Emotion work and feeling rules: Coping strategies of family caregivers of people with end stage dementia in Israel-A qualitative study.

BACKGROUND: End stage dementia is an inevitable phase following a prolonged deterioration. Family caregivers for people with end stage dementia who live in their home can experience an emotional burden. Emotion work and "feeling-rules" refers to socially shared norms and self-management of feelings, as well as projecting emotions appropriate for the situation, aiming at achieving a positive environment as a resource for supporting others' wellbeing. OBJECTIVES: Exploring and describing the experience of family caregivers of people with end stage dementia at home, in Israel, unpacking their emotional coping and the emotional-strategies they use, and placing family caregivers' emotion work in a cultural context. METHOD: We conducted fifty qualitative interviews using semi structured interviews analyzed through a thematic content analysis approach. FINDINGS: Four characteristics of emotion work were identified: (1) sliding between detachment and engagement, (2) separating the person from their condition (3), adoption of caregiving as a social role and a type of social reinforcement, and (4) using the caregiving role in coping with loneliness and emptiness. The emotional coping strategies are culturally contextualized, since they are influenced by the participants' cultural background. DISCUSSION: This article's focus is transparent family caregivers' emotion work, a topic which has rarely been discussed in the literature is the context of caring for a family member with dementia at home. In our study, emotion work appears as a twofold concept: the emotion work by itself contributed to the burden, since family caregivers' burden experience can evolve from the dissonance between their "true" feelings of anger and frustration and their expected "acceptable" feelings ("feeling-rules") formed by cultural norms. However, emotion work was also a major source of coping and finding strength and self-meaning. Understanding and recognizing the emotion work and the cultural and religious influence in this coping mechanism can help professionals who treat people with end stage dementia to better support family-caregivers.

Challenges in home care at the end stage of dementia: Hospice units vs. home care units. A qualitative study.

Home hospice units specializing in palliative end-of-life care are uncommon despite the theoretical benefit for people with end stage dementia (PWESD). We described the challenges of caring for PWESD and their families using 24 semi-structured in-depth interviews with professional staff members from two care settings-home hospice units and home care units-in Israel. Staff described end-of-life care for PWESD in four sub-themes: dementia as an end-stage disease; appropriateness of palliative care for PWESD; a family member at the center of care; and "dying-in-place" versus hospitalization. Our findings may enable better services and quality of care for PWESD living at home.

Ethical challenges in end-stage dementia: Perspectives of professionals and family care-givers.

BACKGROUND: In Israel, caring for people with end-stage dementia confined to home is mainly done by home care units, and in some cases by home hospice units, an alternative palliative-care service. Because life expectancy is relatively unknown, and the patient's decision-making ability is poor, caring for this unique population raises ethical dilemmas regarding when to define the disease as having reached a terminal stage, as well as choosing between palliative and life-prolonging-oriented care. OBJECTIVES: Exploring and describing differences and similarities of professional staff members' (PSMs') and family caregivers' perceptions of caring for people with end-stage dementia in two different settings. DESIGN: Qualitative research, using semi-structured interviews analyzed through a thematic content-analysis approach. PARTICIPANTS: Sixty-four interviews were conducted (24 PSMs and 40 family caregivers) in two care-settings-home hospice unit and home care unit. ETHICAL CONSIDERATIONS: The study was approved by the Ethics Committee (BBL00118-17). FINDINGS: We found dilemmas regarding palliative care to be the main theme, including definition of the disease as terminal, choosing "comfort" over "life-prolonging," clarifying patients' wishes and deciding whether or not to use artificial feeding. DISCUSSION: Both PSMs and family caregivers deal with ethical dilemmas and have reached different conclusions, both legitimate. Comprehending dementia as a terminal disease influenced participants' perceptions of the relevancy of palliative care for people with end-stage dementia. Discrepancies between PSMs and family caregivers in caring for people with end-stage dementia were found in both home hospice unit and home care unit environments, raising potential conflicts regarding decisions for end-of-life care. CONCLUSIONS: Communication between PSMs and family caregivers is crucial for the discussion about the discrepancies regarding the unique dilemmas of caring for people with end-stage dementia and bridging the gap between them. Lack of communication and resources can hamper the provision of an acceptable solution for quality and equality of care in the best interest of people with end-stage dementia.

Accreditation systems for Postgraduate Medical Education: a comparison of five countries.

