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The purpose of this cross-cultural study was to evaluate patient perspectives on complementary and alternative medicine (CAM) integration within primary care clinics. It is one of the first multiethnic studies to explore patients' perspectives on the best model for integrating CAM into the conventional care setting. We developed a 13-item questionnaire that addresses issues of CAM use, expectations from the primary care physicians concerning CAM, and attitudes toward CAM integration within a patient's primary care clinic. We constructed the questionnaire with cross-cultural sensitivity concerning the core concepts of CAM and traditional medicine in both the Arab and Jewish communities in northern Israel. Data for statistical analysis were obtained from 3840 patients attending seven primary care clinics. Of the 3713 respondents who were willing to identify their religion, 2184 defined themselves as Muslims, Christians, or Druze and 1529 as Jews. Respondents in the two groups were equally distributed by sex but differed significantly by age, education, self-rated religiosity, and self-reported chronic diseases in their medical background. Respondents in the two groups reported comparable overall CAM use during the previous year, but the Arab respondents reported more use of herbs and traditional medicine. Respondents in both groups stated that their primary expectation from a family physician concerning CAM was to refer them appropriately and safely to a CAM practitioner. Respondents in both groups greatly supported a theoretical scenario of CAM integration into primary medical care. However, Arab respondents were more supportive of the option that non-physician CAM practitioners would provide CAM rather than physicians. [ABSTRACT FROM AUTHOR]

Implementing telemedicine technologies (TT) for patient-physician communication leads to the emergence of new structures of boundaries. Hence, boundary work theory can provide a useful lens for examining how primary care physicians (PCPs) experience TT. The objective of this research was to examine the experiences of PCPs in using TT in their communication with patients. During 2023 in-depth interviews were conducted with 20 Israeli PCPs: family physicians and pediatricians. The concept of boundary work emerged as a focal point, with three forms of boundary work identified in the PCPs' descriptions of their TT experiences: collaborative, competitive, and configurational. Interviewees described improved collaboration with patients who find it difficult to get to the clinic and better service for administrative issues. However, they reported constant power struggles to maintain their authority. They expressed concern about treatment failure and suggested that healthcare organizations reconfigure TT so that it can be used to provide optimal care. They suggested that healthcare organizations should instruct physicians how to best manage TT consultations and regulate its usage. This article demonstrates that while implementing TT in primary care has many advantages, it uncovers boundary work for maintaining power and authority that both PCPs and healthcare organizations should take into account in practice as well as in policy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Information and communication technologies (ICTs) can enable workers to structure work in novel ways, allow for better time management, and increase work scheduling autonomy. Time management and work scheduling are important factors in the field of clinical practice in primary care. Time limits on consultation are a key constraint on the delivery of good care since the length of patient-physician consultation impacts its quality., Objectives: This research aimed to examine the experiences of primary care physicians (PCPs) when using telemedicine technologies (TTs), a type of ICT, in their communication with patients., Methods: During 2023 in-depth interviews were conducted with 20 Israeli PCPs: family physicians and pediatricians., Findings: Perception and management of time emerged as a focal subject in the interviews. The PCPs interviewed described several effects of TTs on time management in primary care. They portrayed TTs as saving time for patients and having a mixed effect on the healthcare organization: both saving and wasting their work time. TTs were described as impacting their time management in the context of work-life balance, allowing them to manage their time during and between appointments., Discussion: For PCPs, TTs can be beneficial for managing time in the clinic, which can contribute to better healthcare. This article, concerning TTs as a type of ICT, contributes to the existing literature which suggests that ICTs can allow for better time management and increase work scheduling autonomy. It also presents several recommendations for better implementation of TTs in healthcare organizations., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Patient-centered care (PCC) has become a central aim for healthcare systems worldwide due to recognition of its advantages. The growing use of telemedicine technologies (TT) raises concerns of diminishing interpersonal contact, especially in primary care, and questions the appropriate way of implementing PCC. This article aims to explore primary-care physicians' (PCP) experiences of PCC when using TT. During 2023 in-depth interviews were conducted with 20 Israeli PCP: family physicians and pediatricians. The PCP described their experiences of using TT in their communication with patients as including some characteristics of PCC but not others. They related to TT as a means of forming relationships and communicating with patients, highlighting its individualistic focus and describing it as a way of coordinating care. When describing the use of TT in their communication with patients, they barely related to empathy and respect for the patient, to their own involvement in the treatment, to shared decision-making, or to a holistic focus on the patient. The absence of interpersonal qualities and soft skills communication from the physicians' TT experience seems to erode their personal well-being and professional satisfaction and may even lead to burnout. We therefore recommend instructing PCP to better integrate PCC into their TT communication with patients since it contributes to the quality of healthcare and is significant for the well-being of both patients and physicians., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: The authors report no conflict of interest.

Purpose: To describe a patient with venous overload choroidopathy in whom venous bulbosities masqueraded as polyps and intervortex venous anastomosis mimicked a branching vascular network, giving the appearance of polypoidal choroidal vasculopathy., Methods: The patient had complete ophthalmic examination including indocyanine green angiography and optical coherence tomography. Venous bulbosities were defined on indocyanine green angiography as focal dilations in which the diameter of the dilation is two times that of the host vessel., Results: A 75-year-old woman presented with combined subretinal and subretinal pigment epithelium hemorrhages in the right eye. During indocyanine green angiography, focal nodular hyperfluorescent lesions connected to a network of vessels were observed, which looked like polyps and branching vascular network in polypoidal choroidal vasculopathy. In both eyes, the midphase angiogram had multifocal choroidal vascular hyperpermeability. There was late-phase placoid staining nasal to the nerve in the right eye. During enhanced depth imaging-optical coherence tomography evaluation, there were no retinal pigment epithelium elevations that would be expected with polyps or branching vascular network in the right eye. A double-layer sign was seen corresponding to the placoid area of staining. Diagnosis of venous overload choroidopathy and choroidal neovascularization membrane was made. She was treated with intravitreal antivascular endothelial growth factor injections for the choroidal neovascularization membrane., Conclusion: Indocyanine green angiography findings in venous overload choroidopathy may mimic polypoidal choroidal vasculopathy, but differentiation is essential because it has implications for treatment. Similar findings may have been misinterpreted in the past and may have previously contributed to conflicting clinical and histopathologic descriptions of polypoidal choroidal vasculopathy.

