support significant effects on chronic pain, yet the mechanisms underlying these effects are not well understood. A limitation of current research is reliance on global measures of functioning or narrow, self-report ratings of chronic pain severity. The present research aims to explore potential mechanisms that may explain the effects of MBIs on chronic pain by focusing on acute pain ratings, using quantitative sensory pain testing (QST) rather than chronic pain ratings. Thirty-six patients (10 men, 26 women, mean age = 58.03, ± 14.9) with chronic low back pain (CLBP) were randomly assigned to an 8-week MBI or wait-list control. QST measures of thermal and pain thresholds, as well as pain ratings to fixed stimuli, self-report measures of chronic pain severity, and interference with daily activities were assessed at baseline and after 8 weeks. We found a significant group X time interactions in self-report ratings of chronic pain severity (p = .04, ηp2 = .12) and interference (p = .04, ηp2 = .11): The MBI group showed a decrease in ratings while the control group showed an increase. Also, while patients in the control group exhibited an increase in suprathreshold pain ratings over time (p = .03, ηp2 = .15), indicating an apparent sensitization effect to painful stimuli, participants in the MBI group maintained their original ratings. The results suggest that mindfulness practice may have a “buffering effect” for CLBP patients, by attenuating their tendency to facilitate pain experience.

IntroductionSeveral studies of normobaric hyperoxia in some neurological conditions have demonstrated clinical benefits. Oxygen enriched air may increase oxygen pressure in brain tissue and have biochemical effects such as on brain erythropoietin gene expression, even in patients without lung disease.ObjectivesThis pilot, randomized, double-blind study examined the efficacy of normobaric hyperoxia as a treatment for depression.MethodsFifty-five consenting patients aged 18-65 years with mild to moderate depression were included in the study. Participants underwent a psychiatric inclusion assessment and a clinical evaluation by a psychiatric nurse at baseline, 2 and 4 weeks after commencement of study intervention. Participants were randomly assigned to normobaric hyperoxia of 35% fraction of inspired oxygen or 21% fraction of inspired oxygen (room air), through a nasal tube, for 4 weeks, during the night. Patients were rated blindly using the Hamilton Rating Scale for Depression (HRSD); Clinical Global Impression (CGI) questionnaire; Sheehan Disability Scale (SDS).Results The present study showed a significant improvement in HRSD (pConclusionsThis small pilot study showed a beneficial effect of normobaric hyperoxia on some symptoms of depression.DisclosureNo significant relationships.

Early on, geriatricians in Israel viewed with increasing alarm the spread of coronavirus disease 2019 (COVID-19). It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country's Ministry of Health, the Israel Medical Association, and the country's largest health fund; this was done to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, a palliative care specialist, and a lawyer/ethicist. The members made every effort to ensure that their recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee's main task was to think through a workable approach because intensive care unit/ventilator resources may be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and in long-term care institutions, a triage instrument, and palliative care. Patient autonomy was emphasized, with a strong recommendation for people of all ages to update their advance directives or, if they did not have any, to quickly draw them up. Considering the value of distributive justice, with respect to triage, a "soft utilitarian" approach was advocated with the main criteria being function and comorbidity. Although chronological age was rejected as a sole criterion, in the case of an overwhelming crisis, "biological age" would enter into the triage considerations, but only in the case of distinguishing between people with equal non-age-related deficits. The guideline emphasized that no matter what, in the spirit of beneficence, anyone who fell ill must receive active palliative care throughout the course of a COVD-19 infection but especially at the end of life. Furthermore, in the spirit of nonmaleficence, the frail, very old, and severely demented would be actively protected from dying on ventilation. J Am Geriatr Soc 68:1370-1375, 2020.

The aim of this study is to assess patient-reported outcome measures (PROMs) related to symptoms among maintenance hemodialysis patients (MHDp). This cross-sectional study was conducted between 2013 and 2015, with 336 MHDp from five hospital hemodialysis units. It included a comprehensive assessment of the prevalence and intensity of 30 common dialysis-related symptoms quality of life and daily function of MHDp, by using the Dialysis Symptom Index (DSI), Quality of Life Short Form (KDQOL-SF), and demographic and clinical characteristics. The five most commonly reported symptoms were identified as tiredness (80%), difficulty becoming sexually aroused (72%), decreased interest in sex (72%), worrying (67%), trouble staying asleep (65%), and trouble falling asleep (64%). Based on the DSI, the mean Overall Burden of Symptoms (OBS), on a scale of 0–30, was 15.4 ± 6.7, while the mean Overall Symptom Severity Score (OSSS), on a scale of 0–150, was 54.8 ± 29.8. Multivariate quantile regression models indicated that major depression is consistently associated with both the OBS and OSSS across different quantiles, whereas time on dialysis > 24 months was associated with the OBS only. Both the OBS and OSSS were inversely associated with KDQOL-SF: the kidney-related (KDCS), physical (PCS) and mental aspects (MCS), across multiple quantiles in multivariate quantile regression models. MHDp bear a heavy burden of symptom which are associated with time spent on dialysis as well as depression. Clinical and research resources should be directed at controlling symptoms, improving daily function, detecting depression, and bettering quality of life.

