Opioid consumption by cancer patients in an Israeli Health Maintenance Organization from 2007-2018.

PURPOSE: Opioids are the cornerstone of therapy for cancer patients with moderate to severe pain. The objective was to characterize opioid purchases by cancer patients in Clalit Health Services (CHS), the largest Health Maintenance Organization in Israel, over the years 2007-2018. METHODS: Data for all CHS cancer patients aged 18 years old and above who purchased an opioid at least once during the 12-year study period were obtained from computerized databases. The amount of opioids was converted into oral morphine equivalents (OME). RESULTS: 108,543 cancer patients who purchased opioids at least once were enrolled. They comprised 30.5% of the CHS purchasers of opioids in the study period. The total number of cancer patients who purchased an opioid at least once increased gradually from 13,057 in 2007 to 20,675 (58% increase) in 2018, while the annual number of CHS cancer patients increased by only 39%. The annual OME per capita increased from 753 mg in 2007 to 1,432 mg in 2018 (91% increase). In 2007 8.1% of the cancer patients purchased opioids and 9.2% in 2018. Two thirds of all cancer patients purchased opioids for three months or less, 11.9% continued for more than one year, and 5.8% for more than two years. CONCLUSIONS: There is a clinically non-significant increase in the rate of cancer patients purchasing opioids. About two thirds of the cancer patients purchased opioids for only three months, and 94% for up to two years. Under-treatment of cancer pain should still be of concern. While patients are prescribed higher doses, under-prescription may still be a problem..

When they stop drinking-examining end-of-life hydration practices and death rattle occurrence.

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

Nocturnal Atrial Fibrillation Caused by Mutation in KCND2, Encoding Pore-Forming (α) Subunit of the Cardiac Kv4.2 Potassium Channel.

BACKGROUND: Paroxysmal atrial fibrillation (AF) can be caused by gain-of-function mutations in genes, encoding the cardiac potassium channel subunits KCNJ2, KCNE1, and KCNH2 that mediate the repolarizing potassium currents Ik1, Iks, and Ikr, respectively. METHODS: Linkage analysis, whole-exome sequencing, and Xenopus oocyte electrophysiology studies were used in this study. RESULTS: Through genetic studies, we showed that autosomal dominant early-onset nocturnal paroxysmal AF is caused by p.S447R mutation in KCND2, encoding the pore-forming (α) subunit of the Kv4.2 cardiac potassium channel. Kv4.2, along with Kv4.3, contributes to the cardiac fast transient outward K+ current, Ito. Ito underlies the early phase of repolarization in the cardiac action potential, thereby setting the initial potential of the plateau phase and governing its duration and amplitude. In Xenopus oocytes, the mutation increased the channel's inactivation time constant and affected its regulation: p.S447 resides in a protein kinase C (PKC) phosphorylation site, which normally allows attenuation of Kv4.2 membrane expression. The mutant Kv4.2 exhibited impaired response to PKC; hence, Kv4.2 membrane expression was augmented, enhancing potassium currents. Coexpression of mutant and wild-type channels (recapitulating heterozygosity in affected individuals) showed results similar to the mutant channel alone. Finally, in a hybrid channel composed of Kv4.3 and Kv4.2, simulating the mature endogenous heterotetrameric channel underlying Ito, the p.S447R Kv4.2 mutation exerted a gain-of-function effect on Kv4.3. CONCLUSIONS: The mutation alters Kv4.2's kinetic properties, impairs its inhibitory regulation, and exerts gain-of-function effect on both Kv4.2 homotetramers and Kv4.2-Kv4.3 heterotetramers. These effects presumably increase the repolarizing potassium current Ito, thereby abbreviating action potential duration, creating arrhythmogenic substrate for nocturnal AF. Interestingly, Kv4.2 expression was previously shown to demonstrate circadian variation, with peak expression at daytime in murine hearts (human nighttime), with possible relevance to the nocturnal onset of paroxysmal AF symptoms in our patients. The atrial-specific phenotype suggests that targeting Kv4.2 might be effective in the treatment of nocturnal paroxysmal AF, avoiding adverse ventricular effects.

Next of Kin's Notification of Patient's Death: A Qualitative and Quantitative Preliminary Analysis.

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

Advance Directives-The Israeli Experience.

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

Minor surgical procedures and musculoskeletal injections by primary care physicians - an Israeli experience.