There is a widespread consensus about the need for accreditation systems for evaluating post-graduate medical education programs, but accreditation systems differ substantially across countries. A cross-country comparison of accreditation systems could provide valuable input into policy development processes. We reviewed the accreditation systems of five countries: The United States, Canada, The United Kingdom, Germany and Israel. We used three information sources: a literature review, an online search for published information and applications to some accreditation authorities. We used template analysis for coding and identification of major themes. All five systems accredit according to standards, and basically apply the same accreditation tools: site-visits, annual data collection and self-evaluations. Differences were found in format of standards and specifications, the application of tools and accreditation consequences. Over a 20-year period, the review identified a three-phased process of evolution-from a process-based accreditation system, through an adaptation phase, until the employment of an outcome-based accreditation system. Based on the five-system comparison, we recommend that accrediting authorities: broaden the consequences scale; reconsider the site-visit policy; use multiple data sources; learn from other countries' experiences with the move to an outcome-based system and take the division of roles into account.

Reintroducing OPV in Israel on the journey to global polio eradication - Estimation at a low rate of contraindicated population.

INTRODUCTION: The 2013 reemergence of wild poliovirus in Israel led to the reinstatement of a routine OPV vaccination. Fearing VAPP in immunocompromised, the MOH regulated contraindications for vaccination candidates and household contacts. In this study we estimate the size of the contraindicated population to OPV vaccination. METHOD: We studied vaccination candidates aged 2-9 and 14-23 months and probable household contacts. Using the rate of contraindications extracted for each study group from a medical records database, a statistical model was built to estimate the probability of contraindications in candidates. RESULTS: 3.9% of the 2-9-month-old study group and 4% of the 14-23-month-old group had contraindications by either self or household contacts. CONCLUSION: A statistical model can provide an estimation of the contraindicated population and can be used in the future when devising vaccination campaigns. In contrast to concerns raised by the MOH, our findings show a smaller than anticipated contraindicated population.

Estimated size of the population at risk of severe adverse events after smallpox vaccination in Israel.

BACKGROUND: The population at risk of adverse events after smallpox vaccination has increased in recent years. This has important implications for preparedness strategies against bioterrorism with the variola virus. The aim of the study was to estimate the size of this special population in Israel. METHODS: The study was conducted in January 2010. Data on patients with contraindications to smallpox vaccination, as delineated by the Israel Ministry of Health for planning post-event strategies, were retrieved from the computerized records of the Department of AIDS and Tuberculosis and the Transplantation Center of the Israel Ministry of Health. In addition, the database of the main Health Maintenance Organization in Israel which insures 60% of the national population was searched using ICD-9 codes and specific medications issued in the last quarter of 2009. RESULTS: Of the 7,563,800 persons residing in Israel in January 2010, 326,318 were at risk of an adverse event after smallpox vaccination. CONCLUSION: Approximately 4.3% of the Israeli population should not be exposed to the currently used smallpox vaccine. This knowledge is important to ensure the effectiveness of mass vaccination programs in the event of a bioterror attack.

[Childhood injuries in Israel--current status and the role of the community pediatrician].

In Israel, as in other developed countries, injury is a major problem in children's health. Injuries are a main cause of morbidity and mortality of children in all age groups, both genders, Jews and Arabs and is also a Leading cause of disability and loss of potential life years. In Israel, every year injuries account for 144 child deaths, approximately 24,000 hospitalizations and about 182,000 ED visits, and it is estimated that about half of all Israeli children sustain an injury requiring primary medical care in the community. The vast majority of those injuries are unintentional. The leading cause of child death from injury is traffic accidents, while home and Leisure accidents are common causes for children's hospitalization due to injury. The death rate is higher among children from low socioeconomic clusters compared to high socioeconomic clusters. Between 2000 and 2008, there was a decrease in child death rates from injury and unintentional injury. Intervention programs involving the safety education of parents by community pediatricians showed effectiveness in increasing safe behaviors and prevention of child injuries. In Israel several programs for injury prevention are implemented in the health system, including parents' education in well-baby clinics for child safety by nurses. Since the community pediatrician is a significant factor in parents' decisions regarding their child's health, it is recommended that he will also educate them concerning child injury prevention.

Soy allergy following early soy feeding in neonates.