Teletherapy, namely, therapy that uses technology for communication between patients and therapists, is challenged by the impersonal nature of remote and digital communication. Using Merleau-Ponty's theoretical concept of intercorporeality, which refers to the perceived reciprocity between two people's bodies during communication, this article aims to elaborate on spiritual caregivers' experience of interacting with patients during teletherapy. Semi-structured in-depth interviews were conducted with 15 Israeli spiritual caregivers who use various forms of teletherapy (Zoom, FaceTime, phone calls, WhatsApp messages, etc.). Interviewees emphasized their physical presence with the patient as a main principle in spiritual care. They indicated the involvement of nearly all senses in physical presence therapy, which allows for joint attention and compassionate presence. When making use of various communication technologies in teletherapy, they reported the involvement of fewer senses. The more senses involved in the session and the clearer it is that space and time are shared by both caregiver and patient, the stronger the caregiver's presence with the patient. Interviewees experienced teletherapy as eroding the multisensory joint attention and intercorporeality and, hence, the quality of care. This article points at the advantages of teletherapy for therapists in general and spiritual caregivers in particular but claims, nonetheless, that it challenges the main principles of therapy. Joint attention in therapy is, fundamentally, a multisensory phenomenon that may be understood as intercorporeality. Our use of the notion of intercorporeality sheds light on the reduction of the senses involved in remote interpersonal communication and its impact on care and, more generally, the interpersonal communication experienced during telemedicine. This article's findings may also contribute to the field of cyberpsychology and to therapists engaged in telepsychology., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: The study examines perspectives of patients in home hospice care; their informal caregivers; palliative health-care providers (HCPs); and family physicians, all regarding patients' unmet needs and quality of life (QoL)-related concerns., Methods: Participants from all 4 groups were approached within 2 months after the patient's admission to the home hospice care unit. Participants completed Edmonton Symptom Assessment Scale (ESAS) and Measure Yourself Concerns and Wellbeing (MYCAW) questionnaires, for patient's QoL-related concerns. Qualitative analysis of short narratives was conducted using ATLAS.ti software for systematic coding., Results: In total, 78 participants completed the study questionnaires: 24 patients, 22 informal caregivers, 22 palliative HCPs, and 11 family physicians. Informal caregivers gave higher scores (i.e., greater severity) than patients for fatigue on ESAS ( p = 0.009); and family physicians lower scores than patients for ESAS drowsiness ( p = 0.046). Compared with patients, palliative HCPs gave higher scores for patient emotional-spiritual concerns (77.2% vs. 41.7%, p = 0.02); lower scores for gastrointestinal concerns ( p = 0.048); and higher scores for overall function ( p = 0.049). Qualitative assessment identified a gap between how patients/informal caregivers vs. palliative HCPs/family physicians regard emotional-spiritual themes, including discussing issues related to death and dying., Significance of Results: The findings of the present study suggest that exploring a multifaceted cohort of home hospice patients, informal caregivers, palliative HCPs, and family physicians may provide insight on how to reduce communication gaps and address unmet needs of patients, particularly regarding emotional and spiritual concerns., Conclusions: While the 4 groups were similar in their scoring of patient QoL-related concerns, there were discrepancies for some concerns (e.g., patient fatigue) and expectations regarding the need to discuss emotional and spiritual concerns, including on death and dying. Educational initiatives with programs providing training to all 4 groups may help bridge this gap, creating a more open and collaborative hospice care environment.

Purpose: To report a case of a full-thickness macular hole after exposure to an extremely powerful handheld laser pointer., Methods: A 14-year-old boy with a laser-induced full-thickness macular hole was evaluated 1 month after a momentary exposure to a 5,000 mW blue laser pointer. Imaging modalities including fundus color, autofluorescence, and spectral-domain optical coherence tomography, acquired both at our clinic and by the referring physician soon after the injury, are used to describe the clinical evolution of the case., Results: Soon after the injury, an intensely white, circular opacification of the retina approximately 400 μm in diameter was seen in the fovea. Early spectral-domain optical coherence tomography images showed full-thickness hyperreflectivity, likely representing tissue necrosis. One month later, a full-thickness macular hole and eradication of the retinal pigment epithelium at its base were evident in the fundus color, autofluorescence, and spectral-domain optical coherence tomography images., Conclusion: High-power laser pointers have become easily available online. The presenting findings after exposure to such high-power devices are distinct from those reported after exposure to weaker laser pointers. Although long exposure to weaker lasers typically produces extensive, calligraphic figures and yellow placoid lesions involving only the outer retina, in our case, a very brief exposure led to focal full-thickness injury of the fovea.

Persuasion knowledge is personal knowledge about persuasion attempts that has an effect on the way people respond to these attempts. Persuasion attempts are made to effectively handling the Covid-19 pandemic, which is dependent on high public compliance with vaccination programs. Drawing on the idea of persuasion knowledge, we aimed at elaborating the various categories of perceived information gaps experienced by vaccine hesitants during the Covid-19 vaccination campaign. At the beginning of 2021 we conducted 20 in-depth interviews with Israelis who had decided not to be vaccinated against Covid-19. Analysis of the interviews revealed three main categories of information gaps experienced by the interviewees: missing information, manipulated information, and discrepant information. We analyzed how these are associated with distrust and may impair the persuasion efforts of governments and health authorities. Perceived information gaps, as part of persuasion knowledge, may increase negative responses, and therefore constitute an important factor in persuasion campaigns., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Context and Objectives: To explore the feasibility of implementing the joint guideline on integrative medicine for pain management in oncology, published by the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO), for integrative oncology (IO) services in supportive and palliative care., Methods: A qualitative research methodology was co-designed by the SIO-ASCO guideline committee, with the Society for Complementary Medicine, Israel Medical Association (IMA). A questionnaire with five open-ended questions exploring barriers and enablers to implementing the guideline was distributed to chairs and board members of nine IMA-affiliated medical societies; four deans of Israeli medical schools; and nurses from the Israeli Society for Oncology Nursing. Respondent narratives were qualitatively analyzed using ATLAS.Ti software for systematic coding., Results: Questionnaires were completed by 52 physicians and nurses from medical oncology, hematology, gynecological oncology, pediatric oncology, palliative medicine, pain, family medicine, internal medicine, and integrative medicine. The SIO-ASCO guidelines were endorsed by nine IMA-affiliated societies. The domains identified included the importance of guideline implementation in clinical practice; barriers and facilitators to implementation; practical aspects required for this implementation (e.g., IO training); clinical indications for referral; budget-related issues; and clinical and administrative models enabling practical implementation of the guideline., Conclusion: We found across-the-board consensus among the nine IMA-affiliated societies supporting the current guideline. This, while identifying potential facilitators and barriers in order to address the implementation of the SIO-ASCO guideline recommendations., (Copyright © 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To explore responses from primary care physicians (PCPs) from an integrative physician (IP) consultation and recommended integrative oncology (IO) treatment program., Methods: Chemotherapy-treated patients were referred by their oncology healthcare professional to an IP, a physician dually trained in complementary medicine and supportive cancer care. The consultation summary and patient-centered IO treatment program was then sent to the patient's PCP, with PCP-to-IP responses analyzed qualitatively using ATLAS.Ti software for systematic coding and content analysis. Trial Registration Number NCT01860365 published May 22, 2013., Results: Of the 597 IP consultations conducted, 470 (78.7%) summaries were sent to patients' PCPs, with only 69 (14.7%) PCP-to-IP responses returned. PCPs were more likely to respond if the patient was Hebrew-speaking (78.3% vs. 65.1%, P = 0.032). Systematic coding identified four predominant themes among PCP narratives: addressing the patient's medical condition and leading QoL-related concerns; patient-centered reflections; available resources providing support and promoting resilience; and PCP attitudes to the IO treatment program., Conclusion: PCP-IP communication can provide valuable insight into the patient's bio-psycho-social care, addressing the patient's health-belief model, emotional concerns, caregiver-related factors, preferences, and barriers to adherence to IO care., Practice Implications: Healthcare services should consider promoting IP-PCP communication in order to facilitate better patient outcomes from an IO treatment program., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To describe two patients with chronic central serous chorioretinopathy (CSC) showing what appeared to be retinal pigment epithelium detachments (PED) lacking imaging findings consistent with retinal pigment epithelium (RPE) over the elevation., Method: The patients underwent comprehensive ophthalmic examination, including multicolor fundus photography, fundus autofluorescence (FAF), and spectral-domain optical coherence tomography (SD-OCT)., Results: A 70-year-old male and a 58-year-old male, both diagnosed with chronic CSC, showed PED-like lesions that were hypoautofluorescent, suggesting an absence of RPE. SD-OCT B-scans showed serous, dome-shaped elevations composed of a narrow, mildly hyperreflective band (9-10 μm thick) that demonstrated hypertransmission of light. The material that constituted the elevation was contiguous with the outer portion of the RPE band at the lesion borders., Conclusion: Based on the multimodal imaging findings we hypothesize that these elevations of the retina have lost their overlying RPE. A thin layer of material that could represent a residual layer of basal laminar deposit produced by the RPE remains overlying the detachments, possibly accounting for their dome shape and structural stability.

