The coronavirus pandemic in Israel: A comparison between holocaust survivors and other older adults

Introduction

The COVID-19 pandemic places older adults at increased risk for hospitalization and mortality. It also involves social isolation and negative effects of limited mental, social and physical activity. Holocaust survivors could be especially vulnerable to such effects due to their early life traumas. Previous research suggests that in times of life crises, Holocaust survivors may be both most vulnerable (i.e., wear-and-tear hypothesis); yet they may also demonstrate resilience.

Objectives

Thus, the current study examines the effects of the COVID-19 pandemic on the mental health and well-being of Holocaust survivors in Israel, compared to adults who did not experience the Holocaust.

Methods

We collected data from 305 older adults aged 75 and above in Israel during the COVID-19 pandemic. Of these, 114 were Holocaust survivors and 191 did not experience the Holocaust. Participants were asked about their worries of COVID-19 infections, will to live, loneliness and depression and how these changed during the COVID-19 pandemic.

Results

Holocaust survivors were worried to a greater extent from COVID-19 infection and from close others becoming infected, compared to older adults who did not experience the Holocaust. Moreover, survivors reported greater loneliness and depression overall and also reported that these measures became worse during the pandemic. On the other hand, despite these differences, the two groups were similar in their will to live.

Conclusions

Holocaust survivors seem to be more vulnerable to the COVID-19 pandemic, strengthening the vulnerability hypothesis. Policy makers and practitioners should pay special attention to this particularly vulnerable population during these difficult times.

Disclosure

No significant relationships.

The Impact of early retirement, nation-related and personal characteristics on cognitive decline

Background

The increasing prevalence of cognitive decline (CD) in old age has become a global challenge. Our study aims to enhance understanding of this phenomenon by evaluating longitudinal effects of personal and national determinants on memory decline (MD) among European retirees.

Methods

We used data from two interviews collected in 12 European (EU) countries and in Israel by SHARE - a multidisciplinary, cross-national bank of survey data. Our sample included 11,930 retirees aged 50+ who were interviewed at baseline (T1) and again four years later (T2). MD was evaluated by the change in the recalled number of words at T2 compared to those remembered at T1. Ten words were presented at each interview and participants were asked to repeat them, first immediately and again after a few minutes (maximum 20 words). The scale for evaluation of change over time ranged from -20 to + 20.

Results

Except for gender, all of our explanatory variables had a significant effect on MD including age, education, health/function status, depressive symptoms, early retirement, active lifestyle and EU-countries divided into four geographical regions. Decline over time in physical and mental health variables had an additional significant negative effect on memory.

Conclusions

These findings lead us to suggest focusing on what we know and are able to change in order to postpone MD. In addition to promotion of national policies to prolong years of education and participation in the workforce, we recommend introducing programs that encourage people to postpone retirement, and adjusting workplace conditions in order to enable older persons to continue contributing to the workforce. We also suggest promoting an active lifestyle among older adults, especially in Mediterranean and eastern European nations by implementing health and active leisure education programs.

Key messages

Declines in health and functioning negatively affect memory, while education and active lifestyle have a protective effect. Moreover, early retirement has a similar negative effect on memory change in each of the studied EU-regions even when controlling for all of the personal and behavioral factors.

Subjective evaluation of health in old age: the role of immigration status and social environment

The study investigated the role of immigration status on self-rated health, general health, and well-being among elderly persons by comparing two groups of elderly persons who immigrated from Eastern European countries to Israel-veterans and new immigrants. It also examined the factors that explain self-rated health in both groups. Data for this study (n = 784) were taken from a study based on structured home interviews of a random sample of Israeli Jewish elderly (70+) conducted in 1994. The results show that the new immigrants are younger and have higher education than the veterans, but their economic status is lower and they have a lower percentage of men and married persons. The new immigrants also rank themselves lower than the veterans on a variety of measures of health and psycho-social well-being. It is suggested that the stress caused by immigration and factors related to the standard of living and health services in the countries of origin outweigh the relative advantage that the new immigrants have, in terms of age and education, in influencing their health and well-being. Self-rated health among the new immigrants is explained mainly by objective measures of health, economic status and a feeling of control over life, while among the veterans it is explained by these variables as well as by other psycho-social variables such as self-esteem and social support. These findings suggest careful analyses of subjective evaluations of health in different socio-cultural subgroups in society for theoretical reasons and for purposes of planning interventions directed to promote health and psycho-social well-being of elderly persons on the community level.

Variation in intensive care unit outcomes: a search for the evidence on organizational factors

This study was undertaken to determine the extent of empirical evidence on the role of organizational factors in the critical care literature and to categorize these factors. Studies evaluating organizational factors were identified through electronic and hand searching of the critical care literature. Sixty-three publications relating to 54 different studies were identified. The studies were grouped into eight main categories: staffing, teamwork, volume and pressure of work, protocols, admission to intensive care, technology, structure, and error. Studies evaluating organizational factors exist in the critical care literature, and there is evidence that the number is increasing each year. Results indicate that organizational factors may have an impact on mortality after case mix adjustment. Some areas have been investigated more thoroughly than others and are ripe for systematic review. Variation in case mix adjusted hospital mortality after intensive care is an old theme. This study has shown that emerging data will help us understand mortality differences and deliver better outcomes for patients.

Compliance with home rehabilitation therapy by parents of children with disabilities in Jews and Bedouin in Israel

Among key points in making progress and succeeding with a therapeutic programme for children with disabilities is parental compliance with the regime for their child. The purpose of this study was to evaluate factors influencing compliance with home therapy in the Jewish and Bedouin populations. Data were collected by structured questionnaires. A total of 193 families participated (84% response rate) with children who ranged in age from 6 months to 6 years (mean age at first visit to the centre was 9.5 years in Jews and 16.1 years in Bedouin). Compliance was significantly lower among the Bedouin. Multivariate regression analysis showed that the strongest contributory factor in lack of compliance was being Bedouin. The second factor was intensity of questioning destiny, indicating that parents with these feelings may be less likely to comply with therapeutic regimes. Other factors which were associated with compliance were parents' education and socioeconomic status: lower levels on these dimensions corresponded with lower parental compliance. These results were illuminated by a trial intervention programme for Bedouin families which involved telephone contact, translation facilities, and detailed explanations during visits to the centre. Intervention increased the compliance rate of the Bedouin appointments with specialists to 76% (91 of 120 appointments) thereby reaching similar levels to those of the Jewish group. These preliminary results indicate that the strong association between non-compliance and being Bedouin may be due to factors of communication, and that the Bedouin are receptive to therapeutic interventions when communicated in their own language.

