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Biomedical subjects

H I Schwartz

Publications and source records attributed to H I Schwartz.

At least 19 recordsLinked to original sources
PubMed2006

The impact of low-dose aspirin on endoscopic gastric and duodenal ulcer rates in users of a non-selective non-steroidal anti-inflammatory drug or a cyclo-oxygenase-2-selective inhibitor.

BACKGROUND: The effect of low-dose aspirin on endoscopic ulcer incidence in cyclo-oxygenase-2-selective inhibitor or non-selective non-steroidal anti-inflammatory drug users remains controversial. AIM: To compare prospectively the incidence of endoscopic ulcers in healthy subjects receiving low-dose aspirin plus celecoxib or naproxen. METHODS: In this double-blind, placebo-controlled, 1-week study, subjects (50-75 years) were randomized to receive aspirin 325 mg o.d. plus either celecoxib 200 mg o.d., naproxen 500 mg b.d., or placebo. Baseline and end of study endoscopies were performed. The primary end point was incidence of one or more gastric and duodenal ulcers. RESULTS: A lower incidence of gastric and duodenal ulcers was seen in celecoxib/aspirin-treated subjects (19%) vs. naproxen/aspirin (27%; RR: 0.63, 95% CI: 0.44-0.92). Both naproxen/aspirin and celecoxib/aspirin groups demonstrated a higher incidence of gastric and duodenal ulcers vs. placebo/aspirin (8%; RR: 3.7, 95% CI: 1.8-7.6 and RR: 2.6, 95% CI: 1.2-5.8, respectively). CONCLUSIONS: Fewer endoscopic ulcers were observed in patients treated with celecoxib/aspirin vs. naproxen/aspirin. However, celecoxib/aspirin was associated with a significantly higher incidence of gastric and duodenal ulcers than aspirin alone. Further studies are required to determine the generalizability of these findings in the aspirin users and to determine the appropriate strategy to minimize risk in susceptible patients.

Aged↗
PubMed2001

Life-sustaining treatment and assisted death choices in depressed older patients.

OBJECTIVES: The major purpose of this study was to examine the effect of depressed mood in older, medically ill, hospitalized patients on their preferences regarding life-sustaining treatments, physician-assisted suicide (PAS), and euthanasia and to determine the degree to which financial constraints affected their choices. DESIGN: Cross-sectional study. SETTING: General medical hospital. PARTICIPANTS: One hundred fifty-eight medically hospitalized, nondemented patients age 60 or older, mean age 74.1 (range 60-94). The sample was divided, based on Center for Epidemiologic Studies-Depression (CES-D) scores, into a depressed group (n = 71) and a nondepressed control group. MEASUREMENTS: Subjects underwent a structured interview evaluating their life-sustaining treatment choices and whether they would accept or refuse PAS or euthanasia under a variety of hypothetical conditions. These choices were reevaluated with the introduction of financial impact. In addition, assessment included measures of depression, suicide, cognition, social support, functioning, and religiosity. RESULTS: Depression was found to be highly associated with acceptance of PAS and euthanasia in most hypothetical clinical scenarios in addition to patients' current condition. Compared with nondepressed people, depressed respondents were 13 times as likely to accept PAS when considering their current condition (95% confidence interval [CI] 1.68-110.98), and over twice as likely to accept PAS when facing a hypothetical terminal illness or coma. Depression alone was weakly associated with life-sustaining treatment choices but, when financial impact was introduced, significantly more depressed subjects refused treatment options they had previously desired than did nondepressed subjects. The presence of suicidal ideation, even passive ideation, was strongly predictive of life-sustaining treatment refusals and increased interest in PAS and euthanasia. Depression's effect on acceptance of PAS was confirmed by logistic regression, which also showed that religious coping was significantly correlated with less interest in PAS in two hypothetical scenarios. CONCLUSION. Depressed subjects and even subjects with subtle, passive suicidal ideation were markedly more interested in PAS and euthanasia than nondepressed subjects in hypothetical situations. Depressed subjects were also particularly vulnerable to rejecting treatments if financial consequences might have resulted.

