Tetrachloroethylene (PCE, Perc) Levels in Residential Dry Cleaner Buildings in Diverse Communities in New York City

Fugitive tetrachloroethylene (PCE, perc) emissions from dry cleaners operating in apartment buildings can contaminate residential indoor air. In 1997, New York State and New York City adopted regulations to reduce and contain perc emissions from dry cleaners located in residential and other buildings. As part of a New York State Department of Health (NYSDOH) study, indoor air perc levels were determined in 65 apartments located in 24 buildings in New York City where dry cleaners used perc on site. Sampling occurred during 2001–2003, and sampled buildings were dispersed across minority and nonminority as well as low-income and higher income neighborhoods. For the entire study area, the mean apartment perc level was 34 μg/m(3), 10-fold lower than mean apartment levels of 340–360 μg/m(3) documented before 1997. The maximum detected perc level was 5,000 μg/m(3), 5-fold lower than the maximum of 25,000 μg/m(3) documented before 1997. Despite these accomplishments, perc levels in 17 sampled apartments still exceeded the NYSDOH residential air guideline of 100 μg/m(3), and perc levels in 4 sampled apartments exceeded 1,000 μg/m(3). Moreover, mean indoor air perc levels in minority neighborhoods (75 μg/m(3)) were four times higher than in nonminority households (19 μg/m(3)) and were > 10 times higher in low-income neighborhoods (256 μg/m(3)) than in higher income neighborhoods (23 μg/m(3)). Logistic regression suitable for clustered data (apartments within buildings) indicated that perc levels on floors 1–4 were significantly more likely to exceed 100 μg/m(3) in buildings located in minority neighborhoods (odds ratio = 6.7; 95% confidence interval, 1.5–30.5) than in nonminority neighborhoods. Factors that may be contributing to the elevated perc levels detected, especially in minority and low-income neighborhoods, are being explored

Problematic Events in Critically Ill Patients: The Perspectives of Surrogate Decision-Makers

Background/Aims: Critically ill patients are particularly vulnerable to breakdowns in medical care due to the severity and complexity of their illness. Although many critically ill patients are unable to communicate or participate in their own care, their surrogate decision-makers (SDMs) are likely to have important insights regarding preventable problematic events that may occur in the intensive care unit (ICU). We describe the perspective of SDMs of critically ill patients with such events. Methods: We enrolled SDMs of adult critically ill patients with respiratory failure in any of the 7 ICUs at a single tertiary medical center in central Massachusetts. Participating SDMs were contacted by telephone approximately 4 weeks after the patient’s discharge and screened for those who identify a problematic event. Problematic events are defined as something that “went wrong,” that could have been prevented, and that had a deleterious impact on the patient or SDM. Participants who identify an event that meets the above criteria were invited to undergo an in-depth qualitative interview. Results: Of the 127 SDMs we approached for participation, 91 (72%) agreed to participate, and complete follow-up is available on 70 of the 91 participants (77%). Of those with complete follow-up, 43% (30 of 70) identified at least one eligible problematic event, with many SDMs identifying multiple events. Problematic events included breakdowns in medical care (delay in diagnosis, misdiagnosis, delayed or inadequate treatment, preventable complications, and premature discharge) and major lapses in communication (insufficient information, inadequate access to health care providers, problems with communication regarding end-of-life preferences, and episodes of rude or dismissive treatment by health care providers). These problems had a significant negative impact on patients and their families leading to physical harm, prolonged hospitalization, rehospitalization, severe emotional distress, life disruption, and provision of medical care inconsistent with patients’ wishes. Discussion: SDMs frequently identify preventable problems in the care of critically ill patients with significant adverse consequences for both patients and SDMs. These findings highlight the importance of the perspective of SDMs of critically ill patients in understanding breakdowns in care and may identify targets for preventing such events

Surrogate decision makers\u27 perspectives on preventable breakdowns in care among critically ill patients: A qualitative study

OBJECTIVE: To describe surrogate decision makers\u27 (SDMs) perspectives on preventable breakdowns in care among critically ill patients. METHODS: We screened 70 SDMs of critically ill patients for those who identified a preventable breakdown in care, defined as an event where the SDM believes something went wrong , that could have been prevented, and resulted in harm. In-depth interviews were conducted with SDMs who identified an eligible event. RESULTS: 32 of 70 participants (46%) identified at least one preventable breakdown in care, with a total of 75 discrete events. Types of breakdowns involved medical care (n=52), communication (n=59), and both (n=40). Four additional breakdowns were related to problems with SDM bedside access to the patient. Adverse consequences of breakdowns included physical harm, need for additional medical care, emotional distress, pain, suffering, loss of trust, life disruption, impaired decision making, and financial expense. 28 of 32 SDMs raised their concerns with clinicians, yet only 25% were satisfactorily addressed. CONCLUSION: SDMs of critically ill patients frequently identify preventable breakdowns in care which result in harm. PRACTICE IMPLICATIONS: An in-depth understanding of the types of events SDMs find problematic and the associated harms is an important step towards improving the safety and patient-centeredness of healthcare

Speak Up! Addressing the Paradox Plaguing Patient-Centered Care

Beneath the patient-centered rhetoric that dominates health care lurks a major paradox: The language of patient-centered care is omnipresent, but the reality is falling short. Patients are bombarded with surveys, post-discharge calls, opportunities to share “compliments and concerns,” and requests to “speak up.” In actuality, patients\u27 perceptions of care are often ignored and rarely translate into improvements. Two flaws underlie this paradox