The will to live: gender differences among elderly persons

The purpose of the study was to investigate the will to live by evaluating its association with the wish to prolong life and with indicators of well-being among men and women. First were assessed the strength of the will to live, and its relationship to the wish to prolong life in hypothetical illness conditions. Next, association between the will to live and explanatory factors, such as religious beliefs, fear of death and dying, physical and psycho-social dimensions of well-being were comparatively evaluated among men and women. Data were collected from a random sample of 987 Israeli elderly persons by structured interviews at the participants' homes. Findings indicated that women express a significantly weaker will to live than men, and less desire to prolong life by medical interventions in all the hypothetical health conditions presented to them. Gender differences were also found on the variables which contribute to the explanation of the will to live: For both genders, psycho-social indicators of well-being had more explanatory power than health indicators of well-being, but this finding was more striking among women. The implications of these findings for the study of the perceived meaningfulness of life, and the potential use of the will to live as an indicator of well-being are discussed.

The prematurity stereotype in Israeli health care providers

Research on the prematurity stereotype was extended by randomly assigning 158 Israeli medical and nursing students to view full-term infants labelled either 'full-term' (FTL) or 'premature' (PL). One-half of the students were additionally assigned to a goal condition in which they were informed that their judgements would be evaluated for their accuracy. Overall, students were found to show strong stereotyping effects, rating PL infants more negatively than FTL infants when asked questions about their expectations for the infants' growth and development as well as their expectations for how mothers of these infants might behave during a medically related contact concerning her infant. However, the content of the stereotype varied across type of health care provider when general perceptions of the infants' status characteristics were elicited, with pre-clinical medical students showing greater levels of stereotyping than upper level students. Only limited effects involving the goal condition were found. When communicating with mothers, upper level students reported that they would respond more time-expediently and pre-clinical students reported that they would show more empathy. The findings emphasize the important role stereotypes play in interpersonal processes, including caregiver-patient interactions. Implications for medical education and practice are discussed.

Use of the Functional Bowel Disorder Severity Index (FBDSI) in a study of patients with the irritable bowel syndrome and fibromyalgia

OBJECTIVE

The purpose of this study was to evaluate the utility of the Functional Bowel Disorder Severity Index (FBDSI) as a measure of severity of disease among patients with the irritable bowel syndrome (IBS) and matched controls.

METHODS

A total of 75 IBS patients and 69 matched controls completed questionnaires on bowel symptoms, health status, quality of life, psychological distress, concerns, anxiety, and sense of coherence. All participants also were tested for fibromyalgia (FS), a functional disorder of the musculoskeletal system. All participants were administered a questionnaire that included the FBDSI. On the basis of their responses to the questionnaire, the controls were subdivided as healthy controls (n = 48) or IBS nonpatients (n = 21). On the basis of the FS classification, 75 IBS patients were subdivided as IBS only (n = 50) or IBS and FS combined (n = 25).

RESULTS

The mean FBDSI score was higher for the IBS patients than the controls (100.5+/-12.7 and 23.5+/-3.9, respectively; p < 0.001). IBS nonpatients had an intermediate score of 42.3+/-18.0. Patients with both IBS and fibromyalgia had the highest mean FBDSI score: 138.8+/-31.5. There was no association between FBDSI and age or gender, but FBDSI was significantly associated with other measures of health status.

CONCLUSIONS

An association was found between the FBDSI and IBS patient status: IBS nonpatients, patients with IBS only, and patients with both IBS and fibromyalgia had increasingly severe scores. The results provide support for the validity of FBDSI as a measure of illness severity in functional gastrointestinal disorders.

Use of the Functional Bowel Disorder Severity Index (FBDSI) in a study of patients with the irritable bowel syndrome and fibromyalgia

OBJECTIVE

The purpose of this study was to evaluate the utility of the Functional Bowel Disorder Severity Index (FBDSI) as a measure of severity of disease among patients with the irritable bowel syndrome (IBS) and matched controls.

METHODS

A total of 75 IBS patients and 69 matched controls completed questionnaires on bowel symptoms, health status, quality of life, psychological distress, concerns, anxiety, and sense of coherence. All participants also were tested for fibromyalgia (FS), a functional disorder of the musculoskeletal system. All participants were administered a questionnaire that included the FBDSI. On the basis of their responses to the questionnaire, the controls were subdivided as healthy controls (n = 48) or IBS nonpatients (n = 21). On the basis of the FS classification, 75 IBS patients were subdivided as IBS only (n = 50) or IBS and FS combined (n = 25).

RESULTS

The mean FBDSI score was higher for the IBS patients than the controls (100.5+/-12.7 and 23.5+/-3.9, respectively; p < 0.001). IBS nonpatients had an intermediate score of 42.3+/-18.0. Patients with both IBS and fibromyalgia had the highest mean FBDSI score: 138.8+/-31.5. There was no association between FBDSI and age or gender, but FBDSI was significantly associated with other measures of health status.

CONCLUSIONS

An association was found between the FBDSI and IBS patient status: IBS nonpatients, patients with IBS only, and patients with both IBS and fibromyalgia had increasingly severe scores. The results provide support for the validity of FBDSI as a measure of illness severity in functional gastrointestinal disorders.