Activities of Daily Living↗
PubMed2000

Physicians' voices on physician-assisted suicide: looking beyond the numbers.

Most empirical research examining physician views on physician-assisted suicide (PAS) has used quantitative methods to characterize positions and identify predictors of individual attitudes. This approach has generated limited information about the nature and depth of sentiments among physicians most impassioned about PAS. This study reports qualitative data provided by 909 physicians as part of a larger survey (N = 2,805) regarding attitudes toward and experiences with PAS and palliative care. Emergent themes illustrate important clinical, social, and ethical considerations in this area. The data illustrate the diverse and ardent responses that PAS evokes among certain physicians. The role of physicians' personal values is central to discussions about legalization of PAS. Polarized views such as those expressed by physicians in this study are not likely to be reconciled, thereby constraining the development of public policy regarding PAS.

Attitude of Health Personnel↗
PubMed2000

Physician-assisted suicide in Connecticut: physicians' attitudes and experiences.

OBJECTIVE: This study examined aspects of physician attitudes toward physician-assisted suicide (PAS) not fully examined to date: evaluation of risks related to PAS, particularly the presence of depression, and the influence of religious and professionally-based values. DESIGN: Anonymous, self-administered mailed questionnaire using Dillman methodology. PARTICIPANTS: Targeted sample of physicians licensed by the Connecticut Department of Public Health in 1997 (n = 2,805 completed surveys; 40% response rate). DATA INCLUDE: Physician and patient characteristics, attitudes toward physician assisted suicide, and confidence in treating depression. RESULTS: Religious affiliation, religiosity, ethnicity and medical specialty were strongly associated with views on PAS. Seven percent of respondents had been asked to write a lethal prescription during the past year, 15% of whom (n = 24) had complied with at least one request. CONCLUSIONS: Most respondents expressed concern regarding certain risks associated with PAS, including movement toward involuntary euthanasia and the influence of undetected depression. Findings raise practical issues to be addressed through statutory or professional safeguards if PAS were to be legalized.

Adult↗
PubMed1999

Twice-daily versus thrice-daily clarithromycin in combination with ranitidine bismuth citrate in the eradication of Helicobacter pylori.

BACKGROUND: Ranitidine bismuth citrate (RBC), 400 mg bid for 4 weeks, plus clarithromycin, 500 mg tid, is a regimen approved by the US Food and Drug Administration for the eradication of Helicobacter pylori in patients with duodenal ulcers. Proof that the clarithromycin portion of the regimen could be given twice daily without loss of efficacy would reduce cost and improve patient compliance. The objective of this study was to compare the H. pylori eradication rates in patients who had duodenal ulcer and were randomly assigned to 4 weeks of treatment with RBC, 400 mg bid, in conjunction with 2 weeks of therapy with either clarithromycin, 500 mg tid, or clarithromycin, 500 mg bid. PATIENTS AND METHODS: Patients who had a duodenal ulcer and were H. pylori-positive by at least two tests were randomly assigned to (1) RBC, 400 mg bid for 4 weeks, plus clarithromycin, 500 mg tid for 2 weeks, or (2) RBC, 400 mg bid for 4 weeks, plus clarithromycin, 500 mg bid for 2 weeks. H. pylori eradication was assessed 4 weeks after completion of RBC plus clarithromycin. RESULTS: Three hundred eighty-three patients from 78 centers had a duodenal ulcer and were H. pylori-positive. The modified intent-to-treat (MITT) and the per-protocol (PP) eradication rates were statistically equivalent between the twice-daily (65% MITT, 74% PP) and thrice-daily (63% MITT, 73% PP) clarithromycin treatment regimens. Incidence and types of adverse events did not differ between the two groups. CONCLUSIONS: For eradicating H. pylori in patients with duodenal ulcer, clarithromycin, 500 mg bid for 2 weeks, with RBC, 400 mg bid for 4 weeks, is equivalent to clarithromycin, 500 mg tid with RBC. The potential enhancement of patient compliance, reduced cost of clarithromycin, and equivalent efficacy would support the use of twice-daily clarithromycin in triple-therapy regimens with RBC.