Objective To explore the subjective experience of pain relief by cannabis. Design Qualitative data were collected through in-depth semistructured interviews. Interview transcripts were analyzed using interpretative phenomenological analysis (IPA). Subjects Nineteen patients, aged 28 to 79, who were treated with medical cannabis under the supervision of a pain clinic in Israel. Results Three key themes that emerged from the analysis were explored: 1) the Sigh of Relief, describing the corporal sensation of using cannabis, including a sense of relaxation and reduction in pain; 2) the Return to Normality, describing the comprehensive effect of using cannabis, including an increased ability to sleep, focus, and function; and 3) the Side Effects of using cannabis. Conclusions We propose the term Restored Self to conceptualize the effect of medical cannabis. Restored Self is the experience of regaining one’s sense of self, sense of normality, and sense of control over one’s life.

Context Exposure to dying patients can contribute to secondary traumatic stress (STS) among palliative care workers. Peritraumatic dissociation (PETD), an individual's personal proneness to dissociation during exposure to a stressful event, is the strongest predictor of post-traumatic stress, but existing research on its relationship to STS is limited. Objective To compare the level of STS among palliative workers with clinical levels of PETD compared with those without clinical levels of PETD. Methods A cross-sectional self-report survey. Setting/Participants These include about 420 physicians and nurses working in hospital-based and/or home-based palliative care units. Inclusion criteria: two years' experience with at least 10 hours/week of direct care for terminally ill patients. Results About 144 participants returned completed questionnaires (response rate 35%). Sixty percent reported a nonclinical level of dissociation. Workers with a clinical level of dissociation had significantly higher levels of STS compared with workers who did not. Awareness of an interaction effect between PETD and fear of dying progression can advance our understanding of how the development of PETD during exposure to dying can have an impact that is beyond the main effect on STS. Conclusions The clinical level of PETD correlates significantly with STS. Further research is needed to understand whether STS is related to the individual's own vulnerability, as reflected by their personal proneness to dissociation, during exposure to death and dying.

Palliative care is an approach meant to improve the quality of life of patients facing life-threatening illness and to support their families. An international workshop on palliative care took place in Caesarea, Israel under the auspices of the National Institute for Health Policy Research on July 4-5th, 2018, with the goal of discussing challenges to the development and integration of palliative care services in Israel. At the workshop, both national and international figures in the field of palliative care and health policy addressed several issues, including truth telling, religious approaches to end of life care, palliative care in the community, pediatric palliative care, Israel’s Dying Patient Act, the Ministry of Health’s National Plan for palliative care, and challenges in using advance directives. We summarize the topics addressed, challenges highlighted, and directions for further advancement of palliative care in the future, emphasizing the critical role of the Ministry of Health in providing a framework for development of palliative care.

Background:Exposure to the death and dying of others is an anxiety-provoking condition that can contribute to psychological stress. However, the results of empirical studies that evaluated work-related outcomes among physicians and nurses with repeated exposure to dying patients are not consistent.Objective:Our aim was to evaluate whether a high level of exposure to death and dying (LED) can increase the risk for poor professional quality of life (ProQoL) in most healthcare workers, but it can also improve ProQoL in a subset of healthcare workers with specific characteristics.Method:We employed a cross-sectional survey designed to better understand the role of LED as a predictor of ProQoL among healthcare workers.Setting and Participants:Comparison of physicians and nurses with high LED (home-based palliative care units) with a matched group of physicians and nurses with low LED (primary care units) and evaluation of possible interaction effects among LED, death anxiety (DA), and engagement as predictors of ProQoL.Results:The final sample included 110 questionnaires from the high-LED group (response rate = 39%) and 131 from the low-LED (response rate = 24%) group. Workers with high LED reported an increased level of compassion satisfaction (CS) and low to moderate levels of burnout (BU) and secondary traumatic stress (STS), with no significant differences with respect to other healthcare providers. Although levels of CS, STS, and BU did not differ between groups, a univariate MANOVA revealed that the interaction effect of LED × Engagement reduced levels of CS and that the interaction effect of LED × DA increased STS among workers with high LED.Significance of results:LED was significantly correlated with ProQoL among healthcare workers with high LED due to the reported interaction effect. These findings imply, for the first time, that there is a possible correlation between engagement and the risk for poor ProQoL among workers with high LED. Further research is essential to gain a better understanding of this issue.