[Patient satisfaction and hospital services evaluation: comparison of and private patients]

"Sharap" is a private medical service integrated within our public clinic and hospital services. Clients may choose their physician by paying a fee in addition to what their health insurance agency (Kupat Holim) pays for. All other hospital services are supplied to all patients alike. The main purpose of this study was to evaluate the extent to which this declared policy is maintained in practice. During 5 months in 1997, 198 Sharap patients and 198 regular patients were interviewed in the the general surgery, cardiac surgery, ENT, cardiology, newborn and gynecology wards of this hospital. Both groups were similar in regard to cause of hospitalization, gender, age group (10-year age ranges), and length of hospitalization (at least 24 hours). Similar levels of satisfaction with hospitalization in general and with the nursing service and with supportive services were found in both groups. However, Sharap patients were more satisfied with their physicians than regular patients (87% vs 74%, respectively). Similar results were also found using indirect measures of satisfaction. About 86% in both groups reported having achieved the goal of improvement in health. A high proportion of respondents from both groups (82% and 88%, respectively) could not distinguish between Sharap and regular patients in the ward. However, a greater proportion of regular patients (35% vs 21%) wanted more extensive explanations from their physicians regarding their treatment. Sharap patients belonged to higher socio-economic classes than regular patients. Our evaluation indicates that although the Sharap service enables the affluent to choose their preferred physician, resulting in a different doctor-patient relationship, the service does not create a significant feeling of discrimination among hospitalized patients, and does not interfere with the high level of health services available to the public at large.

Life-sustaining treatments: what doctors do, what they want for themselves and what elderly persons want

In view of the current social dilemmas regarding the use of life-sustaining treatments (LST) at the end of life, the purpose of the study was to reveal sources of interpersonal and intrapersonal conflict among the most involved parties, in a society where open doctor-patient communication about end-of-life treatment is rare. Two comparative analyses were conducted: (a) between physicians' practice and elderly persons' preferences regarding the use of different life-sustaining treatments in different illness conditions, and (b) between physicians' hypothetical practice for an elderly person in a metastatic cancer condition, elderly persons' preferences and physicians' preferences for themselves, should they be in the same illness condition. Data were collected in Israel from 339 physicians working in two medical centers, and from a random sample of 987 elderly persons. Attitudes and practice regarding artificial tube feeding, mechanical ventilation and cardiopulmonary resuscitation (CPR) in three different illness conditions were evaluated by close-ended questions. The findings indicate disagreements between the elderly and the physicians on a number of issues: in general, physicians report that they would use more LST than what the elderly report that they would want. Physicians differentiate among different illness conditions and different LST more than elderly persons do. Physicians are more likely to use artificial feeding than CPR, while elderly persons prefer the use of CPR more than artificial feeding. The comparison of physicians' hypothetical practice, the wishes of the elderly, and physicians' wishes for themselves regarding the use of LST in a metastatic cancer condition, shows that physicians would use LST differently from what the elderly want, and that they want less LST for themselves than they would order for elderly patients. The discrepancies found between the physicians' practice and the elderly persons preferences reflect differences in perceptions of artificial feeding and a lack of public knowledge regarding the effectiveness of CPR. They also reflect differences in attitudes regarding the prolongation of life in various illness conditions. The discrepancy between physicians' practice and their preferences for themselves underscores the personal and professional dilemmas related to these issues, which are faced daily by many physicians, and impede their compassionate behavior toward patients. Increasing the awareness of physicians of such discrepancies, and providing them with appropriate behavioral tools, including communication skills, is a timely need which should be addressed by the medical profession, medical services and medical schools.

Stability of elderly persons' expressed preferences regarding the use of life-sustaining treatments

The purpose of the study was to assess the stability of expressed preferences for the use of life-sustaining treatments (LST) in severe illness conditions over two years. The two year longitudinal study included three structured interviews with a one-year interval (1994, 1995, and 1996). At baseline, 1138 Israeli elderly persons (70+) were interviewed, 802 and 638 were interviewed in the following stages. Stability over time was assessed on the basis of score differences on two different indices that measured the wish to prolong life. Overall 70% of the respondents had stable preferences for the use of LST over time. This result was similar on both indices. The large majority of those with stable preferences (86%) did not want to prolong life already in the baseline interview. This was the most stable group. Among those who changed their wishes, the group that wanted LST less at stage 3 (20%) was twice as large as the group that wanted LST more (10%). These findings, which are similar to those reported in a study of an American sample, indicate a high level of stability in elderly persons' expressed preferences for LST at the end of life, and, therefore, strengthen the ethical basis for using advance directives. They also indicate that elderly persons of different cultural backgrounds may face similar problems regarding the prolongation of life and respond to them similarly.

Patient complaint strategies in a general hospital

This study aimed to understand specific complaint behaviors of inpatients regarding perceived problems in the receipt of hospital services and to study the effect of provider responses to the different complaint strategies on patients' overall satisfaction with hospital services. The analysis was performed on 155 patients who had reported a problem in the receipt of services and had acted to elicit a change. Three complaint strategies were studied--formal, informal, and a combination of both. The use of these strategies was studied in relation to type of hospital service and the type of ward where the problem emerged. Two questions were investigated--what strategy leads to the best outcome for the patients? and how does each outcome affect overall satisfaction with hospital services?

The sense of coherence index and the irritable bowel syndrome. A cross-sectional comparison among irritable bowel syndrome patients with and without coexisting fibromyalgia, irritable bowel syndrome non-patients, and controls

BACKGROUND

Sense of Coherence (SOC) is a global orientation that affects coping with stressors. A strong SOC is associated with better health outcomes. The purpose of this study was to evaluate SOC among patients with irritable bowel syndrome (IBS) and matched controls.

METHODS

Seventy-nine IBS patients and 72 matched controls completed questionnaires and were tested for fibromyalgia (FS). The controls were subdivided into healthy controls (n = 49) or IBS non-patients (n = 23), and the patients into IBS only (n = 54) or IBS and FS (n = 25).

RESULTS

The mean SOC score was higher for the controls than for the IBS patients (65.7+/-1.2 and 59.6+/-1.1, respectively; P = 0.003). There was no significant difference between the healthy controls and the IBS non-patients. The controls had a higher SOC than patients with IBS only and patients with IBS and FS (P = 0.0004).

CONCLUSIONS

An association was found between IBS and SOC. No causality can be inferred from this study. Individuals with low SOC may be more likely to express symptoms in terms of psychologic distress and increased health care utilization because of poor coping skills. Conversely, the presence of IBS may affect SOC negatively. Further longitudinal studies could clarify the potential of SOC as a predictor variable (for example, for treatment results) or an outcome variable.

Exaggerated blood pressure response at exercise in normotensive subjects: demographic and stress performance characteristics

BACKGROUND

Exercise testing is an important diagnostic and prognostic procedure in the assessment of patients with hypertension. An exaggerated blood pressure response to exercise among normotensive subjects was found to be one of the best predictors of future hypertension. The demographic characteristics of patients with an exaggerated blood pressure response during exercise have not been adequately described.