Purpose: To investigate the use of dynamic widefield scanning laser ophthalmoscopy (SLO) and B-scan ultrasonography in imaging vitreous abnormalities in patients with complaints of floaters., Methods: Twenty-one patients underwent both dynamic SLO and B-scan ultrasonography to image their vitreous abnormalities. After reviewing these videos, patients graded each imaging technique on a scale of 1 to 10, based on how closely it represented their visual perception of floaters., Results: The mean age of the patients (12 women and nine men) was 47.7 ± 18.5 years. The patients graded a median score of nine for SLO imaging (mean = 8.43) compared with a median score of 5 (mean = 4.95) for ultrasound ( P = 0.001). Widefield SLO imaging demonstrated three-dimensional interconnectivity within the condensations of the formed vitreous that exhibited translational and rotational movements with eye saccades., Conclusion: Floaters are a common complaint, but it is difficult to know whether imaging findings of the vitreous correlate to what patients perceive. Widefield SLO seems to image vitreous abnormalities related to how patients perceive their own floaters better than B-scan ultrasonography. Despite the term "floaters", the vitreous abnormalities in the videos seemed to be manifestations of a complex three-dimensional degeneration of the vitreous framework.

Objective: To report the long-term outcomes of anti-vascular endothelial growth factor (VEGF) treatment in eyes with peripapillary choroidal neovascularisation (PPCNV) associated with age-related macular degeneration (AMD)., Methods: A retrospective cohort study included patients with AMD-related PPCNV. Eyes were treated with anti-VEGF according to pro re nata regimen. Inactivation index was calculated as the proportion of disease inactivity from the total follow up time., Results: Sixty-seven eyes of 66 consecutive patients were included in the study; mean follow-up time was 53.2 months. Best corrected visual acuity (BCVA) remained stable for the first four years of follow up, with a significant deterioration in BCVA thereafter. Baseline BCVA was a significant predictor of final BCVA (p < 0.001). The mean inactivation index was 0.38 ± 0.23. Subretinal fluid (SRF) at presentation was significantly associated with decreased inactivation index (p < 0.05). Worse baseline BCVA, SRF and pigment epithelium detachment (PED), male sex, and younger patient age were associated with increased risk for recurrence after first inactivation (p < 0.05)., Conclusion: The use of anti-VEGF agents in the treatment of AMD-related PPCNV managed to preserve BCVA in the first four years of follow-up. Male sex, SRF and PED at presentation and baseline BCVA are associated with increased risk for PPCNV recurrence after the first inactivation, and should prompt careful follow-up in these patients., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Context and Objectives: The present study examined the perspectives of healthcare providers (HCPs) in designing a multi-disciplinary model of supportive cancer care for the relief of dermatology-related symptoms caused by monoclonal antibody therapies., Methods: The study employed a mixed research methodology, with qualitative research embedded within a pragmatic prospective study of a registry protocol study. Patients undergoing oncology therapy with MoAB, anti-HER2, and anti-PD-L1 monoclonal antibodies were identified among a cohort of patients referred to an integrative oncology (IO) consultation for symptom relief and improved quality of life (QoL). Case studies with significant dermatology-related concerns were selected and presented to a panel of 6 HCPs trained in medical oncology, oncology nursing, family medicine, supportive cancer care, and IO. HCP narratives were qualitatively analyzed and assessed using ATLAS.Ti software for systematic coding., Results: Of the 924 patients referred to the IO consultation, 208 were treated with monoclonal antibodies, from which 50 were selected for further evaluation. Of these, 7 cases were presented to the HCP team who were asked to identify treatment gaps requiring a multi-disciplinary approach. Qualitative analysis identified 3 major themes: a biophysical perspective; a psycho-social-spiritual perspective; and the implementation of integrated care., Discussion: There is a need for a multi-disciplinary approach when treating patients suffering from monoclonal antibody treatment-related skin toxicities. HCP-reported themes highlight the need to identify patients for whom such an approach is warranted; conditions in which a psycho-social-spiritual perspective should be considered, in addition to a bio-physical approach; and considerations of who should be designated as the patient's primary case manager., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To assess the in vivo effects of bimatoprost 0.03% (Lumigan®) on the orbital fat in a rat model., Methods: Twenty rats were randomly divided into two groups: bimatoprost was administrated to the right eye by topical drops (group 1) or retrobulbar injection (group 2), and saline was administrated to the left eye by similar administration routes (controls). Four weeks later, all rats were sedated and euthanized, both orbits exenterated, and thin sections through the intraconal orbital fat were obtained., Results: Average adipocyte cell count was significantly lower in the bimatoprost treated orbits (drops or retrobulbar injection, 29.5 vs. 67.5 cells per slide in the control globes, p=0.046). Fat cells were not detected in 9/20 (45%) bimatoprost treated orbits     ., Conclusions: Orbits treated with bimatoprost by drops or retrobulbar injection demonstrated significant decrease in adipocytes cell count compared with controls. Bimatoprost could be an effective treatment for inactive thyroid eye disease.

Although vaccination uptake is high in most countries, pockets of suboptimal coverage remain, such as those observed among ultra-orthodox Jews in Israel and elsewhere, posing a threat to both individual and public immunity. Drawing on the Precaution Adoption Process Model (PAPM), this study proposes a Non-Vaccination Stage Model (NVSM) to analyze the decision-making process among Non-Vaccinating Parents (NVPs), focusing on the ultra-orthodox Jewish population of Israel. In-depth interviews were conducted with 10 Israeli ultra-orthodox Jewish NVPs (mothers). The interviews revealed five stages in the participants' decision-making process: Being good mothers who vaccinate their children; Emergence of doubts regarding the risks of vaccination; Personal vaccination policy-hesitancy concerning vaccination; Decision not to vaccinate; Confirmation signs of what participants perceive as a wise decision. NVSM can help understand parents who consider non-vaccination to be healthier behavior and explore the various stages of their decision-making process. Differentiating among the various stages of NVPs' decision-making processes enables application of different intervention approaches by policymakers and healthcare practitioners.

