Ursula K Braun

Baylor College of Medicine | BCM · Veterans Affairs Medical Center

Buprenorphine is a semi-synthetic long-acting partial µ-opioid receptor (MOR) agonist that can be used for chronic pain as a sublingual tablet, transdermal patch (Butrans®), or a buccal film (Belbuca®). Buprenorphine’s unique high receptor binding affinity and slow dissociation at the MOR allow for effective analgesia while offering less adverse ef...

Palliative care plays a crucial role in enhancing the quality of life for individuals facing serious illnesses, aiming to alleviate suffering and provide holistic support. With the advent of telehealth, there is a growing interest in leveraging technology to extend the reach and effectiveness of palliative care services. This article provides a com...

Most patients with pancreatic cancer at some point present with symptoms related to exocrine pancreatic insufficiency (EPI). These include diarrhea, abdominal bloating, indigestion, steatorrhea, weight loss, and anorexia. Even though up to 80% of pancreatic cancer patients eventually present with symptoms related to exocrine pancreatic insufficienc...

Background: Opioid-induced constipation (OIC) is a pervasive and distressing side effect of chronic opioid therapy in patients with cancer pain, significantly impacting their quality of life. Peripherally acting μ-opioid receptor antagonists (PAMORAS) were developed for treatment-resistant OIC but most studies were conducted with non-cancer patient...

Background: Cancer anorexia-cachexia syndrome (CAS) is a multifactorial condition that is highly prevalent in advanced cancer patients and associated with significant reduction in functional performance, reduction in quality of life, and increased mortality. Currently, no medications are approved for this indication. Recently, the American Society...

Most patients with pancreatic cancer at some point present with symptoms related to exocrine pancreatic insufficiency (EPI). These include diarrhea, abdominal bloating, indigestion, steatorrhea, weight loss, and anorexia. Even though up to 80% of pancreatic cancer patients eventually present with symptoms related to exocrine pancreatic insufficienc...

Outcomes 1. Demonstrate knowledge of pharmacokinetics of pancreatic enzyme replacement therapy 2. Recognize best practice in educating patients regarding correct use of pancreatic enzyme replacement therapy 3. Identify common patient misconceptions as a means of improving education Importance Pancreatic cancer is a leading cause of cancer-related...

Palliative care is a specialized health care service for individuals with serious illness at any stage and can be provided in any setting. Current national consensus developed by palliative care experts recommends the inclusion of pharmacists in an interdisciplinary team (IDT) to provide quality palliative care. However, national registry data repo...

This chapter discusses appropriate preventive testing in older adults, which requires weighing the benefits and burdens of testing. Decisions regarding which tests to offer need to be stratified by patients’ estimated life expectancy, which is not just determined by chronological age alone but more so by physical and cognitive functioning as well a...

COVID‐19 continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguide...

COVID‐19 continues to impact older adults disproportionately with respect to serious consequences ranging from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these issues have focused attention on how these resources are ulti...

Acute‐on‐chronic liver failure (ACLF) occurs in about 25% of hospitalized patients with decompensated cirrhosis (DC) (1) and is associated with high, short‐term mortality (1, 2). The European Association for the Study of the Liver (EASL) – Chronic Liver Failure (CLIF) EASL‐CLIF Acute‐on‐Chronic Liver Failure in Cirrhosis (CANONIC) study showed that...

Case Presentation on Pazopanib Wound Healing Side Effects

Background: Physician-assisted suicide (PAS) is a controversial practice, currently legal in nine states and the District of Columbia. No prior study explores the views of the American Geriatrics Society (AGS) membership on PAS. Design: We surveyed 1488 randomly selected AGS members via email. Participants: A total of 369 AGS members completed...

Reflexive testing, standardization of the mutation test ordering procedure and results reporting, and elimination of the preauthorization requirements could facilitate the utilization of targeted therapies.

Current national guidelines recommend genomic testing on all stage 4 non-small cell lung cancers (NSCLC) of adenocarcinoma histology. Mutations are most often found among young, Asian, females without a history of smoking. As these characteristics are uncommon in the Veterans Health Administration (VHA) patient population, we sought to understand o...

Patients with advanced lung diseases commonly experience burdensome symptoms like dyspnea, cough, anorexia, fatigue, and comorbid psychiatric symptoms like anxiety and depression that need to be treated aggressively. Progression of these symptoms is associated with diminishing quality of life and impairments in activities of daily living. The patho...