METHODS AND RESULTS

The demographic and stress performance characteristics of 2 groups of normotensive patients referred for exercise testing, one composed of patients with an exaggerated blood pressure response (group I, n=146) and a group of patients with a normal blood pressure response (group II, n=439) were prospectively compared. Patients in group I were older than those in group II (54+/-12 vs 51+/-13 years, P < .05). More men than women were found in both groups, yet significantly more in group I than in group II (83% vs 69% P < .001). Significantly more among the patients in group I had a higher level of education and were of Western origin than those in group II (P < .01). The resting systolic and diastolic blood pressures were higher in group I than in group II (131+/-18 vs 119+/-14 mm Hg, P< .001, and 81+/-8 vs 76+/-7 mm Hg, P < .001, respectively). The patients in group I achieved a higher percentage of the maximal predicted heart rate (88+/-7 vs 85+/-9 beats/min, P < .01). No significant differences were found between the groups in the duration of stress test and effort ischemia.

CONCLUSIONS

Patients with a hypertensive blood pressure response during stress testing have specific demographic and exercise characteristics.

Patients with coronary collaterals and normal left ventricular systolic function: clinical, hemodynamic, and angiographic characteristics

One hundred and twenty consecutive patients with significant coronary artery disease, normal left ventricular systolic function, and coronary collaterals were compared with 111 patients with the same characteristics but with no collaterals. No significant differences were found between the two groups in hypertension, diabetes mellitus, and smoking. The left ventricular end diastolic pressure was 16.4+/-7 in the study group and 16.9+/-6.9 in the controls (NS). Significantly more diseased vessels were observed in the study group than in the control group (2.1+/-0.6 versus 1.7+/-0.6, p=<0.001). One hundred and one totally occluded vessels were found in the study group but only two in the control group. The richest collateral supply was to the right coronary artery: 94 sources to 85 diseased vessels (111%) including 66 sources to 52 totally occluded arteries (127%); to the left anterior descending: 59 sources to 89 diseased vessels (66%) including 37 sources to 33 totally occluded arteries (112%). The poorest supply was to the left circumflex: 17 sources to 69 diseased vessels (25%), including nine sources to 16 totally occluded arteries (56%). No collaterals were observed in 14 totally occluded vessels in the study group and in two of the controls, while the systolic function at rest was still normal. It is suggested that coronary collaterals are important in preserving left ventricular systolic and diastolic performance at least at rest. Not readily visible collaterals may also prevent systolic dysfunction.

Health and well-being among elderly persons in Israel: the role of social class and immigration status

OBJECTIVES

The purpose of the study was to compare three groups of Israeli elderly that differ in social class and immigration status on measures of health and psycho-social well-being, and assess the factors which explain their self-rated health (SRH).

DESIGN

Based on a random sample of Israeli Jewish elderly (70 +), data were collected from 1138 persons during 1994 by structured home interviews.

RESULTS

Social class differences among Israeli veterans were mainly found with regard to psycho-social characteristics. They were less conspicuous in health measures. New immigrants, who had a higher level of education than the veterans, but ranked lower on economic status, reported lower levels of health and psycho-social well-being than the veterans. Self-rated health among the immigrants was mainly explained by objective measures of health, and economic status, while in the higher social class of veterans it was also explained by education and psycho-social variables such as self-esteem and social support.

CONCLUSIONS

These findings indicate that in contradiction to the convergence hypothesis, social class and immigration status affect health and well-being also in old age. It is suggested that the immigration crisis and factors related to the standard of living and health services in the countries of origin, as well as the lower social and economic status of the immigrants in Israel, outweigh their relative advantage in age and education in influencing their health and well-being. The differences found among the three groups in the factors that explain self-rated health have implications for the use of economic status as a relevant indicator of social class when considering health status among the elderly, and for the interpretation of SRH, as a global measure of health, in different socio-cultural groups.

Medical students' attitudes regarding the use of life-sustaining treatments for themselves and for elderly persons

This study investigated students' wishes regarding the use of life-sustaining treatments (LST) in different health conditions compared with their evaluations of the wishes of elderly people, and with reports of a group of elderly people about themselves. Data were collected from two consecutive classes of first year medical students (n = 101), and a random sample of Israeli elderly aged 70+ (n = 987) who responded to fixed-choice questions regarding their will to live and wishes for three kinds of LST in a number of hypothetical illness conditions. The students were also asked to assess elderly's wishes. Students ranked the will to live of elderly persons significantly lower than their own. The elderly ranked their will to live significantly lower than did the students, but higher than the students assumed about them, indicating that although the will to live is weaker among older people, it is stronger than young persons believe. With regard to the use of LST, students believe that old people want less LST than themselves, but the elderly want even less LST than assumed by the students. The best predictors of students' wishes for themselves were fear of dying and religiosity. Fear of dying, the students' self-esteem and religiosity were the best predictors of their evaluations of the elderly's wishes. The results indicate that both the elderly and the students have a relatively strong will to live, but this desire is dependent on quality of life. The implications of this study for medical education are discussed.

Coronary collaterals in patients with normal and impaired left ventricular systolic function

One hundred and twenty consecutive patients with significant coronary artery disease, normal left ventricular systolic function and coronary collaterals (group A) were compared to 120 patients with the same characteristics but with left ventricular systolic dysfunction (group B). No significant differences were found between the two groups on age, hypertension, diabetes mellitus and smoking. The left ventricular end diastolic pressure was 16+/-7 in group A, and 24+/-9 in group B (P<0.01). The number of diseased vessels was similar in both groups. More completely occluded vessels were found in group B (155 vs. 101 in group A). No significant difference was detected between the two groups in the distribution of the diseased vessels. In both groups, the richest collateral supply was to the right coronary artery, followed by collaterals to the left anterior descending. The poorest supply was to the left circumflex. In conclusion, patients with normal and abnormal left ventricular systolic function have similar coronary collateral characteristics.

[Telling the bad news: do the elderly want to know their diagnoses and participate in medical decision making?]