Background: There are no published studies on notification of death by a next of kin to the treating medical staff. Aim: To explore the content and circumstances of death notifications by next of kin to the treating medical staff in a palliative home care unit. Design: A cross-sectional study that combines qualitative and quantitative analysis. Setting: Assessment of 153 telephone death notifications by a next of kin to the treating medical staff. Results: The qualitative analysis of death notifications revealed 2 themes: direct and indirect death notifications. In direct notifications, death was portrayed by the notifier in direct and specific words such as death, the patient has died, or the patient is not alive. Indirect notifications included nonspecific or general descriptions of death such as breath cessation, it ended, or it’s over or finished. Direct notifications tended to include specific requests from the medical staff and expressed acceptance and closure, while indirect notifications tended to include more general requests and expressed more panic, distress, or doubt in death. Although spouses were more likely to serve as the primary caregiver, the children or other family members were more likely to notify the treating staff. In 30% of the notifications, there was an element of doubt or uncertainty. Emotions were expressed in 20% of the notifications. Cessation of breathing was the most common physical sign mentioned. Conclusion: Medical staff members who receive notifications of death should expect and be prepared for the expression of varied emotions and doubts as an integral part of the notification.

Context Pain is a common complaint in maintenance hemodialysis (MHD) patients yet is often inadequately assessed and undertreated. Objectives The objective of this study was to evaluate the prevalence, characteristics, intensity, and impact of pain in MHD patients. Methods In a cross-sectional study conducted between 2013 and 2015, 336 MHD patients from five hemodialysis units in hospitals owned by Clalit were interviewed and evaluated. Study tools included the Brief Pain Inventory, The Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale, and demographic and clinical characteristics. In addition, computerized pharmaceutical data were reviewed. Results Pain was experienced by 82% of the study population (mean pain level: 7.2 ± 2.2) in the 24-hour period before the interview, while 61.5% experienced neuropathic pain characteristics. Of patients with pain, two-thirds reported being regularly treated with pain medications, while 24.5% received nondrug pain treatment. Mean pain relief due to Brief Pain Inventory was 62.5 ± 30%. In multivariate analysis, female gender, a high comorbidity index, and time on dialysis >24 months were associated with the presence of significant pain in the previous 24 hours. In addition, severe pain report was associated with female gender, depression, ≥4 painful sites, and unemployment. Finally, neuropathic pain was associated with time on dialysis >24 months, depression, ≥4 painful sites, and current intensity of pain >2. Conclusion Pain is common in MHD patients and is significantly associated with female gender, comorbidity, time on dialysis, and depression. Results of this study may serve as a starting point for palliative interventions for MHD patients.

Although diabetes mellitus (DM) is often associated with painful neuropathic syndromes, a significant number of DM patients suffer from non-neuropathic (nociceptive) pain. Unfortunately, there is insufficient data on the epidemiology of nociceptive pain in DM patients and its effect on their quality of life.To characterize pain in type 2 DM patients, and assess its effect on their quality of life.The study population included 342 type 2 DM patients, 18 years of age and above (mean age 70.7 ± 9.7), who reported having pain. The study questionnaires included the Brief Pain Inventory (BPI), the S-LANSS scale to assess pain with neuropathic features, life impact, and socio-demographic data.One hundred and fifty-five DM patients (46.5%) reported having pain of predominantly neuropathic origin. Almost 75% of patients with neuropathic pain were females, compared to 57.8% of patients with nociceptive pain (P = 0.002). More patients with neuropathic pain reported constant daily pain (57.6% vs. 42.4%, P0.0001), and worse pain during the night (53.3% vs. 46.7%, P = 0.045). The pain affected daily activities, walking capacity, and mood. Patients with neuropathic pain reported a greater negative effect of pain on their quality of life than those with nociceptive pain (41.0% vs. 15.3%, P0.0001).The impact of neuropathic pain in DM patients is much more significant than nociceptive pain and affects their quality of life and daily function to a greater degree.

Opioids are considered a cornerstone in the treatment of pain. They are rarely used in almost half of the countries of the world, especially in children.The aim of this study was to assess opioid use over a ten-year study period from 2001-2010, among children 0-18 years old who are members of Clalit Health Services (CHS), the largest HMO in IsraelData on the purchase of opioids, authorized for use in Israel, was obtained from the computerized databases of CHS. In addition, the patient's demographic details and cancer morbidity were also extracted. The data was analyzed after all the doses of all opioids consumed (fentanyl patch, oxycodone, methadone, hydromorphone, oral transmucosal fentanyl) were converted into oral morphine equivalents (OME).In all, 1,098 children purchased at least one opioid prescription during the study period. Of them, 27.3% had a diagnosis of cancer and 55.5% were female. A 42% decrease in total annual OME (mg) purchased, from 209,443 mg to 122,048 mg, was observed from 2001 to 2010. There was no specific pattern or trend in the annual number of pediatric and adolescent patients who purchased at least one opioid drug during the study period. In 86.5% of the cases, children with a non-cancer cause of pain purchased opioids for only one month.There is a low and inconsistent rate of opioid consumption among pediatric and adolescent members of the CHS. Further study is needed to explore the reasons for this low opioid consumption rate in this population group.