ABSTARCT BACKGROUND: Since minor surgical and musculoskeletal problems are commonly seen in primary care, primary care physicians are expected to possess the skills required to perform minor surgical procedures (MSP) and musculoskeletal injections (MSI). OBJECTIVE: To evaluate the performance of MSP and MSI by primary care physicians in the Southern District (Negev) of Clalit Health Services (CHS) health maintenance organization (HMO) in Israel. METHODS: A structured self-report questionnaire was sent to all 277 primary care physicians, other than pediatricians, working in the Southern District (Negev) of CHS HMO. RESULTS: One hundred fifty one of the 277 questionnaires (54%) were completed and returned. Sixty five percent of the primary care physicians perform any MSP and 46% perform any MSI. The main barriers reported for performing MSP and MSI were lack of time (74% and 66%, respectively) and training (41% and 60%, respectively). Forty percent of the physicians cited remuneration as a potential motivating factor. A logistic regression model showed that male physicians and physicians who work full or part-time in rural areas, are more likely to perform MSP (Odds ratio 2.12 and 2.24, respectively). Male physicians, especially board-certified family physicians, are more likely to perform MSI (Odds ratio 2.86 and 7.0 respectively). CONCLUSION: MSP and MSI are practiced by only some primary care physicians. HMOs and individuals responsible for designing training curricula in family medicine and primary care can encourage primary care physicians to perform MSP and MSI by providing courses, specific compensation, and dedicated time. This can strengthen the bond between primary care physicians and patients, reduce waiting time for patients, and save money for HMO's.

[Communication between the primary care physician, hospital staff and the patient during hospitalization].

BACKGROUND: HospitaL admission is a crisis for the patient and his family and can interfere with the continuity of care. It may lead to mistakes due to communication problems between the primary care physician and the hospital medical staff. OBJECTIVE: To explore the communication between the primary care physician, the hospital medical staff, the patient and his family during hospitalization. METHODS: A total of 269 questionnaires were sent to all Clalit Health Services-South District, primary care physicians; 119 of these questionnaires (44.2%) were completed. RESULTS: Half of the primary care physicians thought that they should, always or almost always, have contact with the admitting ward in cases of internal medicine, oncology, surgery or pediatric admissions. However, the actual contact rate, according to their report, was only in a third of the cases. A telephone contact was more common than an actual visit of the patient in the ward. Computer communication between the hospital physicians and the primary care physicians is still insufficiently developed, although 96.6% of the primary care physicians check, with the aid of computer software, for information on their hospitalized patients. The main reasons to visit the hospitalized patient were severe medical conditions or uncertainty about the diagnosis; 79% of the physicians thought that visiting their patients strengthened the level of trust between them and their patients. There are sometimes communication difficulties and barriers between the primary care physicians and the ward's physicians due to partial information delivery and rejection from the hospital physicians. The main barriers for visiting admitted patients were workload and lack of pre-allocated time on the work schedule. No statistically significant differences were found between communication variables and primary care physician's personal and demographic characteristics. CONCLUSIONS: The communication between the primary care physician and the hospital physicians should be improved through mutual workshops promoting communication channels conducted by the academic institutes and health maintenance organizations and the Ministry of Health.

Continuous subcutaneous delivery of medications for home care palliative patients-using an infusion set or a pump?

PURPOSE: The purpose of this study was to evaluate safety, feasibility, and efficacy of continuous drug delivery by the subcutaneous route through a solution bag connected to an infusion set compared with an infusion pump in a home palliative care setting. METHODS: Patients in need of continuous subcutaneous medication delivery for pain control, nausea, and/or vomiting were recruited. The study was designed as a double-blind, crossover study. The patient was connected to two parallel subcutaneous lines running simultaneously, connected together to a line entering the subcutaneous tissue. One line is connected to an infusion set and the other to a pump. The infusion set included a 500-cc solution bag connected to a 1.5-m plastic tube containing a drip chamber controlled by a roller clamp that is gravity driven without hyaluronidase. Active medications were randomly assigned to start in either administration method and switched after 24 h. An independent research assistant evaluated symptom control and side effects at baseline and every 24 h for 2 days using a structured questionnaire. Another independent research assistant connected the lines after adding medications and evaluated technical and clinical failures. RESULTS: Twenty-seven patients were recruited, and of them, 18 completed the study. Incidents in fluid administration were more common through the infusion set (18 times) compared to the pump (only twice). On the other hand, no clinical significant change was noted in the average symptom levels and side effects when medications were given through the infusion set versus the pump. No local edema or irritation was observed in either way of administration. CONCLUSIONS: In a home palliative care setting with a medical staff on call for 24 h, using medications for symptom control can be considered to be infused to a fluid solution bag through an infusion set instead of using a syringe driver or a pump when there is a responsible caregiver to follow up on the fluid. Subcutaneous constant drug delivery through a pump is more accurate.

[How patients choose their new family physician and what do they know about him?].