In view of reported changes in western countries in the preferred model of doctor-patient relations, we evaluated the wishes of elderly persons for open doctor-patient communication with regard to terminal disease. Data was collected in 1994 from 987 elderly persons (70+) by structured interviews. Most of respondents wanted open communication and wished to be involved in medical decisions regarding life-sustaining treatment. However, only a minority tell their physicians and/or family members of their wishes. This suggests that most of the elderly expect physicians to be the first to initiate discussions of these issues. The results also indicate that among the elderly, those more educated, less religious, and those living in Israel longer, are more likely to want open communication with their physicians. This is explained by the relationship of these characteristics with the dominant cultural values of this group, and its acceptable models of relations in other areas of life.

Wishes regarding the use of life-sustaining treatments among elderly persons in Israel: an explanatory model

This study investigates the wishes of Israeli elderly concerning the use of life-sustaining treatments (LST) at the end of life, and suggests an explanatory causal model for these wishes. The data include 1138 Israeli elderly (70+) respondents. The results indicate that most of the elderly want to prolong their life in mild health conditions, including having cancer with a relatively good prognosis, while only a small percentage want LST in severe illness. Structural equation analysis (LISREL) of wishes for LST in severe illness conditions revealed that personal experience with other people's illnesses is the single most powerful explanatory factor affecting choice regarding LST directly and indirectly, channeled through fear of death and fear of dying. The results of such experiences whether positive or negative affect wishes for LST in the same direction; however, since they are mostly negative, past experience mostly weakens the will to prolong life by LST. Beliefs and feelings regarding life and death, such as fear of death, fear of dying, the will to live and religiosity, are also good predictors of wishes for LST. Those who fear death, have a strong will to live, and those who are more religious are more likely than others to want to prolong their life by LST, while those who fear dying want it less. Religiosity affects these wishes directly and indirectly through fear of death, fear of dying, and the will to live. Health status and social support have only a minor effect on wishes for LST: the higher the present quality of life, the more likely are the elderly to want LST. Most of the socio-demographic characteristics have no significant effect on elderly persons' wishes for LST. Only gender has a minor direct and indirect effect, channeled through the fear of dying and the will to live. Women in comparison to men want less LST because they fear dying more and have a weaker will to live. The results of this study shed some light on the explanatory factors of wishes for LST in severe illness conditions. More research is needed in order to promote social understanding of the concerns and wishes of the most relevant parties regarding the use of LST. This is a necessary condition for the formulation of new societal guidelines for general policy and daily behavior.

[Angina pectoris and the severity of coronary artery stenosis]

The relationship between angina pectoris and the severity of coronary artery disease was evaluated in 146 patients with normal segmental and global, left ventricular, systolic performance. None had unstable angina or a previous myocardial infarction. A strong relationship was found between angina and the severity of coronary artery disease (p < 0.005). Significant, stable, angina pectoris as a clinical symptom indicated advanced coronary artery disease in this selected group of patients.

The Professional Self-esteem of Physicians Scale, structure, properties, and the relationship to work outcomes and life satisfaction

This paper presents a scale to measure the professional self-esteem of physicians. It describes the scale's theoretical basis, psychometric properties, and its value for explaining physicians' well-being. Statistical analyses, conducted on data from two independent studies of physicians in Israel (ns = 214 and 122), indicate internal consistency and construct validity of the scale. Scores on professional self-esteem are associated positively with life satisfaction and work satisfaction and negatively with burnout. Scores also correlate significantly with global self-esteem and with anxiety. The professional self-esteem scale appears to be a useful tool for explaining professionals' work performance, work-related well-being, and general well-being.

Preferences for different life-sustaining treatments among elderly persons in Israel

The purpose of this study was to assess elderly persons' wishes regarding the use and choice of different life-sustaining treatments (LST). Data were collected from a random sample of 987 Israeli elderly persons, aged 70+. Interviewees were questioned about their wishes for artificial feeding, mechanical ventilation, and cardiopulmonary resuscitation in five different illness conditions. Results indicate that significantly more of the respondents would want to prolong their life in mild rather than in severe illness conditions. Significant differences are found, however, among subgroups who differ on religiosity, gender, education, and health status. The findings also indicate that in all five illness conditions, elderly persons are more likely to want cardiopulmonary resuscitation than artificial feeding. This is explained by the fact that the public's main source of information is television dramas, and that there is a lack of communication about the use of LST among physicians and patients and their families.

Compassionate-empathic physicians: personality traits and social-organizational factors that enhance or inhibit this behavior pattern

Compassionate-empathic physicians (CEPs) are desired by patients, but rarely found in medical settings. The purpose of this study was to promote our understanding of this gap by determining personal characteristics that distinguish CEPs from other physicians, and organizational factors that might enhance or inhibit physicians' compassionate-empathic behavior (CEB). In the first stage of the study, three groups of physicians who differed in their compassionate-empathic pattern of behavior toward patients were identified by a sociometric questionnaire distributed to 324 physicians in a general hospital. In the second stage, almost all of these physicians (N = 308) were asked to fill out a self administered structured questionnaire, and 214 (69.5%) responded. Comparisons among the three groups show that the physicians identified as CEPs, more than other physicians, are younger, have fewer years in medical practice, and score higher on pro-social, non-stereotypic attitudes toward patients and on empathy measures. Their self-esteem is, however, similar to that of the non-CEPs. The CEPs express similar levels of satisfaction with work on most dimensions, but they report more emotional exhaustion (burnout) than other physicians. A consensus among all physicians was found with regard to two rank orders: (a) the important qualities for being "a good physician"; and (b) the important qualities for being promoted in the hospital. However, while empathic behavior was considered the most important quality for being "a good physician", it was ranked as the least important for being promoted in the hospital. The conclusions can serve as a scientific base for improving methods of selection of medical students, and for re-evaluating the existent criteria for promoting medical staff in general hospitals.

