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Biomedical subjects

B Rosenfeld

Publications and source records attributed to B Rosenfeld.

At least 19 recordsLinked to original sources
PubMed2001

A randomized, double-blind, placebo-controlled trial of psychostimulants for the treatment of fatigue in ambulatory patients with human immunodeficiency virus disease.

BACKGROUND: Fatigue is a commonly encountered symptom of human immunodeficiency virus (HIV) disease, associated with significant psychological and functional morbidity and poor quality of life. Preliminary studies on the treatment of fatigue from the cancer and multiple sclerosis literature suggest that psychostimulants may be effective in reducing fatigue. OBJECTIVE: To compare the efficacy of 2 psychostimulant medications, methylphenidate hydrochloride (Ritalin) and pemoline (Cylert), with a placebo intervention for the treatment of fatigue in patients with HIV disease. METHODS: In this double-blind trial, 144 ambulatory patients with HIV disease and persistent and severe fatigue were randomized to treatment with methylphenidate, pemoline, or placebo. Medications were titrated up to a maximum dose of 60 mg of methlyphenidate hydrochloride, 150 mg of pemoline, or 8 capsules of placebo daily. Fatigue was measured using 2 self-reported rating scales, the Piper Fatigue Scale (PFS) and the Visual Analogue Scale for Fatigue (VAS-F). We also used the timed isometric unilateral straight leg-raising task, a measure of muscular endurance. Quality-of-life and psychological well-being measures included the Beck Depression Inventory, the Brief Symptom Inventory, and the 36-Item Short-Form Medical Outcomes Study Health Status Survey. Side effects were monitored using the Systematic Assessment for Treatment Emergent Events and the Extra-pyramidal Symptom Rating Scale. All measures were rated weekly. RESULTS: One hundred nine subjects completed the 6-week trial; 15 patients (41%) receiving methylphenidate and 12 patients (36%) receiving pemoline demonstrated clinically significant improvement compared with 6 patients (15%) receiving placebo. Patients receiving methylphenidate or pemoline demonstrated significantly more improvement in fatigue on several self-reported rating scales (PFS total score, P=.04; affective subscale, P=.008; sensory subscale, P=.04; and VAS-F energy subscale, P=.02). Analysis of the regression slopes by means of hierarchical linear modeling demonstrated a significantly greater rate of improvement in PFS total scores among patients receiving psychostimulants compared with the placebo group (P=.02). There were no significant differences in the efficacy between methlyphenidate and pemoline on any outcome measure studied. Improvement in fatigue was also significantly correlated with improvement in measures of depression, psychological distress, and overall quality of life. Severe side effects were relatively uncommon among this sample, and only hyperactivity or jitteriness occurred significantly more often among subjects receiving active medication. CONCLUSIONS: Many patients with HIV- and acquired immunodeficiency syndrome-unrelated fatigue respond favorably to treatment with methylphenidate or pemoline. Both psychostimulants appear to be equally effective and significantly superior to placebo in decreasing fatigue severity with minimal side effects. Moreover, improvement of fatigue was significantly associated with improved quality of life and decreased levels of depression and psychological distress.

Ambulatory Care↗
PubMed2001

Variations in complication rates and opportunities for improvement in quality of care for patients having abdominal aortic surgery.

BACKGROUND: The purpose was to assess the current variation in complication rates and evaluate the association between specific types of complications and in-hospital mortality and total hospital charges for patients having abdominal aortic surgery. PATIENTS/METHODS: We studied 2987 patients for abdominal aortic surgery in Maryland from 1994 to 1996 and used discharge diagnoses and procedure codes to identify diagnoses that most likely represent major surgery complications. We evaluated how in-hospital mortality and total hospital charges related to specific complications, adjusting for patient demographics, severity of illness, comorbidity, and hospital and surgeon volumes. Discharge data was obtained from the hospital marketing departments. RESULTS: Complication rates varied widely among hospitals. Complications independently associated with increased risk of in-hospital death include cardiac arrest with an odds ratio (OR) of 90 and a 95% confidence interval (CI) of 32-251, septicemia (OR 6.1, CI 3.3-11.3), acute myocardial infarction (OR 5.7, CI 2.3-14.3), acute renal failure (OR 5.0, CI 2.3-11.0), surgical complications after a procedure (OR 3.1, CI 2.0-4.9), and reoperation for bleeding (OR 2.2, CI 1.1-4.8). The population-attributable risk for in-hospital mortality was 47% for cardiac arrest and 27% for acute renal failure. CONCLUSIONS: In abdominal aortic surgery on patients in Maryland, the rates of some complications vary widely and are independently associated with increased in-hospital mortality and hospital charges (charges differ from costs). Efforts to reduce these complications should help to decrease both levels.