Opioid analgesia is a mainstay of the treatment of cancer pain. Treatment of pain in patients with cancer with an ongoing substance abuse disorder can be difficult. We report the ethical challenges of treating a patient with cancer with a concomitant substance abuse disorder in an outpatient palliative care setting. We present an analysis of ethica...

https://deepblue.lib.umich.edu/bitstream/2027.42/137692/1/jgs14842_am.pdf

Surrogate decision-making is a difficult task requiring application of the substituted judgment standard, or in the absence of knowledge of patients’ wishes or values, the best interest standard in deciding for others. Because patients empower their surrogates to various degrees depending on their decision-making style, surrogate decision-making ca...

In this position statement, we define unbefriended older adults as patients who: (1) lack decisional capacity to provide informed consent to the medical treatment at hand; (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so; and (3) lack family, friends or a legally authorized surrogate...

Objective: We examined the utility of a brief values inventory as a discussion aid to elicit patients' values and goals for end-of-life (EoL) care during audiotaped outpatient physician-patient encounters. Method: Participants were seriously ill male outpatients (n = 120) at a large urban Veterans Affairs medical center. We conducted a pilot ran...

Background: Pilot data revealed gaps in knowledge and utilization of genomic-based targeted therapy among oncologists. We report these findings, and offer a protocol for a qualitative research project aimed to elicit oncologists’ perceptions regarding use of genomic-based targeted therapy for Veterans with lung cancer at the VHA. Using the Cabana e...

To describe self-reported decision-making styles and associated pathways through end-of-life (EOL) decision-making for African-American, Caucasian, and Hispanic seriously ill male Veterans, and to examine potential relationships of race/ethnicity on these styles. Forty-four African American, White, and Hispanic male Veterans with advanced serious i...

Background: Medical education leaders have called for a curriculum that proactively teaches knowledge, skills, and attitudes required for professional practice and have identified professionalism as a competency domain for medical students. Exposure to palliative care (PC), an often deeply moving clinical experience, is an optimal trigger for rich...

We examined initiation of cholinesterase inhibitors (ChEIs) to determine whether ChEIs were being newly prescribed without sufficient evaluation for dementia and/or delirium and to explore whether there are differences in outcomes, such as mortality, hospital readmission rates, and duration of hospitalization, between patients newly started on ChEI...

Patients near the end of life often undergo invasive procedures, such as biliary stenting for obstructive jaundice, with the intent of relieving symptoms. We describe a case in which the medical team and a patient and family are considering a second palliative biliary stent despite the patient's limited life expectancy. We review available evidence...

INTRODUCTION The aim of this update is to summarize scientifically rigorous articles published in 2010 that serve to advance the field of palliative medicine and have an impact on clinical practice. METHOD We conducted two separate literature searches for articles published between January 1, 2010 and December 31, 2010. We reviewed title pages from...

Many physicians will at some point care for patients who will receive life-sustaining treatment by default, because there are no instructions available from the patient as to what kind of care is preferred, and because surrogates are likely to ask for everything to be done when they do not know a patient's preferences. We use the methods of ethics...

Previous studies have shown racial/ethnic differences in preferences for end-of-life (EOL) care. We aimed to describe values and beliefs guiding physicians' EOL decision-making and explore the relationship between physicians' race/ethnicity and their decision-making. Seven focus groups (3 Caucasian, 2 African American, 2 Hispanic) with internists a...

Chronic open-angle glaucoma is a leading cause of blindness and visual impairment in older adults. Optic nerve damage and the associated peripheral and subsequent central vision loss are irreversible, but early diagnosis and treatment will give patients the best chance to maintain functional vision and quality of life. Primary care physicians can a...

Hypertension and dementia are common illnesses in geriatric patients, resulting in significant morbidity and mortality. The objective of this study was to investigate racial and ethnic differences in blood pressure control and medication utilization in veterans aged 65 years or older with a diagnosis of both hypertension and dementia. We conducted...

Chronic open-angle glaucoma is a leading cause of blindness and visual impairment in older adults. Optic nerve damage and the associated peripheral and subsequent central vision loss are irreversible, but early diagnosis and treatment will give patients the best chance to maintain functional vision and quality of life. Primary care physicians can a...

We propose a reconceptualization of surrogate decision making when patients lack an advance directive stating their preferences about life-sustaining treatment. This reconceptualization replaces the current 2-standard model of substituted judgment (based on the patient's prior preferences and values) and best interests (an assessment of how best to...