Behavior, attitudes, and expectations regarding the use of life-sustaining treatments among physicians in Israel: an exploratory study

The use of life-sustaining treatments (LST) for prolonging lives of terminally ill patients without being able to improve the quality of life is a source of ethical, medical, economic and legal dilemmas for physicians. Although physicians in all Western countries face these dilemmas, they are unique in each society due to the special combination of its dominant religion, and its priorities regarding social values and legislation. This paper presents opinions, attitudes, expectations and behavior regarding the use of LST among 25 physicians attached to one teaching hospital in Israel. The data, which was collected by in-depth, semi-structured interviews, indicate that all of the physicians agree that life does not always have to be artificially prolonged. The general message that the physicians conveyed was that they deal quite effectively with these issues. They are not at all bothered by economic considerations and found ways to deal with the legal, ethical and medical dilemmas. It is suggested that in Israel the core issue is not the current law, but lack of communication among physicians and between physicians and patients/families. The relevance of the dominant model of the doctor-patient relationship and applications for medical education and practice are discussed. A list of hypotheses derived from this exploratory study for future intra-societal and inter-societal research is presented.

[Direct percutaneous transluminal coronary angioplasty]

Early reperfusion in acute myocardial infarction (AMI) effectively reduces mortality. Direct. percutaneous. transluminal coronary angioplasty (PTCA) is a recognized alternative to intravenous thrombolytic therapy in early AMI. Of 289 PTCAs performed during a year, 29 (10%) were direct PTCAs. Indications for direct PTCA in 21 patients (72%) were large infarcts, and in 8 (28%) cardiogenic shock. The left anterior descending artery was involved in 15 patients (52%), the right coronary artery in 10 (34%), the left circumflex in 3 (10%), and the left main artery in 1 (3%). Satisfactory opening of the occlusion was achieved in 26 (90%); there was partial success in 2 (7%) and failure in 1 (3%). 4 patients required stent deployment for treatment of dissection. There was no major complication. A patient in whom success was only partial, and the one in whom PTCA failed, were sent for operation. These data do not differ from our success rate in elective PTCA. It is concluded that direct PTCA is a safe procedure with a high rate of successful reperfusion in AMI.

Medical and psychosocial predictors of morbidity and mortality: results of a 26 year follow-up

This study investigates the extent to which sociodemographic, medical and psychosocial factors measured in 1967 among 1,649 American-born Israelis predict their physical and emotional health status 26 years later. In 1993, mail questionnaires were completed by 673 (40.8%) of the 1967 respondents. Evidence was obtained regarding the death of 204 (12.4%) of the 1967 respondents. The 1967 predictor variables included: sociodemographic characteristics, self-assessed health and medical risk factors, and psychosocial resources. The 1993 outcome variables included a multidimensional measure of health, physical functioning, and emotional well-being. Bivariate and multivariate statistical analyses were used to determine the predictive power of the variables measured in 1967 on the 1993 health outcomes, controlling for potential confounders. These analyses showed that the deceased in 1993 were older than the respondents; in 1967 they had reported more health problems and had more medical risk factors; they also had less formal education, were less likely to be married, and had lower adjustment scores than the respondents. Among the 1993 respondents, the addition of psychosocial variables to the explanation of health outcomes, controlling for sociodemographic and medical risk factors, contributes strongly (13%) to emotional well-being. Their contribution to general health and physical functioning is weak (2 to 3%), but statistically significant. These results show the importance of a multifactorial approach to the long-term prediction of health and illness outcomes.

Psychosocial factors among members of religious and secular kibbutzim

Mortality in 11 secular kibbutzim between 1970 and 1985 was nearly twice that of 11 matched religious kibbutzim. A cross-sectional study was undertaken in 1991 in 10 of these settlements, 5 religious and 5 secular, to determine whether differences in risk factors could explain the unequal survival. These comprised physical, physiologic and biochemical measurements, health-relevant behaviors and psychosocial variables. This report addresses the psychosocial aspect of the study, which included assessment of sense of coherence, hostility, satisfaction with self, work-related stress, social supports and social contacts using self-administered questionnaires. The response rate among the sample of men and women, aged 35-64 years, was 76% (437 respondents, 208 men and 229 women). Analysis of variance and logistic regression (the latter comparing the upper or lower fourths of the distribution vs. the rest) were used. Religious kibbutz members reported a higher sense of coherence (odds ratio = 1.58, 95% CI 1.02 to 2.46) and a lower level of hostility (odds ratio = 0.49, 95% CI 0.33 to 0.75) than their secular counterparts. Findings for satisfaction with self and work-related stress were inconsistent; there were significant interactions between religious affiliation, sex and age. Younger women reported less satisfaction with self and higher work-related stress than the other age-sex groups in both types of kibbutz. There was no difference in social support or frequency of social contact between religious and secular kibbutzim. Voluntary work was more frequent among the religious kibbutzim. The findings are consistent with an interpretation that Jewish religious observance may enhance the formation of certain protective personality characteristics. Membership in a cohesive religious kibbutz community may increase host resistance to stressors and thereby promote overall well-being and a positive health status. This could reflect an interplay of individual and collective attributes of religion.

Relation between shortness of breath, left ventricular end diastolic pressure and severity of coronary artery disease

The relation of shortness of breath to left ventricular end diastolic pressure and the severity of coronary artery disease was evaluated in 146 patients with normal segmental and global left ventricular systolic performance. None had chronic lung disease, cardiomyopathy, previous myocardial infarction, uncontrolled hypertension or unstable angina pectoris. A strong relationship was found between shortness of breath and elevated left ventricular end diastolic pressure, and a borderline relationship with the severity of coronary disease. Shortness of breath as a clinical symptom indicates diastolic dysfunction in this selected group of patients.

Angiographic follow-up of coronary artery ectasia

Of 1,125 patients catheterized over a period of 8 years, 68 (6%) had coronary ectasia. Twenty-five of them were catheterized at least twice and constituted the study group. The time between the first and last catheterization ranged from 2 to 8 years (mean +/- SD = 4.2 +/- 1.6). Coronary ectasia was more frequent in males (88%). The frequency of involvement was: the right coronary (47%), the left circumflex (30%), the left anterior descending (21%) and the left main arteries (2%). Proximal segments were most frequently involved (48%). Diffuse involvement was found in 29%. Severity of ectasia progressed in 6 segments (14%) and 2 new ectatic segments appeared over the follow-up period. During that period, 2 patients had myocardial infarction, 1 of them due to a total occlusion of an ectatic segment. There were no deaths. In conclusion, coronary ectasia has a relatively benign course.