Aortic Aneurysm, Abdominal↗
PubMed2001

The use of highly active antiretroviral therapy (HAART) in patients with advanced HIV infection: impact on medical, palliative care, and quality of life outcomes.

The effect of highly active antiretroviral therapy (HAART) in the treatment of HIV infection is usually measured by survival, CD4 lymphocyte counts, HIV-1 RNA viral load testing, and the occurrence of opportunistic infections. This pilot study sought to measure the impact of HAART treatments on a wide range of clinical outcomes and psychological variables in a sample of patients with advanced HIV infection. Seventy patients with advanced AIDS who were protease inhibitor naïve were started on HAART regimens. Patients were admitted to an AIDS inpatient unit of a long-term care facility that provides treatment and palliative care. All patients were diagnosed with AIDS, had CD4 cell counts below 300/cc(3), and had a projected survival of greater than one month. Patients were started on triple-drug HAART regimens with daily medical supervision and observation. In addition to standard clinical and laboratory markers, a series of observer-rated and self-report instruments were used to measure various physical and psychological factors (e.g., pain and symptom distress, psychological well-being, depression). Data were collected at baseline and after 1 and 3 months of HAART therapy. As expected, the CD4 count increased and viral load levels decreased significantly over the 3-month study period. In addition, patients improved significantly in body weight, and serum albumin and ferritin levels. The only psychosocial measure that improved significantly with treatment was depression. Ratings of pain intensity, physical and psychological symptom distress, and overall quality of life did not change. Of the 70 patients studied, 84.3% were still alive after the 3-month study period. Of these, 6 (8.6%) were discharged to community. However, 17 surviving patients (24.3%) had HAART regimens discontinued due to drug intolerance and 11 patients (15.7%) expired during the study period. While these data are preliminary, HAART regimens appear to have positive effects on CD4 count, HIV viral load, and several other measures of physical well-being in patients with advanced AIDS. Despite these improvements, the benefits of treatment on pain and symptom distress, and psychological well-being were less clear. In addition, treatment failure (mortality and intolerance) were not uncommon in this sample (40%). Further research is clearly necessary to better understand the benefits of HAART therapy in patients with advanced HIV infection.

Adult↗
PubMed2001

The changeable nature of patients' fears regarding chemotherapy: implications for palliative care.

The side effects of chemotherapy are feared by cancer patients as they begin their treatment. In this study, we investigated patients' anticipatory fears about chemotherapy. We then re-assessed these fears three to six months after the initial interview for patients who received chemotherapy during that time. We also examined symptom distress at these intervals. Hair loss, vomiting, infection, nausea, and weight loss were ranked as the most feared side effects of cancer treatment for the group as they began treatment. Patients beginning chemotherapy endorsed frequent or intense levels of fatigue, worrying about the future, pain, and sleep problems. No differences were found in the reporting of symptoms based on gender, age, or educational level. While changes in symptom distress over the study period were unremarkable, changes in fears about chemotherapy were of interest. The most feared symptoms were re-ordered following the treatment experience. The endorsement of nausea and vomiting, alopecia, and loss of appetite decreased significantly. Thirty-five percent fewer chemotherapy patients reported vomiting as one of their most feared side effects; 45% fewer patients who received anti-emetics reported vomiting as one of their most feared side effects. Effective treatments, such as those that have been developed to treat acute chemotherapy-related emesis, can relieve the fears of patients on treatment. We conclude that patients' fears about treatment are fluid and malleable. Patients' fears of suffering related to chemotherapy treatment change in response to the provision of adequate management. We discuss the implications of these findings for palliative care education.

Aged↗
PubMed2001

The eICU: it's not just telemedicine.