Adult↗
PubMed1999

The physician-assisted suicide policy dilemma: a pilot study of the views and experiences of Connecticut physicians.

Development of fully informed public policy regarding physician-assisted suicide (PAS) requires a thorough understanding of the experiences, attitudes, and beliefs of physicians with respect to this issue. This study gathered data on physician characteristics, attitudes toward PAS, factors influencing attitudes toward PAS, and sensitivity to the role of depression in a sample of 397 psychiatrists, internists, and family practitioners in Connecticut. Central considerations included: the influence of religious values, professional discipline and practice patterns, and ability to diagnose depression in a single evaluation. Psychiatrists were significantly more likely to be supportive of PAS than were internists or family practitioners. Most respondents expressed concern regarding the influence of depression on PAS requests. A subset of physicians endorse PAS yet do not share such concern about risks, suggesting substantial challenges for policy-makers.

Attitude of Health Personnel↗
PubMed1997

Physician compliance with practice guidelines.

BACKGROUND: Physician adherence to established practice standards has become an important national issue. Despite the proliferation of formal standards of practice, there is little evidence that the mere availability of guidelines results in changes in physician practices. This paper presents the results of a study of the effectiveness of a computerized monitoring and notification system in increasing physician compliance with treatment guidelines. METHODS: This study prospectively compared medical staff practices in two one-year periods utilizing a computer system which tabulated noncompliance and provided reminders. RESULTS: Overall, there was a statistically-significant decrease in the number of alerts issued in year two compared to year one; alerts were issued on 15% vs 29% of all patients (P < .001). The average number of alerts per patient decreased to .20 from .41. CONCLUSIONS: The study results indicate that a clinical decision support system such as that described can improve adherence to treatment guidelines.

Adult↗
PubMed1995

Using science to influence the Supreme Court on the right to refuse treatment: amicus curiae briefs in Washington v. Harper.

The Supreme Court's use of empirical behavioral science data has grown dramatically in the 40 years since Brown v. Board of Education. Most of these data are submitted in amicus curiae (friend of the court) briefs submitted by parties with an interest in the outcome of the significant mental health law cases coming before the court. The increasing use of such briefs raises important questions. Is there evidence that the court is actually influenced by such briefs? Can scientific/professional organizations present scientific data objectively in a clearly adversarial document? A review of the nine amicus briefs filed in Washington v. Harper, a right to refuse treatment case, and a comparison of the Court's opinion with that of the dissent demonstrate that both the majority and the dissent refer to arguments contained in the briefs, incorporate elements of these arguments, and occasionally paraphrase references cited in the briefs. It remains unclear whether the Court uses such arguments to formulate opinions or to justify them. A comparison of the briefs presented by the American Psychological Association and the American Psychiatric Association highlights the challenge to scientific objectivity inherent in participation in the amicus process.

Antipsychotic Agents↗
PubMed1992

An empirical review of the impact of triplicate prescription of benzodiazepines.

In 1989 New York became the first state to add benzodiazepines to the list of controlled substances requiring a triplicate prescription, allowing the state to track prescribing patterns and target providers, pharmacies, and patients for investigation when misuse is suspected. Studies by the state reporting that regulation has significantly reduced inappropriate prescribing and illicit diversion of benzodiazepines without affecting legitimate prescribing practices are being challenged by other studies showing that patients with legitimate needs for benzodiazepines are being denied them, often after abrupt discontinuation. Several reports indicate a significant increase in the prescribing of benzodiazepine substitutes that are less safe and effective, along with increased overdoses of some substitute drugs. Changes in physicians' legitimate prescribing practices may reflect their fears of the damage to career and peace of mind that follows investigations by regulatory agencies.

Anti-Anxiety Agents↗
PubMed1991

Regulation of benzodiazepine prescribing practices: clinical implications.