The role of age and an expanded Health Belief Model in predicting skin cancer protective behavior

Skin cancer (SC), the most common form of cancer in the US, with a rapidly growing incidence, has become a target for health education. Sun exposure protective behavior (SEPB) is currently believed to be the best means to prevent it. Focusing on age differences, this paper applies an expansion of the Health Belief Model (HBM) to the prediction of engagement in SC protective behaviors in four age-groups, following an intervention program. It is based on data collected by a structured questionnaire completed by 509 members of four kibbutzim in Israel. The results indicate that the proposed model explains the SC-related protective behaviors of the older age-groups (45+) much better than that of the younger groups (15-44). The older age-groups are also more likely to change risky behavior following the intervention. The youngest age-group (15-29), although being highest at risk for SC due to sun exposure habits, is least likely to change them and least likely to participate in the intervention. Beliefs about sun tanning, sun exposure habits (barriers) and degree of exposure to the intervention are the best predictors of the likelihood to engage in SEPB in the younger age-groups, while among the older groups the best predictors are the value of health and appearance. These findings suggest that health education programs should develop different messages for different age-groups. Regarding SC, it seems especially important to focus prevention efforts on adolescents and young adults by recruiting the beauty and fashion industries as well as legislation. The merits of age group analyses in the research of health behavior are discussed.

Measuring patient satisfaction in primary care: a joint project of community representatives, clinic staff members and a social scientist

We describe the process of planning and developing a questionnaire and conducting a patient satisfaction survey in a neighbourhood clinic in Beer-Sheva, Israel. The project was conducted by the clinic staff members, patient representatives and a medical sociologist. The satisfaction survey was conducted in patients' homes, with a 67% response rate. General satisfaction and satisfaction with specific components of service are described. Patient satisfaction was higher among men than among women, and negatively correlated with family size. The strongest predictor of general satisfaction was satisfaction with physicians' services. Implications of the survey results were decided upon by active collaboration between the clinic staff and the patient representatives. The inferences drawn from the patients' replies and the changes introduced as a result of them, are discussed. Health care consumers should be active participants in carrying out surveys of satisfaction on a regular basis.

[AIDS-related knowledge, behavior and attitudes of workers in Israel]

Control of the AIDS pandemic depends largely on the success of educational programs designed to persuade the population at risk to use currently recommended methods of prevention. In Israel there are no regular national surveys on the health-related behavior of the population. The consequent lack of reliable data makes it difficult both to develop and to evaluate AIDS-related educational programs. A survey was therefore conducted among 536 employees of 3 workplaces in Dec. 1992, using anonymous questionnaires. The level of general knowledge of the disease was good, although in selected areas there were deficiencies: more than 20% of the men and 40% of the women believed that AIDS can be contracted through the use of public toilets. More than 50% of the subjects indicated that they would like more information on the disease, and believe that insufficient education is given youth regarding the use of the condom. Women tended to be more worried than men about the possibility of contracting AIDS, and were more likely to adopt preventive behavior and educate their children in this regard. These findings indicate the need to design separate educational programs for men and women. Further on-going surveys in representative samples of the general population are urgently needed to monitor trends in AIDS-related knowledge, attitudes and behavior.

Left ventricular performance in patients with normal coronary arteries: hemodynamic characteristics and clinical follow-up

Of 111 patients with normal coronary angiograms, 68 patients had elevated left-ventricular end diastolic pressure and 'low-normal' ejection fraction (Group I) while the other 43 patients had normal left ventricular end diastolic pressure and 'high normal' ejection fractions (Group II). Although the number of patients was too small for meaningful statistical analysis, systematically a higher percentage of patients with diabetes mellitus, hypertension, hypercholesterolemia and smoking history was found in Group I. In contrast to the patients in Group II, patients in Group I tended to have more angina and ischemic events.

Coping with the Gulf war: subculture differences among ischemic heart disease patients in Israel

The purpose of this study was to assess short term effects of the Gulf war on ischemic heart disease patients of different ethnic origin. Three dimensions of patients' reactions to the war situation were studied: psychological, physical and behavioral. The study first focused on changes in patients' responses on these dimensions over three stages of the war, differentiated according to degree of threat. Second, differences stemming from ethnic origin were examined among patients who live in the same geographical region, use the same health services and were exposed to the same threatening life event. One hundred ischemic heart disease patients were interviewed while waiting in outpatient hospital clinics for a regular examination at the end of the war. The results of intrapersonal comparisons showed that the intensity of responses, as expected, increased significantly on the three dimensions from the week before the war started to the first week of the war, which was the most stressful period for Israelis. During the last week of the war, however, when stress was significantly reduced, the expected change was found primarily with regard to psychologic responses. That is, worries were significantly reduced, but no significant reduction in frequency of anginal pain and in drug consumption followed, indicating differences in the adjustment process on the psychologic and physical levels. Subcultural differences were found in the studied responses: Patients of Asian or North African countries of origin reported having more frequent anginal pains, and consuming more drugs than patients from Western countries.(ABSTRACT TRUNCATED AT 250 WORDS)

Compassionate physicians: personality traits and prosocial attitudes

Three groups of physicians were identified based on their compassionate behavior. Associations with personal characteristics indicate that physicians with high self-esteem are more likely than those with low self-esteem to behave in congruence with their attitudes towards people.

Abnormal thallium stress test and normal coronary angiograms: catheterization and clinical characteristics

Left ventricular end-diastolic pressure at rest, left ventricular ejection fraction, thallium segmental abnormalities, as well as sex, age and presence of diabetes mellitus, hypertension, hypercholesterolemia and smoking excess were analyzed in 40 patients with abnormal thallium stress test and normal coronary angiograms. Of these patients, 25 had elevated left ventricular end-diastolic pressure and "low normal" ejection fraction (group 1), while the other 15 had normal left ventricular end-diastolic pressure and "high normal" ejection fraction (group 2). The left ventricular end-diastolic pressure was 18.1 +/- 4.5 mm Hg in group 1 vs. 8.5 +/- 2.4 mm Hg in group 2 (P < 0.000). The ejection fraction was 57.6 +/- 8.3% in group 1 vs. 63.9 +/- 9.1% in group 2 (P < 0.05). There was no difference between the groups in relation to the abnormal segment on thallium stress tests, aged and sex. Although the number of patients was too small for meaningful statistical analysis, most of the patients with diabetes mellitus, hypertension, hypercholesterolemia or smoking history were in group 1. Thus, the patient population with abnormal results on radionuclide exercise tests and angiographically normal coronary arteries probably comprises two groups: a) patients with decreased diastolic and relatively decreased systolic performances which might reflect coronary flow disturbances, and b) patients with normal diastolic and systolic performances, probably reflecting "true false positive thallium stress test".

