Leonard E. Braitman

Approaching the End of Life: Attitudes, Preferences, and Behaviors of African-American and White Patients and Their Family Caregivers

PURPOSEnTo investigate differences in attitudes, preferences, and behaviors regarding end of life in terminally ill patients and their designated family caregivers.nnnPATIENTS AND METHODSn68 African-American and white patients with stage III-B or IV lung or stage IV colon cancer and 68 patient-designated family caregivers interviewed between December 1999 and May 2001.nnnRESULTSnWhite patients were more likely to have a durable power of attorney (34% v 8%, P =.01) and were more likely to have a living will (LW; 41% v 11%, P =.004) than were African-American patients. More African-American than white patients desired the use of life-sustaining measures (cardiopulmonary resusitation [CPR], mechanical ventilation, tube feeding) in their current condition (all P >.12). In a near-death condition, African-American patients were more likely than white patients to desire each of the life-sustaining measures (all P <.004). There was no patient-caregiver agreement beyond chance regarding preferences for initiation of CPR, tube feeding, or mechanical ventilation in the patients current condition or in the near-death condition. In the near-death condition in patients without LWs, there was disagreement in 46% of patient-caregiver pairs about CPR, in 50% about mechanical ventilation, and in 43% about tube feeding.nnnCONCLUSIONnAlthough most patients and families endorse the primacy of the patient in decisions at end of life, the majority do not take supporting actions. Disagreements between patients and families about the use of life-sustaining measures in patients without LWs may result in patients preferences being superseded at end of life.

Estimation of the Risk of Thrombocytopenia in the Offspring of Pregnant Women with Presumed Immune Thrombocytopenic Purpura

Abstract Background and Methods. The optimal management of immune thrombocytopenic purpura during pregnancy remains controversial because the risk of severe neonatal thrombocytopenia remains uncertain. We studied the outcome of the index pregnancy in 162 women with a presumptive diagnosis of immune thrombocytopenic purpura to determine the frequency of neonatal thrombocytopenia and to determine whether neonatal risk could be predicted antenatally by history or platelet-antibody testing. Results. Two maternal characteristics were identified as predicting a low risk of severe neonatal thrombocytopenia: the absence of a history of immune thrombocytopenic purpura before pregnancy, and the absence of circulating platelet antibodies in the women who did have a history of the condition. Eighteen of 88 neonates (20 percent; 95 percent confidence interval, 13 to 30 percent) born to women with a history of immune thrombocytopenic purpura had severe thrombocytopenia (platelet count <50×109 per liter at birth), as co...

Endotracheal tube selection in children: A comparison of four methods

STUDY OBJECTIVEnTo determine the accuracy of four methods of endotracheal tube size selection in the pediatric population.nnnSTUDY DESIGNnProspective, blinded comparison.nnnSETTINGnThe Childrens Hospital of Philadelphia.nnnPARTICIPANTSnTwo hundred thirty-seven children aged 1 month to 9 years old undergoing elective surgery requiring endotracheal intubation.nnnSELECTION PROCEDURESnConsecutive sample.nnnINTERVENTIONSnFour methods of determining proper endotracheal tube size in children were compared. These methods included direct comparison with the width of the fifth finger, direct comparison with the diameter of the fifth finger using a ring-sizing device, direct comparison with the width of the fifth fingernail, and estimation using a formula ([age in years + 16]/4). In infants, a 3.0-mm (internal diameter) endotracheal tube was predicted for those 3 months of age and younger, and a 3.5-mm endotracheal tube was predicted for those from 3 to 9 months of age. The size of the endotracheal tube used in the operating room was recorded, as was the air leak around the tube. An appropriately sized endotracheal tube was determined by an air leak with ventilation pressures between 5 and 40 cm of water.nnnMAIN RESULTSnDirect comparison using the width and the diameter of the fifth finger predicted an endotracheal tube between 1 mm smaller and 0.5 mm larger than that used by the anesthesiologists in 11% and 14% of patients, respectively. The age-based formula predicted an endotracheal tube size in this range in 97.5% of patients, and direct comparison with the width of the fifth fingernail predicted an endotracheal tube in this same range in 91% of patients. These findings were consistent within all age groups studied.nnnCONCLUSIONnNeither fifth finger width nor fifth finger diameter accurately predicts proper endotracheal tube size in most children. A more accurate estimation can be made using the age-based formula, but when the childs age is unknown or when calculation is awkward or impossible, an accurate estimate can be made using the width of the fifth fingernail.