In an effort to control prescription abuse of benzodiazepines, the New York State Department of Health (DOH) enacted a regulation requiring the use of triplicate prescriptions for these medications. DOH predicted that this regulation would reduce the overall abuse of benzodiazepines and eliminate widescale organized fraud and abuse without any negative impact or reduced availability to patients. Following implementation of the regulation, the authors reviewed all psychiatric emergency room cases and outpatient clinic walk-in evaluations over a 3-month period in an urban medical center and identified 59 cases in which the use of benzodiazepines was a significant presenting problem. Of these, 24 (41%) were judged to be directly related to the new triplicate regulation. In all but one of these cases the patient presented because of symptoms or concerns directly stemming from the refusal by a clinician to continue prescribing a benzodiazepine in a previously established pattern. Typically, abrupt discontinuation of benzodiazepine treatment led to a withdrawal syndrome and/or the unmasking of a previously treated anxiety disorder. In attempting to redress what are essentially criminal substance abuse problems through the regulation of legitimate clinical practice, regulatory agencies may ultimately deprive patients of appropriate, legitimate, and efficacious treatments.

Adult↗
PubMed1991

Informed consent in the electroconvulsive treatment of geriatric patients.

The past 15 years have been marked by an increasingly stringent regulatory atmosphere regarding the administration of ECT, leading to delays in treatment and declines in usage. Regulatory changes requiring judicial intervention in clinical decisions are driven by the notion that only the courts can provide adequate due process protections when legal rights and clinical need conflict. We retrospectively reviewed the documentation of the informed consent process for 62 geriatric patients receiving ECT to assess the degree to which clinicians conformed to the spirit of the informed consent doctrine in a state that allows significant clinical discretion in decisions to administer ECT to patients lacking decisional capacity. In the eight cases in which the patient's decisional capacity was questioned, we found appropriate documentation of the patient's failure to comprehend his condition or the proposed treatment, evidence of a high degree of family involvement in decision making, and extensive use of outside consultants to document decisional incapacity and the need for treatment. Evidence of family participation in decision making was present for a high percentage of cases in which decisional capacity was unquestioned. Our review demonstrated high compliance with the procedural safeguards contained in the state regulation and with the spirit of the informed consent doctrine.

Aged↗
PubMed1988

Neuroleptic malignant syndrome following amoxapine overdose.

The case of a patient who developed the neuroleptic malignant syndrome following an overdose of amoxapine is presented. It is suggested that amoxapine, an antidepressant structurally related to the neuroleptic loxapine, be added to the list of medications that can cause this potentially lethal syndrome. This case illustrates the need for careful evaluation and attention to differential diagnosis when psychiatric patients develop physical signs and symptoms.

Adult↗
PubMed1988

Autonomy and the right to refuse treatment: patients' attitudes after involuntary medication.

The courts' assumption that patients' refusals of treatment are based on autonomous decision making was evaluated by examining the opinions of 24 involuntarily medicated patients about their treatment. At discharge 17 patients felt that their treatment refusal had been correctly overridden by staff and that they should be treated against their will again if necessary. Patients who persistently disapproved of the decision to override their treatment refusal were highly grandiose, engaged in denial of psychotic proportions, and responded poorly to treatment. The results suggest that, for most patients, the decision to refuse psychotropic medication is a manifestation of the patient's illness and does not reflect autonomous functioning or consistent beliefs about mental illness or its treatment. Consequently treatment refusal should be considered primarily a psychotherapeutic issue and, in most cases, should be subject to clinical rather than judicial review.

Adult↗
PubMed1988

The presence of counsel at forensic psychiatric examinations.

In virtually all situations involving forensic psychiatric assessments, the patient is represented by counsel. But does this fact entitle the lawyer to be present at the clinical evaluation? In a series of New York cases spanning a generation, judges have allowed presence of counsel at the psychiatric examination. The most common reason given for such a conclusion is to assure better cross-examination of the expert witness. Psychiatric evaluations mandated by law necessitate several guidelines different from those of the usual doctor/patient relationship. While we may have to accept the presence of attorneys in our consulting rooms, they should be observers only. To allow active intervention would distort the clinical process.

Commitment of Persons with Psychiatric Disorders↗