Purpose: To assess the normal healing process of limbal-conjunctival autograft (LCA) after pterygium removal during the early postoperative period using anterior segment optical coherence tomography angiography (OCTA)., Methods: Prospective case series of seven patients undergoing pterygium removal with LCA transplantation procedure, imaged with anterior segment OCTA, and anterior segment colour photos prior to the procedure and on postoperative day (POD) 1, 3, 7 and 30. Revascularization of the graft was analysed quantitatively and qualitatively to estimate patterns of blood vessel growth. Association between revascularization to graft thickness was also investigated., Results: On POD 1, all autografts showed either minimal flow signal or no signal at all (Mean 7.1 ± 3.3%). Regrowth of blood vessels into the graft was detected on OCTA scans on POD3 (8.7 ± 3.6%) to 7 (14.3 ± 4.1%), as nonorganised vessels formation in their appearance. Blood vessels were seen growing in a centrifugal pattern towards the surrounding conjunctiva, originating from the underlying episcleral vessels. Revascularization flow signal was seen throughout nearly all graft extent on day 30 (21.6 ± 2.2%). Graft oedema was evident on the first week (Mean 611 ± 120 μm, 695 ± 84 μm, 639 ± 96 μm of POD 1, 3 and 7, respectively), reducing substantially by day 30 (300 ± 108 μm)., Conclusions: OCTA imaging can be used to assess the LCA healing process during the early postoperative period. Revascularization occurring as early as 3-7 days post-surgery, seems to originate from the underlying episcleral vessels. Therefore, careful handling of the bare scleral surface during surgery may be prudent for achieving an adequate healing process., (© 2021. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: To compare post-operative vocal outcomes of a voice rest regimen versus no voice restrictions following micro-laryngeal surgery for benign glottic lesions., Methods: This was a combined prospective and retrospective cohort study on 167 patients who underwent micro-laryngeal surgery for benign focal fold lesion removal. Participants were divided into two regimens: standard voice rest (n = 92) or no voice restriction (n = 75). The primary outcome was post-operative vocal improvement, evaluated using voice handicap index questionnaire (VHI-10), GRBAS scale, and computerised acoustic analysis (shimmer, jitter, and the harmonic-to-noise ratio). The secondary outcome was emergence of vocal fold mucosal abnormalities in the immediate post-operative period. Parameters were collected at baseline and at the last clinical visit., Results: There was no statistically significant difference between the voice rest and no-voice rest groups regarding baseline parameters of age, gender, laryngeal pathology, and voice use. Improvement in GRBAS scale values and VHI-10 scores between pre- and post-operative periods between groups did not demonstrate any statistically significant differences (P = 0.5303 and P = 0.1457, respectively). Similarly, the results of computerized voice analysis also showed no differences between groups in terms of shimmer (P = 0.9590), jitter (P = 0.5692), and harmonic-to-noise ratio (P = 0.1871). No correlation was found between the post-operative vocal fold's mucosal abnormalities and the type of voice rest regimen., Conclusion: Voice quality and wound healing were similar regardless of the type of voice rest regimen applied. No voice rest at all was as good as voice rest after micro-laryngeal surgery., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: The research addressing physical and emotional exhaustion among healthcare providers (HCPs) in COVID-19 departments is limited. We examined the impact of integrative medicine (IM) intervention for HCPs working in isolated COVID-19 in-patient departments, addressing concerns and well-being., Methods: HCPs working in 3 isolated COVID-19 in-patient departments underwent 40-min IM treatment sessions (including acupuncture, manual movement, and/or mind-body modalities) provided by integrative oncology practitioners. The MYCAW (Measure Yourself Concerns and Well-being) questionnaire examined HCP concerns and free-text narratives following IM treatments. Data were qualitatively analyzed using ATLAS.Ti software for systematic coding., Results: A total of 181 HCPs underwent 305 IM treatments. Narrative themes focused on physical symptoms (primarily pain and fatigue) and emotional concerns, including perceived communication barriers with patients, and reflections on well-being and insights following IM treatments. HCPs reported feeling a sense of "relief" which was likely related to the 3 main effects of the IM intervention: a sense of "being cared for" and treated; experiencing emotional, sometimes spiritual effects of the treatment; and the feeling of relaxation, combined with the relief of pain. Qualitative analysis identified clusters of emotional and spiritual-related keywords such as "calming," "release," "relaxation," and "disengagement" following the first IM session (119 of 181 narratives, 65.7%)., Conclusions: HCPs working in isolated COVID-19 departments reported improved well-being and the addressing of their concerns following IM treatment sessions provided during their work shift. Further research is needed to explore the impact of IM on HCP burnout and resilience in palliative care settings., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: As intravitreal anti-VEGF injections became the mainstay of treatment for many retinal diseases, the cause of a secondary sustained elevated intraocular pressure is still unclear. The aim of our study was to study the clearance of Aflibercept from the anterior chamber angle, in a rat model, to test if an aggregation exists., Methods: Choroidal neovascular lesions (CNV) were induced in the right eye of 12 brown Norway rats, using indirect laser ophthalmoscope. Intravitreal Aflibercept injection (0.12 mg/3 µl) was performed 3 days after CNV induction. Rats were euthanized at predetermine time intervals of 3, 6, 24 and 48 h post injection, with immediate enucleation for histological analysis with H&E and immunofluorescence staining. Aflibercept molecules were stained with red fluorescence thanks to the formation of the immune complex Aflibercept-Rabbit anti human IgG-Anti rabbit antibodies-Cy3., Results: Immediately after the injection, a strong fluorescence signal was detected, indicating the presence of Aflibercept in the iridocorneal angle. At 3- and 6-h interval a strong signal of Aflibercept was still seen. Six hours post injection, the signal was highly concentrated in Schlemm's canal. In the 2 eyes harvested 24 h post Aflibercept injection, red fluorescence signal intensity was decreased in one eye, occupying mainly intra scleral venous plexuses, and absent in the other eye. At 48 h there was no fluorescence signal, confirming complete clearance of Aflibercept., Conclusions: In our rat model, a complete clearance of Aflibercept from the anterior chamber angle, was seen 48 h after the injection. This finding refutes the theory of possible connection between IOP elevation and mechanical obstruction. Evacuation time of Aflibercept through the angle is of the same magnitude as that of Bevacizumab in the same rat model., (© 2021. The Author(s).)

Objective: We examined the qualitative impact of an online integrative oncology (IO) treatment program, designed in response to the restrictions created by the current COVID-19 pandemic., Methods: Patients undergoing chemotherapy were seen by an integrative physician (IP), together co-designing an IO treatment program of ≥ 6 weekly treatments to alleviate symptoms and improve quality of life (QoL). IO practitioners guided patients and their caregivers online in self-treatment with manual/touch, movement, and/or mind-body modalities. Narratives of both patients and IO practitioners were analyzed for systematic coding, identifying barriers and advantages of the online treatment program., Results: Narratives obtained from 30 patients and eight IO-trained practitioners were examined. The patients had undergone 169 online IO sessions with a total of 327 IO interventions during the 3-month study period. Patient narratives included reflections on both non-specific effects (e.g., less of a "sense of isolation") and specific QoL-related outcomes with the online intervention. IO practitioner narratives focused on barriers to providing manual-movement and mind-body modalities, suggesting practical recommendations on how to address specific QoL-related outcomes using the online IO "toolbox.", Conclusions: Effective online IO practitioner-guided treatments are feasible and may induce both specific and non-specific QoL-related effects. Future research needs to explore online IO interventions for additional situations in which access to IO care is limited.

