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Biomedical subjects

E H Kaplan

Publications and source records attributed to E H Kaplan.

At least 19 recordsLinked to original sources
PubMed2001

Public health consequences of screening patients for adherence to highly active antiretroviral therapy.

Improvements in HIV antiretroviral therapy (ART) have been accompanied by increasing recognition of the importance of adherence to treatment regimens for maximizing patient benefits while minimizing the emergence of drug-resistant virus. Whether clinicians should screen patients for adherence and only administer therapy to those believed likely to adhere has not been resolved. We first examine the implications of data drawn from a recent study reporting physicians' ability to predict whether patients will adhere to highly active antiretroviral therapy (HAART) or not. We then extend previously developed mathematical models of ART to include screening for adherence and focus on resulting drug resistance as well as on HIV and AIDS incidence at the population level. We show that although screening for adherence is likely to reduce the level of drug resistance compared with a policy of treating all HIV patients with HAART, rates of new HIV infections and AIDS cases in the population would likely increase unless screening accuracy is extremely (perhaps implausibly) high.

Acquired Immunodeficiency Syndrome↗
PubMed2001

Evaluating plasma holds in the presence of multiple infections.

To protect plasma supplies, donors are screened for infectious diseases. As an added measure of protection, donations are identified and stored for a period of time to allow future discard in the event that an identified donor subsequently tests positive for some screened disease. Previous models for evaluating such plasma holds have only addressed the case of a single infectious disease. This paper extends the analysis to the case of multiple infections. Given knowledge of the marginal incidence rates for those infections checked, upper and lower bounds for important quantities such as the probability of interdicting an infectious but undetected donation, the expected number of infections interdicted per donation, and the net economic benefits of the holding policy are developed. Several examples are developed, illustrating how the models can be used to evaluate the consequences of a plasma hold.

Blood Banks↗
PubMed2000

Repeat screening for HIV: when to test and why.

This paper presents models for repeat HIV screening under conditions of constant low HIV incidence. The models reveal a direct link between the prevalence of undetected HIV infection and the screening interval between repeat HIV tests. We show how to select screening intervals that either achieve a given HIV prevalence level, or optimally balance the cost of repeat HIV testing against the cost of HIV infection. Alternatively, given an existing repeat screening program, the model implies that cost of infection for which the given screening interval is optimal. The method also suggests how to select an HIV testing technology. The models are applied to existing repeat testing programs in the U.S. Army and among legal commercial sex workers in the state of Nevada in the Far West of the United States.

Cost-Benefit Analysis↗
PubMed2000

Treatment on demand: an operational model.

The goal of "treatment on demand" is to allow all those seeking substance abuse treatment immediate entry into a program. Surprisingly, little is understood regarding the relationship between the demand for treatment, queues, waiting times and treatment admission rates, and treatment capacity. Nor has the increase in treatment capacity required to eliminate drug treatment queues, along with the expected benefits and costs of such an expansion, been studied carefully. In this paper, we present a mathematical model of drug treatment flows for systems where the demand for treatment greatly exceeds available supply. The model produces estimates of queue lengths, waiting times and treatment admission probabilities for any given treatment capacity, and suggests the capacity needed to achieve treatment on demand. The model also enables one to contrast the likely costs and benefits of changes in treatment capacity. We illustrate the model using San Francisco as a case study.

Ambulatory Care↗
PubMed2000

Inner obstacles to psychoanalysts' retirement: personal, clinical, and theoretical perspectives.

To live, age, and retire successfully, life must have meaning. The aged Freud bestowed passionate commitment exclusively on psychoanalysis. Therefore life lost meaning when he stopped analyzing, and so Freud sought death. Identified with this exclusive commitment, successor generations of analysts also aspired to die in harness. Successful retirement requires the conviction that there is life after analysis, with the actualizing of multiple antecedent or new passions. The reactions of three patients to the retirement announcement are discussed.

Anecdotes as Topic↗
PubMed1999

Hold everything! Holding policies for protecting plasma supplies.