In recent years several reports have been published describing dogs' ability to detect, by scent, patients with cancer. This ability is based on the sniffing of volatile organic elements that are secreted by malignant cells or react to them.To evaluate the ability of trained dogs to detect breast cancer cell cultures (MCF7) compared to the control pseudo-normal keratinocyte cell line (HaCaT), and to detect melanoma (BG) and type 2 epithelial lung carcinoma (A549) malignant cell cultures to which they were not previously exposed in the course of their training.Cell cultures were prepared in a standard manner. Two Belgian Shepherd dogs were trained and then tested in a single-blind test (for dogs and trainers) on their ability to detect the "target specimen," a MCF7 breast cancer cell culture. Following this, the ability of the dogs to detect cancer cell cultures that they were not previously exposed to (i.e., A549, BG) was tested. In each test round, four specimens placed in identical blocks were arranged in a line with one meter between them: one target specimen (MCF7, A549, BG), two control specimens (HaCaT), and a sample containing cell culture medium only.The two dogs picked out all the target specimens of MCF7 breast cancer cell cultures that they were trained to detect (10/10) as well as all the target specimens that they were not previously exposed to [A549 (5/5) and BG (5/5)], but did not pick out the control specimens or the cell culture medium. Thus, the sensitivity, specificity, and positive and negative predictive values for both dogs were 100%.The results of this study support the assumption that cancer cells have a unique odor pattern, and that this odor pattern is common to different types of cancer.

Summary Background: The Council for Higher Education in Israel published an extensive report in 2007, calling for a significant increase of undergraduate medical education in Israel in ambulatory care settings. The objective of this article is to propose an action plan aimed at shifting undergraduate medical education in Israel towards ambulatory education. Context: The main barriers to increasing ambulatory education in Israel are lack of academic recognition for teaching and excellence, conflict between patient care, income and teaching, lack of an adequate educational infrastructure and faculty in ambulatory care, and insufficient support and involvement of the health organisations. However, there is great potential for developing ambulatory education in Israel based on existing resources: Israel has a well-established primary care network, has chronic disease management programmes, community-based preventive medicine and health promotion activities, and an emerging structure for home, palliative and terminal care in the community. Innovation: The proposed action plan presents a framework for enhancing ambulatory education in undergraduate medical education in Israel, and allows site-specific adjustments according to the preferences, resources and capabilities of each of the four medical schools. Implications: A national shift to ambulatory education in Israel can be implemented through the existing coordination mechanism of the four medical schools. A government funding policy that encourages the collaboration between four medical schools will be beneficial both in terms of resource utilisation and the engagement of other stakeholders. The recognition of community services and educational excellence can be advanced by establishing academies of teaching scholars.

The Bedouin population of the Negev region in Israel consists of 180,000 Muslims, half of whom live in six townships. The other half is dispersed in small temporary settlements (huts, tents) with no running water or electricity. Accessibility is quite difficult, with no paved roads or any form of motorized public transportation. For patients with advanced illnesses near the end of life, adequate palliative treatment is not available in their rural homestead. A mobile palliative care unit (MPCU) has been established, with the aims of delivering palliative care to terminal patients living in remote regions not easily accessible to the community health care teams and to provide palliative care consultation services to the local primary care teams. The mobile unit consists of a core team of a nurse, a social worker, a physician, and a Bedouin driver-interpreter/translator. The MPCU cares for about 30 patients at any given time, including four to six Bedouins living in rural homesteads, four to six Bedouins living in townships, and the remainder Jewish patients living in the surrounding settlements. One hundred patients were cared for and about 1800 home visits were conducted during the past year, including 15% by the whole mobile unit team, 15% by the physician alone, 25% by the nurse alone, and 25% by the unit's nurse together with the local primary clinic nurse. The average distance covered per home visit was around 70km. Our experience in establishing a culturally sensitive MPCU can be a model to provide palliative care services in remote areas.