Intensive care units (ICUs) are major sites for medical errors and adverse events. Suboptimal outcomes reflect a widespread failure to implement care delivery systems that successfully address the complexity of modern ICUs. Whereas other industries have used information technologies to fundamentally improve operating efficiency and enhance safety, medicine has been slow to implement such strategies. Most ICUs do not even track performance; fewer still have the capability to examine clinical data and use this information to guide quality improvement initiatives. This article describes a technology-enabled care model (electronic ICU, or eICU) that represents a new paradigm for delivery of critical care services. A major component of the model is the use of telemedicine to leverage clinical expertise and facilitate a round-the-clock proactive care by intensivist-led teams of ICU caregivers. Novel data presentation formats, computerized decision support, and smart alarms are used to enhance efficiency, increase effectiveness, and standardize clinical and operating processes. In addition, the technology infrastructure facilitates performance improvement by providing an automated means to measure outcomes, track performance, and monitor resource utilization. The program is designed to support the multidisciplinary intensivist-led team model and incorporates comprehensive ICU re-engineering efforts to change practice behavior. Although this model can transform ICUs into centers of excellence, success will hinge on hospitals accepting the underlying value proposition and physicians being willing to change established practices.

Hospitalists↗
PubMed2000

Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer.

CONTEXT: Understanding why some terminally ill patients desire a hastened death has become an important issue in palliative care and the debate regarding legalization of assisted suicide. OBJECTIVES: To assess the prevalence of desire for hastened death among terminally ill cancer patients and to identify factors corresponding to desire for hastened death. Design Prospective survey conducted in a 200-bed palliative care hospital in New York, NY. PATIENTS: Ninety-two terminally ill cancer patients (60% female; 70% white; mean age, 65.9 years) admitted between June 1998 and January 1999 for end-of-life care who passed a cognitive screening test and provided sufficient data to permit analysis. MAIN OUTCOME MEASURE: Scores on the Schedule of Attitudes Toward Hastened Death (SAHD), a self-report measure assessing desire for hastened death among individuals with life-threatening medical illness. RESULTS: Sixteen patients (17%) were classified as having a high desire for hastened death based on the SAHD and 15 (16%) of 89 patients met criteria for a current major depressive episode. Desire for hastened death was significantly associated with a clinical diagnosis of depression (P=.001) as well as with measures of depressive symptom severity (P<.001) and hopelessness (P<.001). In multivariate analyses, depression (P=.003) and hopelessness (P<.001) provided independent and unique contributions to the prediction of desire for hastened death, while social support (P=.05) and physical functioning (P=.02) added significant but smaller contributions. CONCLUSIONS: Desire for hastened death among terminally ill cancer patients is not uncommon. Depression and hopelessness are the strongest predictors of desire for hastened death in this population and provide independent and unique contributions. Interventions addressing depression, hopelessness, and social support appear to be important aspects of adequate palliative care, particularly as it relates to desire for hastened death.

Aged↗
PubMed2000

The schedule of attitudes toward hastened death: Measuring desire for death in terminally ill cancer patients.

BACKGROUND: The authors examined the reliability and validity of the Schedule of Attitudes toward Hastened Death (SAHD), a self-report measure of desire for death previously validated in a population of individuals with the acquired immunodeficiency syndrome (AIDS), among terminally ill patients with cancer. METHODS: The authors interviewed 92 terminally ill cancer patients, all with a life expectancy of < 6 months, after admission to a palliative care hospital. Patients were administered the SAHD, a clinician-rated measure of desire for death (the Desire for Death Rating Scale [DDRS]), and several measures of physical and psychosocial well-being. RESULTS: The average number of SAHD items endorsed was 4. 76 (standard deviation, 4.3); 15 patients (16.3%) endorsed > or = 10 items, indicating a high desire for death. Internal consistency was strong (coefficient alpha = 0.88, median item-total correlation = 0. 49), as were indices of convergent validity. Total SAHD scores were correlated significantly (correlation coefficient [r] = 0.67) with the DDRS, and somewhat less so with measures of depression (r = 0. 49) and hopelessness (r = 0.55). Lower, but substantial, correlations were observed between the SAHD and measures of spiritual well-being (r = -0.42), quality of life (r = -0.36), physical symptoms (r = 0.38), and symptom distress (r = 0.38). No significant correlation was observed between SAHD scores and social support (r = -0.06) or pain intensity (r = 0.16); however, pain-related functional interference and overall physical functioning were correlated significantly with SAHD scores (r = 0.31 and r = -0.23, respectively). CONCLUSIONS: The SAHD appears to be a reliable and valid measure of desire for death among terminally ill cancer patients. Coupled with previous research in patients with AIDS, these results support the utility of the SAHD for research addressing interest in hastened death in patients with a life-threatening medical illness.