Background: We examine the impact of a 5-day online elective course in integrative medicine (IM) taking place during the COVID-19 pandemic, attended by 18 medical students from two faculties of medicine in Israel., Methods: The course curriculum addressed effectiveness and safety of IM practices highlighting supportive and palliative care, demonstrated the work of integrative physicians (IPs) in designing patient-tailored treatments and taught practical skills in communication regarding IM. Group discussions were conducted via Zoom with 32 physicians, healthcare practitioners and IM practitioners working in integrative academic, community and hospital-based settings, in Israel, Italy, UK and Germany. An 18-item questionnaire examined student attitudes and perceived acquisition of skills for implementing what was learned in clinical practice. Student narratives were analysed using ATLAS.Ti software for systematic coding, identifying barriers and advantages of the online learning methodology., Results: Students reported a better understanding of the benefits of IM for specific outcomes (p=0.012) and of potential risks associated with these therapies (p=0.048). They also perceived the acquisition of skills related to the IM-focused history (p=0.006), learnt to identify effectiveness and safety of IM treatments (p=0.001), and internalised the referral to IPs for consultation (p=0.001). Student narratives included reflections on the tools provided during the course for assessing effectiveness and safety, enhancing communication with patients, enriching their patient-centred perspective, raising awareness of available therapeutic options, and personal and professional growth., Conclusions: Online clinical electives in IM are feasible and can significantly increase students' awareness and modify attitudes towards acquirement of patient-centred perspectives., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Voluminous scholarship has shown that religious leaders play an important role in helping patients cope with health issues. There is, however, little research on the impact of religious leaders on parents' decision-making processes pertaining to childhood vaccination. Ultra-orthodox Jewish religious leaders (rabbis) are considered authorities on health issues, and most of them encourage parents to vaccinate their children. Yet, there have been several recent outbreaks of measles in the ultra-orthodox population in Israel, as well as in other countries. The aim is to study the role played by rabbis in the decision-making process of Israeli ultra-orthodox Jewish parents with regard to vaccination. In-depth interviews were conducted during 2019 with ten Israeli ultra-orthodox Jewish mothers who do not vaccinate their children. The interviewees acknowledged that rabbis generally advocate vaccination. Yet they do not consult them and at times even disregard their instructions. The interviewees search for information on vaccination for themselves (mostly online) and decide not to vaccinate their children based on their assessment of risk. Contrary to the scholarly literature that points to the central role of religious leaders in dealing with health issues, the ultra-orthodox mothers' decision not to vaccinate their children appears to have been made despite the rabbis' instructions and not for religious reasons. These mothers' decision-making process is similar to that of mothers who do not vaccinate their children in other countries with respect to the aspect of gender, the search for information, and the reasons reported. Contacting the ultra-orthodox mothers directly and addressing their concerns about risk increase vaccination rates among the ultra-orthodox Jewish population.

Objective: We aim to characterize the patient population that exhibits reluctance to undergo complementary medicine (CM) treatments in a hospital setting., Methods: We conducted a cross-sectional prospective study among patients prior to hospitalization using structured questionnaires in a single center in Israel. Participants were asked to rate their degree of consent to receiving CM treatments during hospitalization., Results: The CM-reluctant group was 7.1 % of the study cohort. The CM modalities most commonly refused were spiritual guidance, acupuncture, and energy and healing therapies. The CM-reluctant population showed a weaker relation to spiritual content and tended to value complementary medicine's effectiveness less in comparison to the CM-consenting group. The main reason for reluctance was skepticism of the perceived effectiveness of CM., Conclusions: With skepticism playing a major role in decision making, we should question whether the Stakeholders in the field of CM and public health services are succeeding in explaining the benefits and risks of CM treatments., (Copyright © 2021. Published by Elsevier Ltd.)

Context: Manual and movement therapies (MMTs) play a central role in the integrative oncology setting, significantly improving patients' quality of life (QOL). Despite research supporting the effectiveness and safety of these modalities, most oncology health care providers (HCPs) lack any MMT training., Objectives: In this study, we examine the impact of an MMT-based integrative oncology training program with the participation of an international and multidisciplinary group of oncology HCPs. The feasibility of implementing these skills in palliative cancer care is examined., Methods: A three-day evidence-based hands-on teaching program was designed to train oncology HCPs working in supportive cancer care MMT modalities from traditional Chinese and anthroposophic medicine. Prequalitative and postqualitative assessments of the trainees' narratives were analyzed using ATLAS.Ti software (Scientific Software Development GmbH, Berlin, Germany) for systematic coding., Results: The training program was attended by 30 participants from Israel (15), Germany (7), Italy (6), Turkey (1), and Cyprus (1). The group included 13 nurses, 10 physicians, 6 complementary/integrative HCPs, and 1 psycho-oncologist. The pretraining expectations that were met at post-training included gaining knowledge and practical QOL-oriented skills, which could be implemented in the palliative and supportive care setting. A significant change in the attitude of trainees to touch therapy was also identified, with respondents seeing MMTs promoting patient-centered palliative care, including nonverbal communication., Conclusion: An MMT training program for oncology HCPs for QOL-related indications is both feasible and likely to be implemented in palliative and supportive cancer care. Nonspecific effects of MMTs were also recognized for their ability to facilitate patient-centered care., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: In a bid to reduce infection rates by COVID-19 the authorities in some countries, in collaboration with medical regulators and experts, have employed digital technologies to control and regulate citizens' behavior. Public opinion and the public's compliance with these technologies come into play here. The objective of the present study was to examine attitudes expressed in the public discourse toward the use of digital technologies to control people's behavior during the COVID-19 pandemic, as reflected in the media., Methods: Qualitative analysis was performed on posts and comments submitted in response to 12 articles that appeared on the four leading Israeli news sites, on three significant occasions: first, upon the announcement of the use of surveillance technologies by the Israeli security agency (ISA); second, upon the announcement of the launch of the Health Ministry's app that tracks contacts with COVID-19 patients; and third, following reports of petitions lodged with Israel's supreme court challenging the use of surveillance technologies. The analysis was performed using ATLAS-Ti software for systematic analysis., Results: A total of 2551 posts and comments referring to these 12 articles were found, 714 of which were relevant to the purpose of the study. The analysis revealed disagreement between those who supported the measures taken and opponents. Supporters regarded contact tracing by means of digital technologies as essential to the effort to protect people during the pandemic, and believed that employing the ISA's capabilities was the correct way to combat the epidemic. Opponents of the measures rejected the use of tracking technologies, regarding this step as a move toward dictatorship and a violation of fundamental civil rights. Some proposed alternative measures that would obviate the use of such tracking., Conclusions: The primary task of medical practice is to heal illness and alleviate suffering. The debate surrounding the employment of digital technologies during the COVID-19 pandemic highlights the complexity of the close connection between social control and care in times of pandemic. The context of this pandemic has highlighted the interrelatedness of advanced digital surveillance technologies, medical care, and social control exercised by authorities and medical regulators and experts, which raises issues of transparency, trust and mistrust among the public. These issues become all the more relevant when the number of patients grows rapidly, the authorities need to deal with the extended ongoing COVID-19 pandemic, the country has entered a second lockdown, and the public must be persuaded to comply with highly restrictive regulations. Recommendations to policy makers, practical implications, and suggestions for future research are discussed.

The growing number of terror attacks worldwide draws attention to the difficulties that healthcare practitioners experience when they treat terrorists or suspected terrorists. Research literature on the challenges faced by healthcare practitioners treating terrorists in conflict areas is limited. In-depth interviews were conducted during 2016-2017 with 50 Jewish and Arab healthcare practitioners (managers, physicians, and nurses) employed in 11 public hospitals in Israel, who treat Palestinian terrorists and security prisoners, in the context of a prolonged and violent national conflict. Jewish practitioners find it emotionally difficult to treat terrorists and security prisoners. They face an ethical dilemma when called upon to save the lives of those who took life and find themselves identifying with the victims. Arab practitioners identify with both sides of the conflict. Three coping strategies were described: maintaining a humanistic standpoint; adherence to a standard of detached professionalism; and refusal to treat terrorists and security prisoners., (© Copyright 2020 Springer Publishing Company, LLC.)