UNLABELLED: B ACKGROUND:Feeding neonates with humanized milk formula in maternity hospitals may increase the prevalence of milk allergy in infants. However, prospective studies of the possible allergenic effect of very early soy-based formula feeding are lacking. OBJECTIVES: To assess the prevalence of soy allergy in infants fed soy-based formula in the first 3 days of life. METHODS: The study group included 982 healthy full-term infants born within a 7 month period at a hospital that routinely uses soy-based formula to supplement breastfeeding. In-hospital feeding was recorded and the parents were interviewed once monthly over the next 6 months regarding feeding practices and clinical symptoms suggesting soy allergy in the infant. RESULTS: Ninety-nine percent of the infants received soy-based formula supplement in hospital, and 33%-42% at home. No cases of immediate allergic reaction to soy or soy-induced enterocolitis were reported. CONCLUSIONS: The use of soy-based formula in the early neonatal period does not apparently increase the prevalence of soy allergy in infants followed for the next 6 months.

Smallpox revaccination of 21000 first responders in Israel: lessons learned.

OBJECTIVES: Between July 2002 and April 2003, over 21000 individuals were revaccinated against smallpox by the Israeli Ministry of Health. The objectives of the campaign were to create an immunized core of first responders, to review vaccination techniques, and to produce vaccinia immune globulin (VIG). METHODS: The Lister strain of vaccinia virus was used at a concentration of approximately 10(7) pock-forming units (PFU)/ml, and was administered by the multiple-puncture technique. The revaccinees were from varied ethnic backgrounds, almost all were aged 25-64 years, and all participants had been vaccinated against smallpox in the past. RESULTS: The proportion of clinical take was 66.1% (95% CI: 65.2%, 67.0%), similar to past vaccination programs when take also occurred in approximately two thirds of vaccinees. An antibody response occurred in 77.7% (95% CI: 74.8%, 80.6%) of all revaccinees: 94.4% (95% CI: 91.8%, 96.3%) of those with clinical take and 56.6% (95% CI: 51.3%, 61.8%) of those without clinical take. The most common side effects corresponded to symptoms of non-specific viral diseases, and only a few revaccinees reported serious side effects. CONCLUSIONS: The campaign achieved all its basic goals and provided useful lessons for any mass-vaccination programs that might be necessary in the future.

Trends in adrenaline (EpiPen) dispensing in Israel in 1997-2004.

BACKGROUND: The prevalence of allergic diseases has increased over the last 20 years in the Western world. Reports on the growing use of adrenaline auto-injectors (EpiPen and EpiPen Jr) in several countries may point to increased rates of anaphylactic reactions, increased awareness of the risk of anaphylaxis or both. OBJECTIVES: To evaluate the dispensing rate of EpiPen units in Israel from 1997 to 2004. METHODS: The database of the General Health Services (Clalit) was searched to determine the number of EpiPen units dispensed each year from 1997 to 2004. Data on mortality from anaphylaxis were derived from the Central Bureau of Statistics using International Classification of Diseases, 10th revision codes. RESULTS: The dispensing rate of EpiPen units rose gradually from 1689 in 1997 to 2981 in 2004; an overall increase of 76%. No case of death from anaphylaxis was reported from 1998 to 2000. CONCLUSIONS: The dispensing rate of adrenaline auto-injectors has increased considerably over the last 8 years in Israel, although to a lesser degree than in other countries. This is probably a reflection of updated medical policies, in accordance with the clinical guidelines for the management of anaphylaxis and improved public education. Further studies are needed to determine the prevalence of anaphylactic reactions in Israel.

Child injury in Israel: emergency room visits to a children's medical center.

The object of this study was to provide data for policy making and prevention program planning in Israel. The study examined all visits to the Department of Emergency Medicine at the Schneider Children's Medical Center in 1996 (41,279 visits in total). Approximately 22.6% of the emergency room patients were admitted following injury. Most (97%) were unintentional injury. Approximately 42% of the patients were less than 4 years old and about 20% were 2 years old. In all age groups, the rate of boys was double. Approximately 92% were Jews. Despite this low rate of non-Jewish patients, however, they constituted 20% of later hospitalizations. The main injuries recorded were bruises and wounds from blunt objects, falls, motor vehicle-related accidents, and sport injuries. The most commonly injured body parts were the head and upper and lower limbs. In 82%, medical treatment was reported and 7% were hospitalized. In examining injuries over the year, there were no significant differences between the different months, but there were clusters of injuries around various holidays--bicycle and skateboard accidents at Rosh Hashanah, Yom Kippur, and Succoth; pedestrian accidents around Lag BaOmer; burns on Purim, Hannukkah, and Passover; and accidental poisoning around Passover. The findings gave an indication of the nature of the injured population groups. These data could be useful for prevention strategy, both on the level of physical injury as well as on the level of the times of the year, when the risk was higher. The data collected very strongly raise the urgent need for establishing a national surveillance system, which would allow tracking injury-related data with respect to young people throughout the country.