Background: Departments of family medicine in Israel were established in the 1970s. Until now, little or no effort has been made to characterize the productivity of Israeli board-certified family medicine physicians in publishing peer-reviewed scientific articles. Methods: Publications were identified by 2 methods. First, a PubMed search by names of current and past faculty from all the departments of family medicine in Israel (1975–2004). Secondly, all of the departments in Israel forwarded a list of all publications by their faculty (including those that do not appear in Medline). The abstracts of all publications were extracted and were separately and blindly evaluated by 2 reviewers. Publications were classified according to Medline citation, language, journal impact factor, and publication type. Results: A total of 1165 publications were identified and analyzed. More than half of the articles were published in the last 10 years. Seventy-two percent were cited in Medline. Publications in English encompassed 64.7% of the publications, Hebrew 34.6%, and 0.7% other. Approximately 6% of the articles were published in journals with impact factor ≥3, with research articles accounting for 46.9%. The publication output of family medicine in Israel averaged 85.4 publications per 1000 family medicine physicians per year. Almost 70% of the articles were published in non-family medicine journals. Academically affiliated, board-certified family medicine physicians published at higher rates, averaging 334.3 per 1000 academic family medicine physicians per year (data available for 2000–2004 only). Conclusions: Publishing and research are important to the development of family medicine as an academic profession, in which Israeli family physicians show significant productivity.

Objectives Revisions of the diagnostic criteria for irritable bowel syndrome have led to varying prevalence estimates. The Rome III criteria require a lower symptom frequency than Rome II (at least 10% of the time for Rome III, compared with at least 25% of the time for Rome II). In an epidemiological survey of a representative sample of Israeli adults using Rome II, we reported the prevalence for irritable bowel syndrome as 2.9%. The official Rome II integrative questionnaire, used for that study, enables a close approximation of Rome III rates, facilitating a retrospective comparison of these criteria. Methods A representative sample of 1000 adults was interviewed with a validated Hebrew version of the official Rome II integrative questionnaire. The data were re-evaluated retrospectively to compare the Rome II results with a close approximation of the new Rome III criteria. Results The prevalence rates for irritable bowel syndrome were 2.9 and 11.4%, respectively, for Rome II and Rome III. The corresponding consultation rates were 57.1 and 41.7%, indicating that the more strict Rome II criteria may select out a group of patients with more severe disease or greater psychosocial problems. Women made up 71.4% of irritable bowel syndrome by Rome II and 62.5% by Rome III. Conclusions In the present retrospective study, the prevalence rate for irritable bowel syndrome in our population is significantly higher by Rome III compared with Rome II. Rome III may more closely reflect the socioeconomic burden of irritable bowel syndrome compared with the overly strict Rome II. Prospective comparative studies should be conducted to confirm these results.

The prevalence of gastroesophageal reflux disease (GERD) symptoms in the general population is lower in Asian than Western countries. Data are lacking for countries in the Middle East. The aim of the study was to determine the prevalence and severity of GERD symptoms among Israeli Jews. A questionnaire including 8 specific questions for GERD symptoms was administered by telephone interview to a representative sample of the population. One thousand two hundred twenty-one of 1839 individuals were successfully contacted and 981 had valid, complete data. The mean age was 45.0 years and 55% were females. Over the previous year 34.8% of the respondents reported suffering any GERD symptom. Of these 11.6% reported retrosternal burning, 11.7% retrosternal pain, 19.0% an acid taste in the mouth, and 17.5% reflux of gastric content. In all, 6.5%, 5.2%, 10.4%, and 7.9%, respectively, suffered these symptoms at least once a week, and 2.0%, 1.8%, 2.4%, and 2.3%, respectively, defined their symptoms as frequent and severe. Male sex (P = 0.01) and a functional lower gastrointestinal (GI) disorder (P < 0.0001) contributed significantly to the severity of upper GI refluxlike symptoms. In conclusion, GERD symptoms are common among Israeli Jews. The symptoms are generally of mild-to-moderate severity and are significantly associated with lower functional GI disorders.

Item does not contain fulltext CONTEXT: There is need for tools to help detect pain or lack of comfort in persons unable to communicate. However, pain and (dis)comfort tools have not been compared, and it is unclear to what extent they discriminate between pain and other possible sources of discomfort, or even if items differ. OBJECTIVES: To map and compare items in tools that assess pain and the broader notion of discomfort or comfort in people with severe dementia or at the end of life. METHODS: Using qualitative content analysis with six classifications, we categorized each item of four thoroughly tested observational pain tools (Pain Assessment in Advanced Dementia [PAINAD], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], Doloplus-2, and draft Pain Assessment in Impaired Cognition [PAIC]), and four discomfort tools (including distress, comfort, and quality of life in severe dementia or at the end of life; Discomfort Scale-Dementia Alzheimer Type [DS-DAT], Disability Distress Assessment Tool [DisDAT], End-of-Life in Dementia-Comfort Assessment in Dying with Dementia [EOLD-CAD], and Quality of Life in Late-Stage Dementia [QUALID] scale). We calculated median proportions to compare distributions of categories of pain and discomfort tools. RESULTS: We found that, despite variable content across tools, items from pain and discomfort tools overlapped considerably. For example, positive elements such as smiling and spiritual items were more often included in discomfort tools but were not unique to these. Pain tools comprised more "mostly descriptive" (median 0.63 vs. 0.44) and fewer "highly subjective" items (0.06 vs. 0.18); some used time inconsistently, mixing present and past observations. CONCLUSION: This analysis may inform a more rigorous theoretical underpinning and (re)development of pain and discomfort tools and calls for empirical testing of a broad item pool for sensitivity and specificity in detecting and discriminating pain from other sources of discomfort.