Acquired Immunodeficiency Syndrome↗
PubMed2000

A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients.

The clinical assessment of drug-taking behaviors in medically ill patients with pain is complex and may be hindered by the lack of empirically derived information about such behaviors in particularly medically ill populations. To investigate issues surrounding the assessment of these behaviors, we piloted a questionnaire based on the observations of specialists in pain management and substance abuse. This preliminary questionnaire evaluated medication use, present and past drug abuse, patients' beliefs about the risk of addiction in the context of pain treatment, and aberrant drug-taking attitudes and behaviors. This instrument was piloted in a mixed group of cancer patients (N = 52) and a group of women with HIV/AIDS (N = 111). Reports of past drug use and abuse were more frequent than present reports in both groups. Current aberrant drug-related behaviors were seldom reported, but attitude items revealed that patients would consider engaging in aberrant behaviors, or would possibly excuse them in others, if pain or symptom management were inadequate. Aberrant behaviors and attitudes were endorsed more frequently by the women with HIV/AIDS than by the cancer patients. Patients greatly overestimated the risk of addiction in pain treatment. We discuss the significance of these findings and the need for cautious interpretation given the limitations of the methodology. This early experience suggests that both cancer and HIV/AIDS patients appear to respond in a forthcoming fashion to drug-taking behavior questions and describe attitudes and behaviors that may be highly relevant to the diagnosis and understanding management of substance use among patients with medical illness.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Assisted suicide, depression, and the right to die.

The debate surrounding the legalization of assisted suicide continues despite a limited body of empirical research. Relatively few studies have addressed interest in assisted suicide or the desire for hastened death (rather than approval of legislation) among medically ill patients, and this literature is plagued by methodological limitations. In general, this research has demonstrated a significant association between depression and desire for death; however, the magnitude of this association is unclear. Nevertheless, psychological and social factors have typically appeared more influential in determining patients' desire for death than physical symptoms such as pain. The impact of these findings on future legislative efforts to legalize assisted suicide is discussed.

Attitude of Health Personnel↗
PubMed2000

Survival and functional outcome after prolonged intensive care unit stay.

OBJECTIVE: To examine the functional outcome and costs of a prolonged illness requiring a stay in the surgical intensive care unit (SICU) of 7 of more days. SUMMARY BACKGROUND DATA: The long-term benefits and costs after a prolonged SICU stay have not been well studied. METHODS: All patients with an SICU length of stay of 7 or more days from July 1, 1996, to June 30, 1997, were enrolled. One hundred twenty-eight patients met the entry criteria, and mortality status was known in 127. Functional outcome was determined at baseline and at 1, 3, 6, and 12 months using the Sickness Impact Profile score, which ranges from 0 to 100, with a score of 30 being severely disabled. Hospital costs for the index admission and for all readmissions to Johns Hopkins Hospital were obtained. All data are reported as median values. RESULTS: For the index admission, age was 57 and APACHE II score was 23. The initial length of stay in the ICU was 11 days; the hospital length of stay was 31 days. The Sickness Impact Profile score was 20.2 at baseline, 42.9 at 1 month, 36.2 at 3 months, and 20.3 at 6 months, and was lower than baseline at 1 year. The actual 1-year survival rate was 45.3%. The index admission median cost was $85,806, with 65 total subsequent admissions to this facility. The cost for a single 1-year survivor was $282,618 (1996). CONCLUSIONS: An acute surgical illness that results in a prolonged SICU stay has a substantial in-hospital death rate and is costly, but the functional outcome from both a physical and physiologic standpoint is compatible with a good quality of life.