BACKGROUND: A change of residence is the main reason for choosing a new family physician. Patients entering a new clinic need to choose a new family physician. AIMS: To explore the factors influencing new patients' choice of physician. This study examined the importance of the physician's demographic and personal characteristics, the knowledge patients have of their physician and compared these factors between new immigrants, up to five years in Israel, and veteran residents. METHODS: The study population was comprised of a random sample of new patients registered in two family medicine clinics in Beer Sheba, in the two years prior to the commencement of the study. The patients were interviewed by phone using a structured questionnaire in Hebrew or Russian. RESULTS: A total of 166 patients participated in the study. Only 45% of the new patients fulfilled their right to choose their new family physician. About two thirds of the patients consulted either their relatives or the clinic's staff in choosing their family physician. About 78% were satisfied with their family physician. Professionalism and patience were the most important qualities noted by patients as important characteristics of their family physician. Eighty percent of the patients knew their family physician's full name and half knew his country of birth. Only a few knew that their physician performs surgical procedures, treats psychological problems and provides personal or family crisis intervention. Unlike the new immigrants, veteran residents were more aware of the comprehensive approach of the family physician. Veteran residents considered professionalism, patience and availability to be more important qualities in a family physician. These findings were statistically significant. In comparison, new immigrants noted speaking their mother language and mannerisms as being more important. CONCLUSIONS: The majority of patients are satisfied with their family physician, however, more efforts should be made to educate the public, especially new immigrants, in the wide range of medical problems that can be consulted and treated by the family physician in Israel.

High-dose fentanyl patch for cancer pain.

OBJECTIVE: To describe a successful experience with a high dose (1000 microg/hr) of transdermal fentanyl for cancer pain relief. CASE REPORT: A 62-year-old man suffering from rectal carcinoma was treated by our home care hospice unit during his last 3.5 months of life. At admission to our home care unit, he suffered mostly from severe anal pain (verbal pain scale of 10/10) due to advanced disease. He was then on 150 microg/hr transdermal fentanyl. Adjuvant therapy with amitriptyline 50 mg/day and dexamethasone 4 mg/day was added, but it did not relieve his pain. The dose of transdermal fentanyl was increased gradually to 1000 microg/hr with good pain control (verbal pain scale of 1 to 4/10 most of the time). Before his death, he was mentally alert with good pain control. CONCLUSIONS: High doses of transdermal fentanyl (1000 microg/hr; 10 patches) should be considered for pain relief in cancer patients.

[Sexual dysfunction--what is the primary physicians role?].

BACKGROUND: Sexual dysfunction is characterized by disturbances in sexual desire and/or psycho-physiological changes associated with the sexual response cycle in men and women. Studies suggest that it is prevalent in 10-52% of women and 25-63% of men, and could have a tremendous impact on the individual, interpersonal relations, and on the family quality of life. OBJECTIVE: To assess attitudes, knowledge and sexual dysfunction management by Israeli primary care physicians. METHODS: Two hundred and ninety-two physicians from approximately 800 participants who attended a Family Medicine and General Practice conference took part in the study. A self-reply questionnaire was distributed among the participants and 179 completed the full questionnaire (61%). RESULTS: Seventy nine percent of the physicians thought the primary care physician should be the address for treating most sexual dysfunction problems. Physicians indicated that only 12% of their patients treated for sexual dysfunction were female. Significant differences were found between male and female physicians, board certified family physicians, general practitioners and residents in family medicine regarding sexual dysfunction treatment. Board certified family physicians treated more patients with sexual dysfunctions than general practitioners (GP) and residents in family medicine [53% vs. 23% vs. 22% respectively, (p < 0.05)]. The main barriers for treating sexual dysfunctions noted by physicians were lack of time (62%) and knowledge (47%). CONCLUSIONS: Family physicians consider themselves to be the main address for the patient for sexual dysfunction problems. Physicians believe they need more training to overcome lack of knowledge barriers and they need to organize their time to adequately address their patients sexual dysfunction problems.

Teaching geriatric assessment in home visits: the family physician/geriatrician attachment.

BACKGROUND: Geriatric clinical clerkships in Israel teach mostly about the hospitalized elder patient with almost no ambulatory experience. Meanwhile, primary care physicians provide most of the health care to the elderly in the community. This article describes an innovation in the curriculum of the 5th-year family medicine clerkship at the Goldman Medical School of Ben-Gurion University in Israel designed to improve the teaching of geriatrics in the ambulatory setting. DESCRIPTION: During the clerkship, family physicians perform a home visit to one of their home-ridden elderly patients with a small group of medical students. During this visit, a geriatrician from the local hospital is included to the group for teaching purposes. EVALUATION: Most students rated this experience positively as did the family physicians and geriatricians who participated in this experience. CONCLUSIONS: This liaison-attachment teaching experience allows the students to learn aspects of geriatrics that are spared during their geriatric clerkship, allows the family physician to use this opportunity as a consultation for homebound patients, and allows the tertiary care geriatrician to teach in the community.