Background Early diagnosis and treatment of depression are of vital importance in dermatological patients. Objective Our purpose was to evaluate the prevalence of depression among patients visiting a dermatology clinic in southern Israel. Methods Patients who visited the dermatology clinic were interviewed using the Mini International Neuropsychiatric Interview screening tool. Results The study included 384 patients. The screening questionnaire identified 37 patients (9.6%) with major depression, 3 patients (0.8%) with minor depression, and 74 patients (19.3%) with depressive symptoms. Higher prevalence of depression was found among widowers, among divorced or separated patients, and in unemployed patients. Depression was significantly associated with the perception of severity and suffering induced by the skin diseases. Limitations The study was conducted in a cross-sectional design. To confirm causality, a longitudinal study should be conducted. Conclusion Depression should be a consideration by dermatologists in the effective management of skin diseases.

Inappropriate laboratory ordering is a problem affecting medical systems worldwide. An intervention was called for as a result of increasing laboratory costs. Thus, we aimed to assess the impact of introducing computerized laboratory routines to a computerized primary care setting. The study included 380 primary care physician practices of Clalit Health Service (HMO) southern district (CHS-SD) in Israel, caring for 470,000 members. Consensus laboratory routines order sets were electronically introduced into all physicians' computerized medical record (CMR) software, after consensus and internal marketing process. The primary findings were that a previously observed annual increase in laboratory test utilization was stopped, a 2% reduction in total number of tests and a 4 % reduction in the total number of tests per age adjusted person was observed. In conclusion the wide use of CMRs and communication technology combined with an appropriate organizational process can be used to increase appropriate utilization of laboratory tests.

The objectives of this study were to evaluate caregivers' experiences concerning the care of a terminally ill loved one at home, and to compare the death experiences of caregivers with and without access to homecare programs. The primary caregivers of all the patients who died of cancer 6-18 months before the study period (1999-2001) in the Negev area were contacted. This group included 240 caregivers of patients who died in the home palliative care program and 404 caregivers of patients who died with no access to a home palliative care program. A total of 159 caregivers were interviewed, 76 from the home palliative program and 83 who had no access to a palliative care program. Death at home occurred for 80.3% of patients with access to homecare and 20.5% of those without access. Despite the fact that caring for a loved one at home was a greater financial and emotional burden, there was a greater overall satisfaction with the caring experience of those whose loved ones died at home and had access to the homecare program. Given appropriate professional support systems, home-based care at the end of life is preferable to most caregivers.

To identify patients with depression, in primary care clinics in Israel, using the MINI (Mini-International Neuropsychiatric Interview) as a screening tool and to evaluate the health services utilization and costs of the patients identified.Phone interviews (between 1997 and 2000) and health services utilization data extracted from computerized databases.Three primary care clinics belonging to Clalit Health Services (HMO).A random sample of 2755 patients, aged 21-65.MINI score results, utilization data.The study included interviews with 2507 patients. The screening questionnaire identified 5.9% with major depression, 1.6% with minor depression and 14.3% with depressive symptoms. Higher rates of depression were found among women, immigrants, secular or traditional religious Jews, and the unemployed. Those identified with major depression had higher health services utilization and costs. Logistic regression analysis showed that depression was related to older age, female gender, fewer years of education and among seculars. Depressed patients had significantly more somatic comorbidity.Health services utilization and costs of people identified as depressed by the screening tool were higher. Depressive patients had higher comorbidity, which might be partially responsible for the higher cost.

PurposeA possible association between gluten consumption and schizophrenia has been reported. The objective was to compare patients with chronic schizophrenia and matched controls for sociodemographic variables, prevalence of celiac-specific anti-endomysial antibodies and disease-related variables.Subjects and methodsThe study group was comprised of 50 consecutive patients diagnosed with schizophrenia, 18 years of age and older attending the out-patient clinic of the Mental Health Center in Beer-Sheva, Israel. The control group was comprised of mentally normal volunteers who came to primary care clinics for blood tests unrelated to gastrointestinal tract complaints and who were not diagnosed with celiac disease. Known celiac patients and those who refused to participate, did non-speak Hebrew or were incoherent were excluded from the study. All participants in both groups underwent a blood test for anti-endomysial IgA antibody and completed a questionnaire.ResultsEach group was comprised of 50 participants. There were no significant differences between the groups in gender, BMI or country of birth. The mean age of the study group was significantly higher than the controls. All tests for anti-endomysial antibody in both groups were negative.Discussion and conclusionsIn contrast to previous reports, we found no evidence for celiac disease in patients with chronic schizophrenia as manifested by the presence of serum IgA anti-endomysial antibodies. It is unlikely that there is an association between gluten sensitivity and schizophrenia.