APACHE↗
PubMed2000

Methodological issues in assisted suicide and euthanasia research.

A growing body of research has addressed various aspects of the assisted suicide debate. However, this literature is plagued by methodological shortcomings and limitations. This review describes the primary methodological issues and difficulties found in the existing suicide and euthanasia literature. The methodological issues discussed fall into several broad categories, including difficulties in operationalizing and measuring dependent variables, sampling constraints and biases, confounding influences on independent variables, and statistical considerations. These issues are discussed along with implications for the interpretation of the results reported. Where possible, potential solutions are offered, along with recommendations for future research.

Attitude to Death↗
PubMed1999

Symptom prevalence, characteristics, and distress in AIDS outpatients.

Symptom distress is an important but poorly characterized aspect of quality of life in AIDS patients. To assess and characterize the symptoms and symptom distress associated with AIDS, 504 ambulatory patients with AIDS were evaluated between December, 1992 and December, 1995. The assessment included measures of symptom distress, physical and psychosocial functioning, and demographic and disease-related factors. Patients described symptoms during the previous week using the Memorial Symptom Assessment Scale Short Form (MSAS-SF), a validated measure of physical and psychological symptom distress. The mean age was 38.6 years (range 18-69); 56% were male. African-Americans comprised 40% of the sample, Caucasians 35%, and Hispanics 23%. Ninety-three percent had CD4+ T-cell counts below 500, and 66% had counts below 200; 69% were classified in CDC category C (history of AIDS-defining conditions). Fifty-two percent reported intravenous drug use. Karnofsky performance status was > or = 70 in 80% of the patients. No patients were taking protease inhibitors. The mean (+/- SD) number of symptoms was 16.7 +/- 7.3. The most prevalent symptoms were worrying (86%), fatigue (85%), sadness (82%), and pain (76%). Patients with Karnofsky performance scores < 70 had more symptoms and higher symptom distress scores than patients with scores > or = 70 (21.2 +/- 6.5 vs. 15.6 +/- 7.1 symptoms/patient; 2.3 +/- 0.8 vs. 1.6 +/- 0.8 on the Global Distress Index [GDI] of the MSAS-SF; P < 0.0001 for both). Patients who reported intravenous drug use as an HIV transmission factor reported more symptoms and higher overall and physical symptom distress than those who reported homosexual or heterosexual contact as their transmission factor (17.8 +/- 7.5 vs. 15.4 +/- 6.9 symptoms/patient, P = 0.0002; 1.9 +/- 0.9 vs. 1.6 +/- 0.8 on the MSAS-GDI, P = 0.002). Both the number of symptoms and symptom distress were highly associated with psychological distress and poorer quality of life; for example, r = -0.69 (P < 0.0001) between GDI scores and scores on a validated measure of quality of life. Neither gender nor CD4+ T-cell count was associated with symptom number or distress. Responses from this self-referred sample of AIDS outpatients indicate that AIDS patients experience many distressing physical and psychological symptoms and a high level of distress. Both the number of symptoms and the distress associated with them are associated with a variety of disease-related factors and disturbances in other aspects of quality of life. Symptom assessment provides information that may be valuable in evaluating AIDS treatment regimens and defining strategies to improve quality of life.

Acquired Immunodeficiency Syndrome↗
PubMed1999

Clinicians' perceptions of barriers to pain management in AIDS.

A growing body of literature has demonstrated the widespread undertreatment of pain in patients with AIDS. While clinician-related barriers to cancer pain management have been studied, to date there has been no systematic attempt to survey clinician-related barriers to the management of pain in patients with AIDS. We surveyed AIDS health care providers' attitudes towards pain management, as well as their perception of the barriers to adequate pain management in patients with HIV disease. Subjects were 492 AIDS care providers attending continuing education symposia on the clinical management of pain in patients with AIDS in 5 major U.S. cities (New York, Philadelphia, San Francisco, Los Angeles, and Miami). Results indicated that the most frequently endorsed barriers to pain management were those regarding lack of knowledge about pain management or access to pain management experts, and concerns regarding potential substance abuse or addiction. Experience in the management of pain in patients with AIDS was inversely correlated with endorsement of barriers related to pain management expertise and concern regarding potential substance abuse. More experienced clinicians were significantly less likely to cite these factors as barriers to pain management. More knowledgeable respondents were significantly more likely to identify barriers to pain management and individuals with more conservative attitudes towards pain management were significantly more likely to cite substance abuse issues or medical concerns as barriers to pain management.