Analysis of Weight Loss After Bariatric Surgery Using Mixed-Effects Linear Modeling

BackgroundThe standard analysis of bariatric surgery weight outcomes data (using t tests) is well known. However, these uncontrolled comparisons may yield misleading results and limit the range of research questions. The aim of the study was to develop a valid approach to the longitudinal analysis of weight loss outcomes after bariatric surgery using multivariable mixed models. This study has a multi-institutional setting.MethodsWe developed a mixed-effects model to examine weight after gastric bypass surgery while controlling for several independent variables: gender, anastomotic technique, age, race, initial weight, height, and institution. We contrasted this approach with traditional uncontrolled analyses using percent excess weight loss (%EWL).ResultsOne thousand one hundred sixty-eight gastric bypass procedures were performed between 2000 and 2006. The average %EWL at 1, 2, and 3xa0years was 71%, 79%, and 76%, respectively. Using weight as the outcome variable, initial weight and gender were the only independent predictors of outcome (pu2009<u20090.001). %EWL was substantially less accurate than weight as an outcome measure in multivariable modeling. Including initial weight and height as separate independent variables yielded a more accurate model than using initial body mass index. In a traditional uncontrolled analysis, average %EWL was higher in women than men. However, average weight loss was lower, not higher, in women (pu2009<u20090.001) in our multivariable mixed model. Height, surgical technique, race and age did not independently predict weight loss.ConclusionsMultivariable mixed models provide more accurate analyses of weight loss surgery than traditional methods and should be used in studies that examine repeated measurements.

Quality of life and symptom attribution in long-term colon cancer survivors

AIMS AND OBJECTIVESnThis study investigates how long-term colon cancer survivors evaluate their health, functional status and quality of life, and whether there are differences based on age, gender or ethnicity.nnnMETHODSnThirty long-term survivors of at least stage I colon cancer were interviewed in person between December 2004 and May 2005. The interview protocol included the Medical Outcomes Study 36-Item Short Form, Quality of Life--Cancer Survivor, and study-specific questions that asked about physical and non-physical problems they attributed to colon cancer.nnnRESULTSnSubstantial percentages of survivors attributed their problems with lack of energy (83%), sexual functioning (67%), bowel problems (63%), poor body image (47%) and emotional problems (40%) to having had colon cancer. Of those problems attributed to colon cancer, sexual functioning and pain were given the highest severity rankings by survivors. The majority of long-term colon cancer survivors reported distress regarding future diagnostic tests, a second cancer, and spread of cancer. Women reported greater problems completing daily activities as a result of physical problems (P = 0.003) and more pain (P = 0.07) than men. African Americans appear to report marginally better overall quality of life (P = 0.07) and psychological well-being than whites (P = 0.07).nnnCONCLUSIONnThe majority of long-term colon cancer survivors with resected colon cancer and disease-free for 5 years reported problems with low energy, sexual functioning and bowel problems.

A pilot study of cancer knowledge and screening behaviors of Vietnamese and Cambodian women.

Breast and cervix cancer screening behaviors, while suboptimal in all Americans, are of particular concern in minority females. Little is known about cancer knowledge and screening behavior in Southeast Asian populations in the United States. We interviewed 38 Southeast Asian women of Cambodian or Vietnamese origin living in the Philadelphia, Pennsylvania, area. A telephone interview was conducted by bilingual/bicultural interviewers. Seventy-one percent (95% confidence interval [CI], 54% to 85%) of women in the study did not know what cancer was and 74% were unable to identify a cancer prevention strategy. Greater knowledge about cancer and identification of preventive measures were associated with employment outside the home, more years of education, and age, but not with length of time in the United States. Cancer education programs need to identify the patients level of knowledge about cancer, elicit and respectfully address beliefs about causality and prevention, and ensure that health information is provided in a language understandable to the patient.

Plasma concentration of endothelin-1 in women with cocaine-associated pregnancy complications