Background: Urinary tract infection diagnosis is based on urine culture, taken from a midstream collection. Obtaining samples in this manner is difficult in elderly patients suffering from incontinence and in infants. Objectives: (1) Develop a method for urine collection using gel-based diapers and (2) compare culture results from gel-based diapers with those of the same urine, examined by accepted methods. Methods: Urine was collected and cultured by standard bacteriologic techniques at the microbiology laboratory of Soroka Medical Center, Beer-Sheva, Israel. Gel-based diapers were manually dampened with the same urine samples, and samples from diapers were cultured 0 to 3 hours after dampening. Results: Comparison showed good correlation between direct urine cultures and cultures obtained from gel based diapers (R = 1.000). Total sensitivity was 100% and specificity 97%. Conclusions: (1) Urine can be cultured from gel-based diapers and (2) a larger sample of in vivo trials will be needed to make this technique clinically applicable in an outpatient setting.

Scand J Prim Health Care 2002;20:000-000. ISSN 0281-3432 Objectives - When evaluating patients with respiratory tract infections (RTI), physicians have to judge and decide whether the patient has pneumonia or not. This decision is usually made by clinical assessment alone and/or by performing a chest X-ray. The aim of this study was to determine the reliability of physicians' judgements relating to the presence of pneumonia in RTI patients by clinical assessment alone compared with chest X-ray. Design - A prospective, clinical study. Setting - Primary care clinics and a university hospital in southern Israel. Subjects - Two-hundred-and-fifty ambulatory patients with febrile RTI were included in a prospective study. On the basis of a medical interview and physical examination alone physicians were asked to make judgements relating to the study question, and these judgements were compared with the results of chest X-rays. Results - Physicians' judgements of pneumonia had a sensitivity of 74% (49-90%), a spe...

Background Asthma is one of the most common disorders affecting children and adults. There is a large variation in the theoretical and practical knowledge and skills of physicians, and patients often do not receive optimal treatment. Thus, asthma represents a great challenge to the primary health care system. Objective Our aim was to evaluate an intervention programme for the optimization of treatment of asthma in a primary care clinic in the Muslim Bedouin sector in southern Israel. Methods Over a 3-month period, data were collected on the number of nebulizer treatments received by asthma patients in the clinic, referrals to the emergency room, hospitalizations and availability of electric nebulizer equipment or space chambers in the homes of children with asthma. Following this, an intervention programme was designed and implemented to improve treatment of asthma. At the end of the intervention 1 year later, the same data were again collected in the same season as the pre-intervention data. Results Of 3428 children registered in the clinic, 267 were diagnosed with asthma (7.8%). During the 3-month period before the intervention, 73 children had home inhalation equipment, 61 referrals to the emergency room were documented and six children were hospitalized for exacerbation or complications of the disease. Over this time period, 5.54 nebulizer treatments were conducted in the clinic per month per 100 children and adults. Following the intervention, the number of referrals to the emergency was reduced to six children, none of whom was hospitalized. The number of children with home nebulizers was doubled. The number of nebulizer treatments in the clinic dropped to 4.7 per month per 100, a reduction of 15%. Conclusions An intervention including self-management of asthma with an emphasis on the proper use of inhalers and medications, together with improved disease management at the clinic itself, led to a reduction in the episodes of asthma and its complications.

BACKGROUND Psychosocial variables such as major stressful life events/daily stressful events have been associated with health care utilization. OBJECTIVE Our aim was to examine the effects of a guided disclosure protocol (GDP) of past traumas on symptoms and clinic visits among frequent clinic attenders. METHODS Forty-one frequent clinic attenders (> or =2 visits/3 months) took part. Patients were randomly assigned individually to either a casual content writing control group (n = 19) or a trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting event chronologically (day 1), verbally described their thoughts and feelings and described the event's impact on life (day 2), and finally wrote about their current perspective on and future coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits again. RESULTS Compared with controls, GDP patients reported lower symptom levels at 3 months (2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month (5.1 versus 9.7) follow-ups. The percentage of GDP patients making > or =10 visits during the 15 month follow-up was smaller (10%) than among controls (33%). CONCLUSIONS The findings extend previous findings to frequent clinic users, using a new form of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be an inexpensive additional intervention in primary care for reducing symptoms and clinic visits among frequent clinic users.