Attitudes Toward a Potential SARS-CoV-2 Vaccine: A Survey of U.S. Adults

BACKGROUND: Coronavirus disease 2019 (COVID-19) has rapidly instigated a global pandemic. Vaccine development is proceeding at an unprecedented pace. Once available, it will be important to maximize vaccine uptake and coverage. OBJECTIVE: To assess intent to be vaccinated against COVID-19 among a representative sample of adults in the United States and identify predictors of and reasons for vaccine hesitancy. DESIGN: Cross-sectional survey, fielded from 16 through 20 April 2020. SETTING: Representative sample of adults residing in the United States. PARTICIPANTS: Approximately 1000 adults drawn from the AmeriSpeak probability-based research panel, covering approximately 97% of the U.S. household population. MEASUREMENTS: Intent to be vaccinated against COVID-19 was measured with the question, When a vaccine for the coronavirus becomes available, will you get vaccinated? Response options were yes, no, and not sure. Participants who responded no or not sure were asked to provide a reason. RESULTS: A total of 991 AmeriSpeak panel members responded. Overall, 57.6% of participants (n = 571) intended to be vaccinated, 31.6% (n = 313) were not sure, and 10.8% (n = 107) did not intend to be vaccinated. Factors independently associated with vaccine hesitancy (a response of no or not sure ) included younger age, Black race, lower educational attainment, and not having received the influenza vaccine in the prior year. Reasons for vaccine hesitancy included vaccine-specific concerns, a need for more information, antivaccine attitudes or beliefs, and a lack of trust. LIMITATIONS: Participants\u27 intent to be vaccinated was explored before a vaccine was available and when the pandemic was affecting a narrower swath of the United States. Questions about specific information or factors that might increase vaccination acceptance were not included. The survey response rate was 16.1%. CONCLUSION: This national survey, conducted during the coronavirus pandemic, revealed that approximately 3 in 10 adults were not sure they would accept vaccination and 1 in 10 did not intend to be vaccinated against COVID-19. Targeted and multipronged efforts will be needed to increase acceptance of a COVID-19 vaccine when one becomes available. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality

Preferences for COVID-19 vaccination information and location: Associations with vaccine hesitancy, race and ethnicity

This study examined the association between preferences for being informed about the COVID-19 vaccine and where to receive it with vaccination intent and race/ethnicity. We conducted an online survey, oversampling Black and Latino panel members. The 1668 participants were 53.2% female, 34.8% White, 33.3% Black, and 31.8% Latino. Participants who were vaccine hesitant (answered “not sure” or “no” to vaccination intent) were more likely to prefer a conversation with their doctor compared to those who answered “yes” (25.0% and 23.4% vs 7.8%, P \u3c .001, respectively). Among participants who responded “not sure”, 61.8% prefer to be vaccinated at a doctor’s office, compared with 35.2% of those who responded “yes” (P \u3c .001). Preferred location differed by race/ethnicity (P \u3c .001) with 67.6% of Black “not sure” participants preferring a doctor’s office compared to 60.2% of Latino and 54.9% of White “not sure” participants. These findings underscore the need to integrate healthcare providers into COVID-19 vaccination programs

Keeping the patient in the center: Common challenges in the practice of shared decision making.

OBJECTIVE: To examine situations where shared decision making (SDM) in practice does not achieve the goal of a patient-centered decision. METHODS: We explore circumstances in which elements necessary to realize SDM - patient readiness to participate and understanding of the decision - are not present. We consider the influence of contextual factors on decision making. RESULTS: Patients\u27 preference and readiness for participation in SDM are influenced by multiple interacting factors including the patient\u27s comprehension of the decision, their emotional state, the strength of their relationship with the clinician, and the nature of the decision. Uncertainty often inherent in information can lead to misconceptions and ill-formed opinions that impair patients\u27 understanding. In combination with cognitive biases, these factors may result in decisions that are incongruent with patients\u27 preferences. The impact of suboptimal understanding on decision making may be augmented by the context. CONCLUSIONS: There are circumstances in which basic elements required for SDM are not present and therefore the clinician may not achieve the goal of a patient-centered decision. PRACTICE IMPLICATIONS: A flexible and tailored approach that draws on the full continuum of decision making models and communication strategies is required to achieve the goal of a patient-centered decision

Perceived stress is associated with a higher symptom burden in cancer survivors

BackgroundAlthough multiple co-occurring symptoms are a significant problem for cancer survivors, to the authors' knowledge little is known regarding the phenotypic characteristics associated with a higher symptom burden. The objectives of the current study were to evaluate the occurrence, severity, and distress associated with 32 symptoms and examine the phenotypic and stress characteristics associated with a higher symptom burden.MethodsA total of 623 cancer survivors completed a demographic questionnaire, as well as measures of functional status, comorbidity, and global (Perceived Stress Scale) and cancer-related (Impact of Event Scale-Revised) stress. The Memorial Symptom Assessment Scale was used to evaluate symptom burden. Multiple linear regression analysis was used to determine the phenotypic characteristics associated with a higher symptom burden.ResultsThe mean number of symptoms was 9.1 (±5.2). The most common, severe, and distressing symptoms were lack of energy, problems with sexual interest/activity, and hair loss, respectively. Poorer functional status, a higher level of comorbidity, and a history of smoking as well as higher Perceived Stress Scale and Impact of Event Scale-Revised scores were associated with a higher symptom burden. The overall model explained approximately 45.6% of the variance in symptom burden.ConclusionsAlthough cancer survivors report a high number of co-occurring symptoms of moderate severity and distress, in the current study, no disease or treatment characteristics were found to be associated with a higher symptom burden. Clinicians need to assess for general and disease-specific stressors and provide referrals for stress management interventions. Future studies need to examine the longitudinal relationships among symptom burden, functional status, and level of comorbidity, as well as the mechanisms that underlie the associations between stress and symptom burden