In spite of advances in testing technologies for detecting infections such as human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV), occasionally blood or plasma is collected that is potentially infectious, but is not detected as such by existing screening tests. We consider the effect of a holding policy for further reducing the number of potentially infectious units that are released for fractionation. The policy dictates a holding period during which all donated units are stored. If a donor tests positive for the infection in question at a subsequent donation, then all of that donor's units currently in storage are discarded. Otherwise, donated units are released at the end of the holding period. In the case of a single disease, we determine optimal holding periods as well as policies that are as effective as the best screening tests currently available.

Blood Banks↗
PubMed1999

New approaches to HIV surveillance: means and ends. Summary report of conference held at Yale University, 21-22 May 1998, by the Law, Policy and Ethics Core, Center for Interdisciplinary Research on AIDS, Yale University.

A system of HIV surveillance based on AIDS case reporting is no longer adequate to monitor the epidemic of HIV/AIDS in the U.S. We are now faced with the challenge of designing an effective system of HIV surveillance. The "New Approaches to HIV Surveillance: Means and Ends" conference emphasized that there are several alternatives, each with strengths and limitations. The CDC has recommended that all states adopt a system of HIV surveillance based on case reporting. Although it has not specified that such systems need be name-based, CDC appears to reward states that adopt name-reporting systems. The rationale for this stance should be reviewed and made explicit. Name reporting may be superior in some respects to a system of case reports based on unique identifiers (UIs), especially in its greater ability to link surveillance activities to follow up at the individual level. Neither a name-reporting nor a UI approach to case reporting would provide HIV incidence data. The only currently envisioned means of providing incidence data is statistical estimation based on "snapshot estimates" of HIV incidence in sample cohorts. Calibration of this new instrument for HIV incidence estimation against existing data or through field trials is of critical importance.

Centers for Disease Control and Prevention, U.S.↗
PubMed1998

HIV incidence in Ethiopian immigrants to Israel.

The HIV incidence in recent adult Ethiopian immigrants to Israel is estimated through the use of snapshot estimators based on percentage of CD4 progression with time since infection, whereas the preimmigration incidence experienced by this population is estimated using an epidemic model applied to HIV prevalence data obtained from immigrants on arrival in Israel. The snapshot estimators place incidence in adult Ethiopian immigrants in Israel between 3 and 11 infections/1000 uninfected persons/year around May 1995. In contrast, the epidemic model suggests that the incidence experienced by this population before immigration was between 12 and 22 infections/1000 uninfected persons/year. Although the drop in incidence postimmigration is good news, in the aggregate, we estimate that between 50 and 190 new infections have occurred annually in adult Ethiopians who have immigrated to Israel.

Adolescent↗
PubMed1998

Accidental, intravenous infusion of a peanut oil-based medication.

OBJECTIVES: To describe a case of fat embolus syndrome with lipoid pneumonia resulting from intravenous infusion of lipid and to illustrate the potential for accidental intravenous administration of vegetable oil-based progesterone preparations in the treatment of oncology patients. CASE REPORT: A patient with recurrent ovarian carcinoma accidentally received approximately 20 mL (0.29 mL/kg) of a peanut oil-based methylprogesterone product intravenously via infusion pump over 24 hours. The patient developed a lipoid pneumonia with dyspnea, cough, hypoxia, radiographic infiltrates, and a pleural effusion. She was hospitalized for 4 days, and signs and symptoms resolved over 2 weeks following steroids and supportive care. DISCUSSION: Experience with accidental or intentional intravenous lipid overdose in humans is limited. Typical findings of fat embolus syndrome are similar to lipid aspiration, with respiratory distress, hypoxia, and pulmonary infiltrates. In contrast to aspiration, however, fat embolus syndrome results in lipogranulomas surrounding blood vessels, rather than air passages, and potentially produces cerebrovascular, accident-like symptoms. Management of fat embolus syndrome is similar to that for lipid aspiration. However, as seen in this case, fat embolus syndrome typically resolves over several weeks as opposed to the 3-month to 1-year period seen with aspiration lipoid pneumonias. CONCLUSIONS: Accidental intravenous infusion of vegetable oil-based products is a potential complication of the increased use of intravenous progesterones.

Antineoplastic Agents, Phytogenic↗
PubMed1997

Telepsychotherapy. Psychotherapy by telephone, videotelephone, and computer videoconferencing.