Context A major step in end-of-life care was achieved in December 2005 when the Israeli parliament passed the "Dying Patient Law." The law (§31–§36) allows a competent person, even if he/she is healthy, to leave written instructions known as advance medical directives (AD), in which they explain their wishes in detail with respect to future medical treatment should it be determined that they are an incompetent terminally ill patient, as defined by the provisions of that law. Objectives The aims were to characterize the group of individuals that completes ADs, characterize the content of recorded ADs, and analyze trends associated with them. Methods We performed a cross-sectional study of the entire population that signed ADs in Israel from 2007 to September 2010. All computerized AD forms were retrieved from the Ministry of Health's database. A descriptive analysis of trends, characteristics, and authorized procedures relating to the population of AD signatories was done. Results There was an increase in the number of ADs signed during the study period (1167 signatories). About 90% of the AD signatories were 65 years of age or older and 95% were healthy at the time they completed the AD. In an end-stage condition, the mean number of procedures declined was 16.6 ± 4.7 of 19. In a non-end-stage condition, the corresponding mean number was 12.7 ± 3.7 of 15. Conclusion There is a need to increase awareness in the general population of the option to prepare ADs. Family physicians, oncologists, and geriatricians should be more involved in this process.

The objective of this study was to determine whether hypothyroidism is more common in Parkinson patients than in a control group without Parkinson, as suggested in the past. We performed a retrospective file review of all admissions to the geriatric ward during a 1-year period. Concentrations of thyroid stimulating hormone (TSH) and thyroxine (T4) from 92 Parkinson patients were compared with those of 225 randomly selected controls from the same ward. Hypothyroidism was not found to be more common in patients with Parkinson disease as previously suggested. Incidentally, we found an unexpected increase in the prevalence of abnormal thyroid laboratory tests in this group. Statistically significant differences were found in two subgroups, (1) men with Parkinson were more likely to have abnormal thyroid laboratory tests as compared with controls; and (2) 'subclinical' hyperthyroidism was found to be more prevalent in Parkinson patients than in controls. Further research in this field is warranted in non-hospitalized patients.

A prospective, 3-year cohort study of smoking habits was conducted among 9th grade pupils in Israel.A self-administered questionnaire was answered by pupils in the 9th grade and again in the 11th and 12th grades.The baseline questionnaire was answered by 748 9th graders. In the 11th grade 448 (60%) completed the questionnaire for the second time, and in the 12th grade 388 (52%) completed the questionnaire. In all, 312 pupils (42% of the original cohort) completed all three questionnaires. There were no significant sociodemographic differences between these 312 and the original 748. Eight 9th graders (2.6%) were active smokers (at least one cigarette daily for the last month) compared with 64 (20.5%) in the 11th grade (P0.0001 vs 9th grade) and 70 (22.4%) in the 12th grade (P = 0.34 vs 11th grade). Most pupils knew the health hazards of smoking. Variables associated with smoking in the 11th grade included religiosity (religion was associated with lower smoking rates, P = 0.07), past experimentation with smoking (P0.0001), smoking among family members (P0.01), perceived future smoking status (P0.001), self-image (P0.001), influence of a teacher (P = 0.07) or celebrity (P0.05), and effect of peer pressure (P0.01). These results were similar for the 12th grade students except for active or previous smoking by gender (a significantly greater proportion of females than males, P = 0.04).The study design reduces the potential bias of follow-up attrition on assessment of predictors for smoking initiation. Gender, social modeling and peer pressure, past experimentation with smoking, smoking among family members, role models, and self-image were associated with smoking. These factors should be emphasized in intervention programs.

Context Exposure to human suffering may have ramifications for the professional quality of life (ProQol) of palliative care teams. The ProQol scale was designed to assess both negative and positive work-related outcomes and has been used recently for the evaluation of work-related outcomes among palliative care workers. However, the assessment of ProQol among Israeli hospice workers is scant. Objectives The aim of this study was to assess the psychometric properties and the factor structure of the Hebrew version of the 30-item ProQol questionnaire. Methods The study population included 1100 health care providers including physicians, nurses, and social workers in primary health care and palliative care settings. Result A total of 380 workers participated in the study, representing a response rate of 34.5%. The confirmatory factor analysis did not show an adequate "goodness to fit." Using a factor coefficient of 0.35 or greater for inclusion, the exploratory factor analysis revealed a 23-item solution, loaded onto three factors: compassion satisfaction, secondary traumatic stress, and burnout (BU). The internal consistency subscales were 0.87, 0.82, and 0.69, respectively. The subscales showed good convergent and exploratory validity because of significant correlations with measures that examine BU, work engagement, and peritraumatic dissociative experiences. Conclusions Although the findings are consistent with those from studies in other languages, they are different from the original 30-item three-factor structure reported by Stamm. The Hebrew version of the compassion satisfaction subscale was found to be reliable and valid for studies among health care professionals, but further research is needed to improve the BU and secondary traumatic stress subscales.