While the most serious of depressive illnesses in the elderly is major depressive disorder, patients' quality of life can be significantly impacted by dysthmic disorder, sub-threshold depression (minor depression), or a depressive disorder due to a general medical condition, all of which have been shown to be more prevalent than major depression in...

Hypertension and comorbid dementia are common illnesses affecting older adults disproportionally. Medication adherence is vital in achieving therapeutic outcomes. Use of antihypertensive and dementia medications may vary by race/ethnicity and has not been well explored. To evaluate the utilization of antihypertensive and dementia drugs and adherenc...

No national data exist regarding racial/ethnic differences in the use of interventions for patients at the end of life. To test whether among 3 cohorts of hospitalized seriously ill veterans with cancer, noncancer or dementia the use of common life-sustaining treatments differed significantly by race/ethnicity. Retrospective cohort study during fis...

The dying process is characterized by feelings of sadness and fear. It is normal for patients at the end of life to worry and grieve the loss of their health. However, when these feelings become excessive and interfere with all aspects of the patient's life, they are abnormal responses to the stress of terminal illness. Screening for depression in...

The dying process is characterized by feelings of sadness and fear. It is normal for patients at the end of life to worry and grieve the loss of their health. However, when these feelings become excessive and interfere with all aspects of the patient's life, they are abnormal responses to the stress of terminal illness. Screening for depression in...

End-of-life decisions are frequently made by patients' surrogates. Race and ethnicity may affect such decision making. Few studies have described how different racial/ethnic groups experience end-of-life surrogate decision making. To describe the self-reported experience the self-reported experience of African-American, Caucasian, and Hispanic surr...

Older adults frequently have conditions requiring oral anticoagulation. Although clearly benefiting from oral anticoagulation, they are at increased risk for bleeding complications. Regular monitoring to optimize anticoagulation and to reduce the chance of major bleeding complications is required. The impact of oral anticoagulation monitoring by ph...

Despite what they might say, people at the end of life rarely want everything or nothing. Ursula Braun and colleagues explain how to understand and meet their needs

Orthostatic hypotension (OH) is defined as a reduction of systolic blood pressure of at least 20 mmHg, or diastolic blood pressure of at least 10 mmHg from a sitting to a standing position. It is a common physical finding among older adults and associated with significant morbidity and mortality. Use of medications that have the potential to induce...

Percutaneous endoscopic gastrostomy (PEG) tube placement is a widely used method for long-term enteral feeding of demented patients unable to take sufficient food by mouth. National time trends in PEG tube use over the last decade have not been previously reported. The objective of this study was to determine whether use of PEG tubes for patients w...

In an aging population, the number of veterans diagnosed with dementia is likely to increase. Knowledge of existing dementia prevalence will be beneficial in planning for future patient care needs. Our objectives were to assess the prevalence of the dementia diagnosis among those treated at Veterans Affairs (VA) medical centers and determine how it...

We hypothesized that compared to an educational intervention, a single 2 h session of cognitive behavioural therapy (CBT), with 6-week follow-up, would reduce anxiety and depression, improve physical and mental functioning, and lead to a better quality of life and greater satisfaction with treatment in older patients with chronic obstructive pulmon...

Anxiety and depression are extremely common in the elderly with medical problems. They can manifest not only as symptoms of a primary psychiatric illness, but also as physiologic sequelae of medical illnesses and medical treatments. Recognition and treatment of depression and anxiety in the medically ill is especially difficult. If these states go...

Malnutrition is a vexing problem in elderly patients, many of whom suffer from dementia. This article reviews the risk factors for malnutrition in noninstitutionalized, institutionalized, and dementia patients. The authors discuss the poor outcomes of percutaneous endoscopic gastrostomy (PEG) tube feeding for patients with dementia. They recommend...

Schizophrenic patients and normal controls performed a lexical decision task involving the recognition of words which were preceded (primed) by either associated, indirectly associated, or non-associated words. In contrast to normal control subjects who showed no indirect semantic priming effect at an inter-stimulus interval (ISI) of 0 ms, a trend...

The characteristics of the spread of semantic activation in associative networks in normal subjects, thought-disordered (TD) and nonthought-disordered (NTD) schizophrenic patients with respect to time and semantic distance are examined. Direct and indirect semantic priming effects at two stimulus onset asynchronies (SOA) in a lexical decision task...