Coping with recent life events: the interplay of personal and collective resources

The importance of personal and collective resources in coping with recent life events was studied among 230 kibbutz members. The sense of coherence, a global life orientation that detects the ability to avoid stressors and to choose appropriate coping strategies and resources, represented personal resources. Collective resources, embedded in the social system to which one belongs, were measured by membership in a religious kibbutz, the kibbutz being viewed as a powerful, collective-coping resource by itself. Physical well-being, psychological distress, and functional limitations were used as outcome measures. Both types of resources have a salutogenic effect, but sense of coherence appears to be a better resource for avoiding the effect of recent life events and for moderating psychological distress and functional limitation after experiencing such events. The two types of resources have no additive effect, nor do they compensate for each other. Only one significant interaction was found, suggesting that the combination of the two resources is useful in avoiding functional limitation. It is also suggested that collective resources have a slight positive effect on personal resources, which, in turn, take over and become most valuable in coping with recent life events. When stress affects social functioning, these same personal resources facilitate the mobilization of whatever collective resources are available.

Gender differences in the utilization of emergency department services

Some of the suggested explanations of the well documented gender morbidity differences imply that these are not 'real' but the result of women's tendency to perceive and report more symptoms, to magnify symptom severity, and to seek help. To contribute to this debate, gender differences in utilization of a general hospital emergency department (ED), often used as a primary care service and for mild conditions, were studied. Data were collected from the general ED admissions registry for 6815 patients. In our data strikingly more men than women visited the ED during the period studied; generally, the same proportion of men and women were self-referred patients; and similar rates of both sexes were hospitalized regardless of type of referral. Thus, these findings suggest that, at least among ED patients, there is no gender differential in symptoms perception, evaluation, or presentation. Indications for these were somewhat found among young patients (aged 17-24) only. Alternatively, the findings with regard to this age group could reflect professional gender stereotyping at the primary care level.

Life events, sense of coherence and health: gender differences on the kibbutz

The effects of recently experienced life events (RLE) and of a personal coping resource--the sense of coherence (SOC)--on the health of men and women were investigated among members of two small and cohesive communities--two kibbutzim in Israel (n = 230). Results of analyses lend support to previous findings about the negative effects of life events on health, and to Antonovsky's theory about the positive influence of SOC on health. Separate analyses for men and women, however, show that while RLEs negatively affect women's health, SOC has no significant counterbalancing effect on their health. Among men, an opposite pattern is found; their health is not affected by RLE, but is significantly affected by their SOC. Our findings lead to the conclusion that men and women are differentially affected by stressors and make different use of their coping resources. These findings should be taken into consideration in further research on stress, coping and health.

Emergency department utilization: a comparative analysis of older-adults, old and old-old patients

A comparative analysis of Emergency Department (ED) utilization by 2936 older-adults, old, and old-old patients was conducted in the only hospital available for residents of a vast geographical region. All patients (45+) who arrived at the ED during the first week of every even month from September 1986 to August 1987 were selected for the study. No significant differences were found among the three groups with regard to sociodemographic characteristics other than age. Data showed that the old-old use the ED approximately twice as much as the old and the older-adults; they also use the ED more often than the two other groups during the winter season. These two findings indicate the utility of viewing the old-old not only as a part of the elderly population, but also as a unique risk group. Hospitalization rates present a different pattern: they double in each age group moving from the youngest to the oldest. Complaints of an internal medicine nature are more often presented by the two groups of the elderly in comparison to the older-adults, and are followed by more frequent hospitalizations in internal medicine wards. Such findings have practical implications, and should be taken into consideration by policymakers.

Social class differences in coping with a physicians' strike in Israel

The 1983 physicians' strike in Israel lasted 118 days. Striking physicians established alternative medical care centers (ACC) providing primary and specialized medical care on a fee for service basis. This contrasted with the usual pre-paid health insurance system, and provides an interesting natural experiment in health care services. Hospital emergency rooms remained open during the strike. Thus, primary medical care was available in these two settings. This paper compares people of different educational levels as they experienced and adapted to this strike with regard to their expressed need for physicians, their health behavior and outcomes in terms of patterns of utilization of the two services, financial expenses, satisfaction with the ACC's and perceived damage to health caused by the strike. The data were extracted from 719 self-administered questionnaires which were distributed in 14 primary care clinics and among university employees. The results show that the groups with lower levels of education, as compared to groups with higher education levels, reported more need for physicians' care and more damage to health. They were, however, less critical of the parties involved in the strike. When urgent need was reported, all respondents behaved similarly; however, people of lower social classes reported less satisfaction and perceived more damage. In non-urgent need conditions, although lower class respondents had higher utilization rates and higher expenses, they achieved no better results than the higher classes. It is suggested that due to a relative lack of psychological, social and financial resources, people of lower socio-economic classes cope less effectively with sudden changes in the provision of health services.

Emergency department utilization by two subcultures in the same geographical region

An exploratory study of emergency department (ED) utilization, comparing Israeli adult Jews and Bedouin Arabs was conducted. The data interpretation derived from the premise that health services utilization reflects not only morbidity patterns but characteristics of both subcultures and the structure of health services. The Bedouins in the study are a Moslem traditional society going through a rapid process of urbanization and modernization, with a relative deficiency in primary health services. Data were collected from the general ED admissions registry. Patients (17+) who arrived at the ED during the first week of every even month of one calendar year were selected for this study (6815 Jews and 583 Bedouins). The findings indicate that, in general Bedouins use the ED significantly less than Jews. They adjust to the structure of the ED services and use them, more than Jews, as a primary service. Yet, the hospitalization rates of the two populations are similar. In both subcultures the pattern of gender differences changes after the age of 45. The change, however, is in the opposite direction. Differences in ED usage among Bedouin age-sex groups are discussed in terms of changes in social status during a period of socio-cultural transition.