Introduction: To compare the safety and efficacy of the Therapeutic Hyper-CL™ lens versus a standard bandage contact lens (PureVision B&L) for chronic corneal edema., Methods: Prospective, multicenter, randomized, crossover study. Chronic corneal edema patients were randomized to one of two arms. The first arm was fitted with the Therapeutic Hyper-CL™ lens while the second arm was fitted with a standard soft bandage contact lens. Both arms were treated with 5% sodium chloride 6 times a day. After a 7-day treatment period, there was a 7-day washout period, after which the arms were crossed over. Patients were evaluated at days 0 (baseline), 7 (following first treatment allocation), 14 (following washout), and 21 (following second treatment allocation). The primary outcomes were 3 lines of BCVA (best corrected visual acuity) improvement., Results: In total, 49 patients were enrolled. There was significantly greater BCVA improvement rate >3 lines (30.4% versus 17.4%, P =0.04) in the Therapeutic Hyper-CL™ lens group. The mean change in BCVA lines was significantly greater for the Therapeutic Hyper-CL™ lens (3.4 ± 6.7 versus 0.9 ± 2.3, P =0.02)., Conclusions: The Therapeutic Hyper-CL™ lens was associated with a higher chance for significant visual acuity improvement when compared to a standard bandage contact lens combined with 5% sodium chloride. This trial is registered with NCT02660151., Competing Interests: Dr. Daphna is the founder and medical director of EyeYon Medical. Dr. Mimouni and Dr. Marcovich are consultants for EyeYon Medical. The rest of the authors have no conflicts of interest to declare., (Copyright © 2020 Ofer Daphna et al.)

Purpose: Improper suturing may cause an inadequate wound healing process and wound dehiscence as well as infection and even graft rejection in case of corneal transplantation. Hence, training surgeons in correct suturing procedures and objectively assessing their surgical skills is desirable., Methods: Two complementary methods for assessment of suturing skills in two medical fields (general surgery and ocular microsurgery) were demonstrated. Suturing quality is assessed by computer vision software. Evaluation of stitching flow of operation is based on measuring strain induced in an optical fiber that is placed in proximity to the wound and parallel thereto and is pressed and passed by wound stitches., Results: Our software generated a score for suturing outcome in both general surgery and ocular microsurgery when the stitching was done on a patch. Every trainee received a score in the range 0-100 that describes his/her performance. Strain values were recognized when using a patch in general surgery and a rubber patch in ocular microsurgery, but were less distinct in (disqualified) human cornea., Conclusions: We proved a concept of an objective scoring method (based on various image processing algorithms) for assessment of suturing performance. It was also shown that fiber optic strain sensors are sensitive to the flow of stitching operation on a patch but are less sensitive to the flow of stitching operation on a human cornea. By combining these two methods, we can comprehensively evaluate the suturing performance objectively.

Background: Acute acquired comitant esotropia (AACE) is a relatively rare type of pediatric strabismus, often described as a possible presentation of intracranial pathology. The risk of having neurological disease in isolated AACE is not clear, because many previously published cases had other neurological or ophthalmological abnormalities. The purpose of this study was to analyze the incidence of neurological abnormalities in children presenting with AACE and otherwise normal neurological and ophthalmological evaluations., Methods: The medical records of consecutive patients >4 years of age with AACE examined by a single practitioner from 2014 to 2018 were reviewed retrospectively. The main outcome measure was the presence of neurological disease. Children with duction deficits, incomitant esodeviations, and hyperopia of >2.00 D were excluded., Results: A total of 20 children (11 males; mean age, 9.8 ± 4.1 years) were included. Mean esodeviation was 29.5 Δ ± 14.8 Δ (range, 10 Δ -55 Δ ). All had an otherwise normal ophthalmological and neurological evaluations. Of the 20, 19 (95%) had normal brain neuroimaging. One child that did not have neuroimaging was followed over 2 years without developing any neurological sequelae., Conclusions: In our study cohort, pediatric AACE not accompanied by other ophthalmic and neurological abnormalities was not a manifestation of intracranial pathology. In such cases, the decision to perform neuroimaging should take into account other factors, including caregivers' preferences and availability for close monitoring., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the clinical outcomes of using C3F8 as a tamponade agent for the attachment of partially detached Descemet membrane endothelial keratoplasty (DMEK) grafts after failure of previous rebubbling attempts., Methods: Interventional case series. We reviewed the medical records of all DMEK surgeries performed at Rabin Medical Center (Petach Tikva, Israel) between January 2016 and December 2018 in which 10% C3F8 tamponade was used for graft reattachments. Patient demographic details, indication for surgery, early postoperative endothelial cell loss, postoperative visual acuity, intraoperative and postoperative complications as well as graft survival were noted., Results: Five patients were included in this case series. Indications for DMEK were pseudophakic bullous keratopathy (n = 3), failed penetrating graft (n = 1), and Fuchs endothelial dystrophy (n = 1). In 4 of 5 cases, SF6 tamponade was used at the end of the initial DMEK surgery. In 1 case, air tamponade was used. In all cases, partial graft detachment was seen 1 to 2 weeks postoperatively, and anterior chamber rebubbling was performed using 20% SF6 gas. A second C3F8-assisted rebubbling was performed 10 to 70 days after the primary DMEK surgery. In all cases, complete graft attachment was achieved, and the corneas cleared. Early endothelial cell loss rates averaged at 44% ± 26% (range 20%-74%). One case which had a previous trabeculectomy with chronic preoperative and postoperative hypotony had failed 6 months after surgery. All the other grafts were clear at last visit., Conclusions: Tamponade using nonexpansile 10% C3F8 gas can attach partially detached DMEK grafts after the failure of previous air- or SF6-assisted rebubbling attempts.

Current literature on patient-physician concordance emphasizes its advantages. Racial, ethnic, cultural and linguistic concordance was found to impact patient-physician communication positively and to lead to improved healthcare quality and outcomes. Patients' preference for ethnic discordance, on the other hand, appears anomalous and has barely been studied. The present research sought to evaluate the rates of patients from the Jewish majority and the Arab minority populations in Israel who prefer patient-physician ethnic discordance, and to examine the reasons for this preference. A mixed method methodology was employed: a survey (n = 760; 505 Jews, 255 Arabs), as well an exploratory qualitative study based on in-depth interviews with 38 Jewish and Arab patients in Israel. The survey's findings indicate that Arabs are more likely to prefer to be treated by a Jewish physician than are Jews to prefer an Arab physician (family physician - 4.3% vs. 0.4%, p < .0001; surgeon - 5.9% vs. 0.8%, p < .0001). The difference is age-dependent: young Arabs are more likely than older ones to prefer a Jewish physician. The reasons for Arabs' preference for a Jewish physician are fear of a breach of confidentiality, and internalized racism. The reasons for Jews' preference for an Arab physician are the disposition and professionalism attributed to the latter, which are perceived to stem from their need, as a minority population, to excel and to prove themselves. Despite the emphasis placed in scholarship and clinical practice on the importance of cultural and linguistic competency in healthcare, a preference for ethnic discordance should also be taken into account, especially regarding patients from minority collectivist populations., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Organizational language practice and policy are not neutral elements but reflect social and political power relations. The micro-level of working groups is subject to the influence of political conflicts and power relations at the macro-level. In conflict zones in particular, these involve complex considerations. Consequently, the present research sought to examine tensions arising from the language spoken among mixed Jewish-Arab teams in Israeli public hospitals., Methods: In-depth interviews were conducted during 2016-2017, with 50 Jewish and Arab healthcare practitioners - 10 managers, 20 physicians, and 20 nurses - employed in 11 public hospitals in Israel., Results: Our interviews with healthcare practitioners revealed that speaking Arabic in the presence of the patient (not with the patient) may evoke negative feelings and resentment among both Jewish patients and colleagues. Moreover, conflicting attitudes may come into play when Arab practitioners speak Arabic among themselves. Two contexts of language use in Israeli public hospitals can be noticed: the language used in the presence of the patient; and the language used among the practitioners when no patient is present. The former involves the principles of cultural and linguistic competency, and is therefore governed by clear guidelines and procedures. The latter echoes the tensions between the two ethno-national groups in Israel, Jews and Arabs, and is not regulated by a clear policy formulated by the Ministry of Health or by the hospitals' managements., Conclusions: Our analysis of language practice and policy as a multi-leveled phenomenon, where the micro-level of everyday interactions is influenced by the macro-level of political life, indicates a need for meso-level policy, led by the Ministry of Health. A policy of linguistic competency should be publicized and enforced to ensure that in the presence of the patient, practitioners speak a language s/he understands. This policy should also stipulate that among mixed teams of healthcare professionals every language is permissible, while the language spoken in a particular context should be understood by everyone present.