Youth injury in Israel: an appeal for change.

Unintentional injury in children and adolescents have raised public health concerns in recent years, because it is the leading cause of death, a physical burden for the injured person, an emotional and social burden for the families together with an economic burden for society. The National Center for Children's Safety and Health in Israel was established in 1995 at the Schneider Children's Medical Center in order to focus on prevention of childhood and adolescent injury and safety. Over these years data has been collected from the Central Bureau of Statistics, the Ministry of Health, the National Trauma Register, Police and the National Poison Center in order to look for trends and develop strategies for intervention. These efforts, together with the active prevention programs that have been established, resulted in a national report (1) presented to the Minister of Health and other policy makers in 2003. The current situation of youth injuries in Israel, which over the years have not shown any improvement, necessitates a new agenda with a focus on prevention and collaboration between various ministries and agencies in order to implement it. The report alone cannot have an impact upon youth safety, but we hope that it will provide an impetus for developing youth safety strategies and programs based on data. We also believe there is a need for long-term monitoring and follow-up of youth injury trends in Israel.

[Childhood injuries in Israel: status and prevention strategies].

BACKGROUND: In Israel, as in other developed countries, injuries are a leading cause of death and disabilities among children and youth between 1-19 years of age and the leading cause for Potential Years of Life Lost up to 65 years of age. In 1997, 225 children died as a result of accidental injuries, compared to 151 cases of death due to other internal causes. The most prevalent cause of death being motor vehicle accidents, rating 3:100,000: drowning--1:100,000 and falls, burns, suffocation and poisonings--less than 1:100,000 each. Mortality rates are just the tip of the iceberg, the most extreme outcome of an injury. Hospitalization rates and emergency room visits are higher. Injury was the cause for one out of 3 children to visit the emergency department. Hence, in 2001, there were 187,531 visits due to trauma, an annual rate of 712:10,000. The hospitalization rate due to injuries was 67:10,000 and the mortality rate was 8:100,000. Injuries in the community: Data concerning injuries in the community are relatively rare since no surveillance system exist. In their article "Childhood injuries in northern Israel--prevalence and risk factors", Miron at al. describe the prevalence, demographic variables and risk factors of injuries in the community of northern Israel. The article contributes to our knowledge of accidental injuries at the level of the primary care physician in the community. The findings indicate that falls and blows are the most common causes for mild injuries that usually occur in the home and backyard, and Arab children are at special risk for injuries, in general, and falls, in particular. These findings are consistent with existing data. Prevention is the way: 71-95% of all injuries can be prevented by simple means. This has been proven in many countries that managed to reduce mortality from accidental injuries by 10-20%. In the U.S.A., for example, the percentage was reduced to about 35% in a decade. In Sweden, 3 decades of constant preventive efforts combined with close monitoring of the data have proven effective in reducing rate of mortality due to accidental injuries in children by 80%. The strategies which have proven to be effective are education and publicity, safer products and surroundings, promoting public policy, enforcement, data collection, research and evaluation and empowerment. A combination of strategies is most effective. National Vision: Despite the dismal picture, accidental injuries in children can be prevented and are not inevitable. It is wise to look at injuries as a heterogeneous group of illnesses, with different etiology, risk groups, and 'preventive treatments'--a group of diseases which are all preventable. It is very important that a national strategy for child safety be established accompanied by an adequate budget. Above all, it requires a lot of faith and commitment for the only vision: making the world a safer place for children.

Food protein-induced enterocolitis syndrome--not only due to cow's milk and soy.

Over a of 7-year period, six patients (four males, two females aged 3-12 months) were diagnosed with food protein-induced enterocolitis syndrome (FPIES) triggered by foods other than cow's milk and soy: chicken in four, turkey in two, peas in one, and lentils in one (five patients reacted to more than one food type). All reactions developed within 2 h of ingestion of the allergenic food. To exclude other conditions with similar clinical symptoms, three infants underwent work-up for sepsis, one infant underwent work-up to exclude metabolic defects, and one underwent a barium enema to rule out intussusception. All were negative. Pediatricians should be aware that FPIES may be caused by foods other than cow's milk and soy, mainly chicken, turkey and foods from the legume family, and that it may present also in infants older than 6 months.