Acquired Immunodeficiency Syndrome↗
PubMed1999

The association between preoperative patient characteristics and both clinical and economic outcomes after abdominal aortic surgery.

OBJECTIVE: To evaluate the association between patient characteristics and both clinical and economic outcomes in patients having abdominal aortic surgery in Maryland between 1994 and 1996. DESIGN: Retrospective study using an administrative data set. SETTING: All Maryland hospitals that performed abdominal aortic surgery from 1994 through 1996 (n = 46). PARTICIPANTS: All patients who had abdominal aortic surgery in Maryland from 1994 through 1996 (n = 2,987). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors obtained discharge abstracts from the Maryland Health Services Cost Review Commission for patients with a primary procedure code for abdominal aortic surgery. Primary outcome variables were in-hospital mortality, hospital length of stay, and intensive care unit (ICU) days. The authors evaluated the following groups of independent variables: demographic characteristics, severity of illness, comorbid disease, and preoperative admission days. In multivariate analysis, independent predictors of in-hospital mortality were age 61 to 70 years (odds ratio [OR], 3.1; confidence interval [CI], 1.4 to 6.9), age 71 to 84 years (OR, 7.2; CI, 3.7 to 14.1), age 85 years or older (OR, 9.3; CI, 3.9 to 21.9), ruptured aneurysm (OR, 5.3; CI, 3.5 to 8.2), urgent operation (OR, 2.3; CI, 1.1 to 5.2), emergent operation (OR, 3.0; CI, 1.9 to 4.7), mild liver disease (OR, 4.6; CI, 2.0 to 10.9), and chronic renal disease (OR, 6.9; CI, 3.9 to 12.1). Hospital admission 1 to 2 days preoperatively was not associated with a difference in in-hospital mortality but was associated with a 31% increase in hospital days (CI, 23% to 40%) and a 38% increase in ICU days (CI, 19% to 60%). CONCLUSION: In patients having aortic surgery, several patient characteristics such as mild liver disease and chronic renal failure, were associated with increased in-hospital mortality and length of stay. The practice of admitting patients to the hospital 1 to 2 days before surgery should be reevaluated because this was not associated with reduced in-hospital mortality but was associated with increased hospital and ICU stay.

Aged↗
PubMed1999

Measuring desire for death among patients with HIV/AIDS: the schedule of attitudes toward hastened death.

OBJECTIVE: As physician-assisted suicide is debated, a need for standardized measurement of desire for death among medically ill individuals has emerged. The authors present preliminary validation data for a new self-report instrument, the Schedule of Attitudes Toward Hastened Death. METHOD: The participants were 195 patients with HIV/AIDS from two sites: 148 ambulatory patients and 47 patients who had been recently admitted to a facility for end-of-life care. The ambulatory participants completed the 20-item Schedule of Attitudes Toward Hastened Death and several other instruments, including the Beck Depression Inventory and Brief Symptom Inventory. The terminally ill patients also completed the Schedule of Attitudes Toward Hastened Death, along with other measures, and were assessed by clinicians with the Hamilton Depression Rating Scale and the Desire for Death Rating Scale, a global clinician rating of the patient's desire for death. RESULTS: The Schedule of Attitudes Toward Hastened Death demonstrated high reliability. The total score significantly correlated with the clinician rating on the Desire for Death Rating Scale and with ratings of depression and psychological distress. In addition, the Schedule of Attitudes Toward Hastened Death score significantly correlated with pain intensity and physical symptom distress. Factor analysis supported a single factor structure for the instrument. CONCLUSIONS: These results indicate that the Schedule of Attitudes Toward Hastened Death is a reliable, valid measure of desire for death among patients with HIV/AIDS. Further research with this measure may help address many of the unanswered questions emerging from the ongoing debates regarding legalization of assisted suicide.

Acquired Immunodeficiency Syndrome↗