Background: Segregation within the healthcare system is commonly associated with disparities in the utilization of health services and in the outcomes of medical care. In Israel, the Jewish majority and the Arab minority populations are treated in the same healthcare organizations. Nevertheless, demands for ethnic separation in inpatient rooms are raised at times by patients, despite the principle of prohibiting discrimination between patients on the grounds of religion, race, sex and nationality. The study sought to examine patients' attitudes regarding separation between Jews and Arabs in inpatients rooms, and to discover the coping strategies employed by healthcare practitioners., Methods: A mixed methodology was employed. We conducted a survey of a representative sample of the Israeli population (N = 760); and held 50 in-depth interviews with nurses, physicians and managers employed in 11 public hospitals in Israel., Results: In the representative sample survey, 30% of Jews and 21% of Arabs agree that patients should be allowed to choose to be placed in an inpatient room in which only patients of their own ethnic group are hospitalized. Among both Jews and Arabs, a high level of religiosity and a low level of education predict this position. Most Jews (80%) and Arabs (71%) do not agree that the entire healthcare system should be ethnically separated. The in-depth interviews revealed evidence of demands for ethnic separation made at times by Jewish patients, which are often met by the nurses. In some cases, nurses separate Jewish and Arab patients of their own accord. They do this either to promote cultural compatibility between patients or to avoid unnecessary tension and confrontations. In some cases, this step may constitute discrimination against Arab patients. Managers and senior physicians, for their part, are generally unaware of this ethnic separation, or deny that it takes place., Conclusions: Ethnic separation in inpatient rooms does take place some of the time and this runs contrary to the ethos of neutrality in medicine. We recommend implementation of a specific national policy that prohibits ethnic-based separation in hospitals' inpatient rooms. Better communication is required to ensure that policy decisions are clearly conveyed to the wards and that segregation does not become institutionalized.

Context and Objectives: To examine the impact of a complementary/integrative medicine (CIM) program on quality of life (QoL)-related concerns among patients scheduled for chemotherapy for breast and gynecologic cancer., Methods: Chemotherapy-naïve patients were referred by their oncology healthcare professional to an integrative oncology program, where CIM is provided as part of palliative/supportive care. CIM treatments were tailored to patients' preferences and leading concerns, and for most included acupuncture and mind-body-spirit modalities, which were usually co-administered in the week preceding the first chemotherapy cycle. Patients attending the program were considered part of the treatment group; those who chose to receive only standard supportive care as controls. Assessment of quantitative outcomes was conducted during the week before chemotherapy; at 24 h before and after the treatment; and at 1 week post treatment. For this purpose, the Edmonton Symptom Assessment Scale (ESAS) and Measure Yourself Concerns and Well-being questionnaire (MYCAW) were used. Qualitative assessment was based on short narratives at the end of the follow-up MYCAW questionnaire, which were analyzed with ATLAS.Ti software for systematic coding., Results: Of the 55 patients referred, 31 (56%) underwent CIM treatments, with 24 controls. Both groups had similar baseline demographic and cancer-related characteristics. QOL-related outcomes were significantly less impaired following CIM treatments for ESAS fatigue scores (P = 0.013), depression (P = 0.005), and feeling of well-being (P = 0.027); and MYCAW scores for well-being (P = 0.005) and emotional distress (P = 0.02). Qualitative analysis detected both specific and non-specific effects of the CIM treatment regimen, most describing a reduction in pre-chemotherapy anxiety., Conclusion: A patient-tailored CIM program, initiated within a week of the first chemotherapy cycle, may help reduce the severity of fatigue, depression, and impaired well-being among patients with breast and gynecological cancers.

Diversity of the workforce in healthcare facilities, representative of the general population's ethnic/racial composition, is an important health priority. Nevertheless, this diversity may generate tensions. The objective of the study was to assess tensions and coping strategies among ethnic minority and majority healthcare workers. A questionnaire was delivered to 60 healthcare workers employed in emergency departments in two hospitals, where Jewish majority and Arab minority workers care for a mixed Jewish and Arab population. Internal consistency reliability was assessed and the survey data were statistically analyzed. Several differences were found between Arab and Jewish healthcare workers. The questionnaire may be used to examine tensions in other healthcare systems, characterized by ethnic/racial diversity in the workforce. By exploring ethnic/racial tensions, health organizations should be able to manage them better and reduce their frequency.

Objective: Complementary and integrative medicine (CIM) is acknowledged in more and more oncology-care centers as part of supportive and palliative cancer care. However, only limited research is available on medical training of CIM practitioners regarding end-of-life (EOL) care. In this study, we assess the impact of multi-disciplinary EOL training on cultural-diverse groups of CIM-trained healthcare practitioners (HCPs) working in integrative oncology care settings in Germany and Israel., Methods: The authors co-designed an evidence-based patient-centered EOL-training curriculum incorporating palliative and CIM concepts of care. Afterwards, a 3-day course was designed for 25 HCPs working in three anthroposophic-medicine-oriented medical centers in Germany and 14 CIM-trained HCPs from one oncology center in Israel. Qualitative assessment of the EOL-training impact on trainees was assessed 4-month post-intervention. Narratives were analyzed using ATLAS.ti software for systematic coding., Results: Post-training narrative assessment was reported by 18 German and 14 Israeli HCPs comprising 10 physicians, 12 nurses and paramedical practitioners, and 10 CIM therapists and spiritual care-providers. Content analysis of post-training outcomes suggested participants' attitude-change regarding their professional role in EOL care as individuals and as members of a team. Participants acquired practical clinical tools to enhance EOL care and to better communicate with patients about death, implementing a patient-centered, cultural-sensitive approach., Conclusions: EOL training of CIM-trained HCPs enhances communication and palliative clinical skills. Multidisciplinary and international training settings emphasize a cross-cultural perspective and enrich the bio-psycho-social-spiritual model of palliative care.