OBJECTIVEnThe purpose of this study was to determine if the plasma concentration of endothelin-1 is elevated in pregnant women abusing cocaine and to determine how these levels differ from those in patients with preeclampsia and in women with uncomplicated pregnancies.nnnSTUDY DESIGNnPlasma endothelin-1 levels were measured in 30 women with acute cocaine intoxication, 32 women with preeclampsia, 14 pregnant women with chronic hypertension, 26 women with uncomplicated pregnancies, and 16 nonpregnant individuals. Serial samples after delivery were obtained in 12 women with preeclampsia, 10 with cocaine abuse, 4 with chronic hypertension, and 7 with uncomplicated pregnancies.nnnRESULTSnThe mean endothelin-1 concentration in those with cocaine abuse was 18.2 +/- 8.1 pg/ml (95% confidence interval 15.2 to 21.2). This was similar to that in women with preeclampsia (21.1 +/- 5.9 pg/ml, 95% confidence interval 19 to 23.3) (p = 0.2) but significantly different from that in women with chronic hypertension (11.5 +/- 3.6 pg/ml, 95% confidence interval 9.4 to 13.6) (p < 0.001) and women with uncomplicated pregnancies (6.7 +/- 3.9 pg/ml, 95% confidence interval 5.1 to 8.2) (p < 0.001).nnnCONCLUSIONSnEndothelin-1 levels in women abusing cocaine are comparable to those in women with preeclampsia and are significantly higher than those in gravid women with chronic hypertension and women with uncomplicated pregnancies. Elevated levels of endothelin-1 may contribute to some of the pregnancy-related complications in women abusing cocaine.

Family care giving for patients at life's end: report from the cultural variations study (CVAS).

OBJECTIVEnTo investigate differences between African American and White family caregivers in self-reported health, use of social support and external resources, and emotional and financial strain in the context of their care of a family member with advanced cancer.nnnMETHODSnSixty-nine patient-designated family caregivers of patients with advanced lung or colon cancer interviewed between December 1999 and July 2001.nnnRESULTSnMost African American and White family caregivers were able to identify someone else who was helping them in the care of their family member. Few caregivers used outside resources (e.g., home-based medical care, meal delivery, pastoral care, outside social support visitor) to assist in the support and care of the patient. At baseline, White caregivers were more likely to agree that caregiving caused work adjustments, (p=.28, p=.02) and emotional difficulties (p=.32, p=.008) and that caregiving had been completely overwhelming (p=.19, p=.12) than were African American caregivers. At follow-up, among family caregivers of patients who had died, 44% reported having to quit work to provide personal care for the patient. Twenty-five percent of family caregivers reported using most or all of the familys saving in caring for the patient.nnnSIGNIFICANCE OF RESULTSnCaregivers of patients at end of life experience substantial emotional and financial difficulties related to caregiving. Family caregiving is a private undertaking with little use of outside resources to mitigate the burden.

Impact of a Rewards-Based Incentive Program on Promoting Fruit and Vegetable Purchases

Objectives. We assessed the impact of a rewards-based incentive program on fruit and vegetable purchases by low-income families. Methods. We conducted a 4-phase prospective cohort study with randomized intervention and wait-listed control groups in Philadelphia, Pennsylvania, in December 2010 through October 2011. The intervention provided a rebate of 50% of the dollar amount spent on fresh or frozen fruit and vegetables, reduced to 25% during a tapering phase, then eliminated. Primary outcome measures were number of servings of fruit and of vegetables purchased per week. Results. Households assigned to the intervention purchased an average of 8 (95% confidence interval [CI]u2009=u20091.5, 16.9) more servings of vegetables and 2.5 (95% CIu2009=u20090.3, 9.5) more servings of fruit per week than did control households. In longitudinal price-adjusted analyses, when the incentive was reduced and then discontinued, the amounts purchased were similar to baseline. Conclusions. Investigation of the financial costs and potential benefits of incentive programs to supermarkets, government agencies, and other stakeholders is needed to identify sustainable interventions.

Family caregiver satisfaction with care at end of life: report from the cultural variations study (CVAS).

The objective of this study was to examine differences in family caregiver satisfaction with care at end of life based on site of death, in an observational study involving advanced cancer patients and their family caregivers. The study was based on follow-up interviews with 28 family caregivers of 28 patients who died during a two-year prospective study involving 68 patients and 68 family caregivers. Telephone interviews addressed the circumstances of the patients’ death, their satisfaction with the care provided to the patient, and their satisfaction with how well they were attended to by health providers. There were no associations between site of death (died at home vs. did not die at home) and family caregiver satisfaction with the overall care provided to the patient. However, family caregivers of patients who died at home responded that they thought the patient was more at peace (with respect to spiritual and religious matters) than did family care-givers of patients who did not die at home (p = 0.003). Family caregivers of patients who died at home appeared to feel less satisfied with the attention paid to their own wishes regarding the patient’s care (p = 0.13), less satisfied with the emotional support provided to them by healthcare personnel taking care of the patient (p = 0.08), and less satisfied with communication from health providers (p = 0.11). Findings indicate that although dying at home appears to provide a more peaceful death for the patient, it may also distance family care-givers from health professionals and leave them feeling less supported during the patient’s last days of life.