Telepsychotherapy is defined as psychotherapy conducted by a therapist at a location different from the patient's through bidirectional communication technology supporting real-time interactivity in the audio, audiovisual, or text modalities. Various types of telecommunication equipment are considered. Vignettes of 2 cases treated by means of the AT&T Videophone 2500 are presented. Medicolegal aspects and clinical issues, including ethics, confidentiality, patient selection, and therapy technique, are addressed.

Computer Systems↗
PubMed1997

Aging and retirement: a difficult issue for individual psychoanalysts and organized psychoanalysis.

Organized psychoanalysis has a long history of discussing and formulating policies on retirement, but follow-through has been lax and few analysts retire unless forced by illness. Institutes tend to avoid and deny the problem of the impaired analyst. Procedural guidelines are needed for assessing competency and imposing involuntary retirement. The authors recommend that all institute appointments be time-limited and that medical clearance specifically addressing conditions potentially impairing professional functioning be required for appointment and renewal.

Aged↗
PubMed1996

Initial results of a phase II trial of high dose radiation therapy, 5-fluorouracil, and cisplatin for patients with anal cancer (E4292): an Eastern Cooperative Oncology Group study.

PURPOSE: A prospective clinical trial was performed to assess the response and toxicity associated with the use of high dose radiation therapy, 5-fluorouracil, and cisplatin in patients with anal cancer. METHODS AND MATERIALS: Patients with anal cancer without distant metastasis were eligible for this study. Radiation therapy consisted of 59.4 Gy in 33 fractions; a 2 week break in treatment was taken after 36 Gy had been given. A treatment of 5-fluorouracil, 1,000 mg/m2 per day intravenously, was given for the first 4 days of radiation therapy, and cisplatin, 75 mg/m2 intravenously, was given on day 1 of radiation therapy. A second course of 5-fluorouracil and cisplatin was given after 36 Gy of radiation, when the radiation therapy was resumed. RESULTS: Nineteen patients entered this study and received treatment. Thirteen (68%) had a complete response, 5 (26%) had a partial response, and 1 (5%) had stable disease. The patient with stable disease and one of the patients with a partial response had complete disappearance of tumor more than 8 weeks after completion of radiation therapy. Fifteen patients had toxicity of Grade 3 or higher: the worst toxicity was Grade 3 in eight patients, Grade 4 in six patients, and Grade 5 in one patient. The most common form of toxicity of Grade 3 or higher was hematologic. The one lethal toxicity was due to pseudomembranous colitis, which was a complication of antibiotic therapy for a urinary tract infection. CONCLUSION: Radiation therapy, cisplatin, and 5-fluorouracil resulted in an overall response rate of 95%. Significant toxicity occurred, an indication that this regimen is near the maximal tolerated dose. A Phase III clinical trial is planned in which radiation therapy, cisplatin, and 5-fluorouracil will be used as an experimental arm.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1995

HIV incidence among New Haven needle exchange participants: updated estimates from syringe tracking and testing data.

This article provides updated estimates of the rate of new HIV infections among participants in New Haven's legal needle exchange program from syringe tracking and testing data. We previously reported that based on data collected from November 1990 through May 1992, the maximum likelihood incidence rate was zero with a 95% confidence interval of 0-10.2 new infections per 100 drug injectors per year. Expanding this data set through August 1993, the same statistical methods yield a maximum likelihood estimate of 1.63 new infections per 100 drug injectors per year with a 95% confidence interval of 0-7.2. Given these data, the null hypothesis of no new infections cannot be rejected, providing further support for the efficacy of New Haven's needle exchange program.

Confidence Intervals↗
PubMed1995

An analysis of the process of human immunodeficiency virus sexual risk behavior change.

Few studies have tried to identify the process of risk behavior change. In this paper, we present a method for the analysis of the process of risk behavior change; the methodology involves using time series data to form transition probability matrices. We apply the method to human immunodeficiency virus (HIV) sexual risk behavioral data from a cohort of gay men in Amsterdam. We determine the process of risk behavior change in this cohort, and we demonstrate that it is not possible to deduce the process simply from an examination of the static pattern. Our results imply that the risk behavior change that is observed in this cohort may be viewed as a homogeneous one-step Markovian process. This process of risk behavior change has implications for the long-term prediction of HIV seroconversion rates and for the design and evaluation of HIV behavioral intervention studies and vaccine trials. Our results also have implications for the interpretation of relapse behavior.

Cognition↗