Objective: Peripheral neuropathy is a common complication of cancer treatment impairing quality of life and function. This study explored the impact of a complementary and integrative medicine (CIM) program on taxane-induced peripheral neuropathy (TIPN)., Materials and Methods: Taxane-treated female patients with breast and gynecological cancer reporting TIPN-related symptoms were referred to an integrative physician, followed by patient-tailored CIM treatments (acupuncture with/without other modalities). Assessment of study outcomes at 6 to 12 weeks was conducted using the Measure Yourself Concerns and Wellbeing, which documented free-text narratives about patients' experience during the CIM treatment process. Content was analyzed using ATLAS.Ti software., Results: Of the 125 patients treated with taxanes, 69 had been referred for CIM treatment of TIPN-associated symptoms. Multidisciplinary narrative analysis identified 2 groups of CIM-treated patients: those with an apparently moderate improvement in symptoms (n = 35) and those with either only an apparent mild or no improvement at all. For 10 patients, assessment of their response to treatment was unclear. The 2 identified groups had similar demographic, cancer-related, and quality of life-related parameters at baseline. Content analysis of patients with an apparent moderate improvement suggested a short-term (24-48 hours) effect with acupuncture treatment, either alone or combined with manual, mind-body, and anthroposophic music therapies. Symptoms showing improvement included paresthesia and numbness., Conclusions: Acupuncture and other CIM therapies may result in a short-term and transitory reduction in TIPN-related symptoms.

Objective: The objective of the research was to explore attitudes of hospital nurses toward integrative medicine (IM)., Design: A special training program was developed in the Bnai-Zion medical center, a public hospital in Israel, where an innovative IM program was launched., Methods: 65 nurses from 22 wards were asked at the beginning and the end of the program to complete an open-ended questionnaire concerning three major aspects: 1) their attitudes toward complementary medicine and its integration, 2) the importance and impact of the training program and 3) how they perceive their potential role in promoting IM in the wards., Results: Nurses perceive themselves as boundary actors, who can play an important role in promoting IM within the wards. IM training programs for hospital nurses are recommended. This empowers nurses while restoring to clinical practice the essence of nursing as an integrative healing discipline., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Increasing workforce diversity was found to contribute to the narrowing of disparities in health. However, racism toward ethnic minority health professionals has not been adequately researched. In Israel, public healthcare organizations that serve a mixed Jewish-Arab population employ Arab minority healthcare professionals. Instances of prejudice and manifestations of racism toward them, which frequently surface in public discussion and the media, have unfortunately gained little scholarly attention. We used the intergroup contact approach and the theory of the social process of everyday racism as a theoretical framework. The objective of the research was to study race-based experiences of Israeli Arab healthcare professionals., Methodology: We used a qualitative research method that allows respondents to describe their views, experiences, beliefs and behavior in the way they think about them. During 2013 and 2014 we conducted in-depth interviews with a snowball sample of 10 Arab physicians and 13 Arab nurses who work in Israeli public hospitals. The study protocol was ethically approved., Findings: Interviewees noted institutional efforts to maintain egalitarianism and equality. However, at the micro-level, interviewees, mostly nurses, reported instances that ranged from refusal to accept treatment from an Arab nurse, through verbal abuse, to the use of physical violence against them. At the meso-level, interviewees, mostly physicians, reported experiences of institutional discrimination. At the macro-level, one physician reported policy-related discrimination in the context of the immigration of Russian Jewish physicians to Israel., Conclusions: We recommend combining the intergroup contact approach with the social process theory of racism to examine minorities' subjective perceptions, especially in conflictual and violent contexts; conducting broad-based quantitative research in Israeli healthcare organizations, which may have important implications for the specific strategies to be used; and emphasizing the importance of institutional support. By reconstructing race-based experiences of ethnic minority health professionals, health organizations can better manage racial situations and reduce their frequency.

Background: The integration of manual therapies, including reflexology, into conventional care settings is growing extensively. Patients' beliefs, attitudes and expectations toward these therapies interact with their outcomes, but currently there are no validated tools to evaluate these factors. We aimed to design and to validate such a tool specifically targeted into reflexology., Methods: Following input of a multidisciplinary team of experts, the self-administered Inpatient Beliefs, Expectations and Attitudes toward Reflexology (IBEAR) questionnaire was constructed, containing 25 items, 8 referring to demographics and 17 specifically addressing reflexology. Cronbach's alpha was computed to evaluate the questionnaire's internal reliability, and factor analysis was used for further validation (232 patients). Pearson coefficient and Kappa tests were used to test and retest (within 48 hours) the questionnaire on a group of 199 patients, to assure clarity and reliability., Results: For the 232 questionnaires collected, the computed Cronbach's alpha coefficient was 0.716 (acceptable reliability). Factor analysis pointed to two content areas separated into four items addressing attitudes and expectations and five items focusing on beliefs and attitudes. In the test-retest stage, 199 participants filled in the questionnaire for a second time. The Pearson coefficient for all questions ranged between 0.73 and 0.94 (good to excellent correlation) and Kappa scores ranged between 0.66 and 1.0 (moderate to high reliability). Consequently, one of the questions was removed from the IBEAR., Conclusions: The present study provides evidence that the proposed IBEAR questionnaire with 16 items is a valid and reliable tool for evaluation of inpatients' beliefs, expectations and attitudes toward reflexology., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Patients' refusal of treatment based on the practitioner's ethnic identity reveals a clash of values: neutrality in medicine versus patient-centered care. Taking the Israeli-Palestinian conflict into account, this article aims at examining Israeli health care professionals' points of view concerning patients' refusal of treatment because of a practitioner's ethnic identity. Fifty in-depth interviews were conducted with 10 managers and 40 health care professionals, Jewish and Arab, employed at 11 public hospitals. Most refusal incidents recorded are unidirectional: Jewish patients refusing to be treated by Arab practitioners. Refusals are usually directed toward nurses and junior medical staff members, especially if recognizable as religious Muslims. Refusals are often initiated by the patients' relatives and occur more frequently during periods of escalation in the conflict. The structural competency approach can be applied to increase awareness of the role of social determinants in shaping patients' ethnic-based treatment refusals and to improve the handling of such incidents.

The ethos of neutrality dominates biomedicine. It has, however, been criticized for leading to a disregard for diversity in medicine. In this article we employ the 'inclusion and difference' approach to gain an understanding of why the ethos of neutrality, on the one hand, and tensions associated with race/ethnicity, on the other, are relevant to the work of ethnic minority health professionals. We sought to explore tensions associated with neutrality in medicine from the point of view of ethnic minority professionals who work in a context of political conflict. We conducted 33 in-depth interviews with Arab health professionals - physicians, nurses and pharmacists - working in Israeli health organizations. The Arab health professionals perceive medical knowledge as being politically neutral; and medical practice as being impartial, universal and humanitarian. They regard the healthcare sector as a relatively egalitarian workplace, into which they can integrate and gain promotion. Nevertheless, the interviewees experienced various instances of treatment refusal, discrimination and racism. In line with the ethos of neutrality, the Israeli medical code of ethics does not relate specifically to Arab professionals and takes their inclusion and integration in healthcare organizations for granted. The ethos of neutrality in medicine underlies the ambivalence inherent in the approach of 'inclusion and difference'. While perceptions of neutrality, alongside values such as equality, cultural competency, impartiality and humanitarian healthcare, do indeed promote the inclusion of minority professionals in health organizations, these same perceptions mask the need to address political events that impinge on the medical milieu and may present an obstacle to designing specific policies to deal with such events., (Copyright © 2016 Elsevier Ltd. All rights reserved.)