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Biomedical subjects

J H Samet

Publications and source records attributed to J H Samet.

At least 37 records · Page 2Linked to original sources
PubMed1998

Trillion virion delay: time from testing positive for HIV to presentation for primary care.

BACKGROUND: Human immunodeficiency virus (HIV)-infected individuals' initial presentation to medical care frequently occurs at a point of advanced immunosuppression. OBJECTIVES: To investigate the time between HIV testing and presentation to primary care. Also to examine factors associated with delayed presentation. METHODS: One hundred eighty-nine consecutive outpatients without prior primary care for HIV infection were assessed at 2 urban hospitals: Boston City Hospital, Boston, Mass, and Rhode Island Hospital, Providence. Sociodemographics, alcohol and drug use, social support, sexual beliefs and practices, and HIV testing issues were examined in bivariate and multivariate analyses for association with delay in presentation to primary care after positive test results for HIV. RESULTS: Of 189 patients, 74 (39%) delayed seeking primary care for more than 1 year, 61 (32%) delayed for more than 2 years, and 35 (18%) for more than 5 years after an initial positive HIV serologic evaluation. The median CD4+ cell count of subjects was 0.28 x 10(9)/L (range, 0.001-1.71 x 10(9)/L). In multiple linear regression analysis the following characteristics were found to be associated with delayed presentation to primary care after HIV testing: history of injection drug use (P<.001); not having a living mother (P=.01); not having a spouse or partner (P=.08); not being aware of HIV risk before testing (P<.001); and being notified of HIV status by mail or telephone (P=.002). An interaction effect between sex and screening for alcohol abuse was significant (P=.03) and suggested longer delays for men with positive screening test results (CAGE [an alcoholism screening questionnaire containing 4 structured questions], 2+) compared with men without positive screening test results or women. CONCLUSIONS: Patients with positive HIV test results often delay for more than a year before establishing primary medical care. Information readily available at the time of HIV testing concerning substance abuse, social support, and awareness of personal HIV risk status is useful in identifying patients who are at high risk of not linking with primary care. Patients who were notified of their HIV status by mail or telephone delayed considerably longer than those notified in person. Efforts to ensure primary care linkage at the time of notification of positive HIV serostatus are necessary to maximize benefits for both individual and public health and should be an explicit task of posttest counseling.

Alcohol Drinking↗
PubMed1998

Sexual ethics. Disclosure of HIV-positive status to partners.

OBJECTIVE: To determine factors associated with disclosure of human immunodeficiency virus (HIV)-positive status to sexual partners. METHODS: We interviewed 203 consecutive patients presenting for primary care for HIV at 2 urban hospitals. One hundred twenty-nine reported having sexual partners during the previous 6 months. The primary outcome of interest was whether patients had told all the sexual partners they had been with over the past 6 months that they were HIV positive. We analyzed the relationships between sociodemographic, alcohol and drug use, social support, sexual practice, and clinical variables; and whether patients had told their partners that they were HIV positive was analyzed by using multiple logistic regression. RESULTS: Study patients were black (46%), Latino (23%), white (27%), and the majority were men (69%). Regarding risk of transmission, 41% were injection drug users, 20% were homosexual or bisexual men, and 39% were heterosexually infected. Sixty percent had disclosed their HIV status to all sexual partners. Of the 40% who had not disclosed, half had not disclosed to their one and only partner. Among patients who did not disclose, 57% used condoms less than all the time. In multiple logistic regression analysis, the odds that an individual with 1 sexual partner disclosed was 3.2 times the odds that a person with multiple sexual partners disclosed. The odds that an individual with high spousal support disclosed was 2.8 times the odds of individuals without high support, and the odds that whites or Latinos disclosed was 3.1 times the odds that blacks disclosed. CONCLUSIONS: Many HIV-infected individuals do not disclose their status to sexual partners. Nondisclosers are not more likely to regularly use condoms than disclosers. Sexual partners of HIV-infected persons continue to be at risk for HIV transmission.

Disclosure↗
PubMed1998

Alcohol abusers in primary care: readiness to change behavior.

PURPOSE: Assessing readiness to address alcohol problems is an important early step in managing the alcohol abusing patient. We assessed readiness for behavioral change in primary care of patients who screen positive for alcohol abuse based on the CAGE questionnaire. Our hypothesis was that these patients would be predominantly in the contemplation stage, an opportune stage for physicians to facilitate their movement into substance abuse treatment. PATIENTS AND METHODS: We administered the CAGE questionnaire, a well-validated screening tool for detecting alcohol abuse, to 1,211 of 1,335 patients (91%) who attended two urban primary care clinics. Patients who responded positively to one or more CAGE questions were administered two validated instruments that assessed readiness to change alcohol use. We also measured quantity and frequency of alcohol use. RESULTS: Seventeen percent of patients gave a positive response to one or more CAGE questions (209 of 1,211) and were eligible for further evaluation; 92% (192 of 209) agreed to participate. These subjects' mean age was 50 years and the majority (58%) were African American. Of these patients, 23% were in the precontemplative (denial) stage, 14% were in the contemplative stage, and 63% were in the action stage of behavior change, indicating that they were in early or long-term recovery. Stage of readiness to change results were similar for those with one positive response and two or more positive responses to CAGE questions. CONCLUSIONS: Most patients in whom alcohol abuse is detected in primary care using the CAGE questionnaire are either actively addressing their substance abuse or are in recovery. Contrary to our hypothesis, only a minority of patients are in the contemplation stage. Assessment of stage of change is not apparent from the CAGE questionnaire alone. Our results suggest that clinical skills to facilitate relapse prevention would be particularly valuable for clinicians addressing alcohol abuse in the primary care setting.

Adult↗
PubMed1998

The functioning and well being of persons who seek treatment for drug and alcohol use.

We assessed the reliability of the Medical Outcomes Study Short Form Health Survey (SF-20) in a heterogeneous group of persons seeking drug and alcohol treatment. Patients (n = 2688) seeking detoxification and treatment at four intake sites for Addiction Treatment in Boston, Massachusetts, received all components of the SF-20 including physical, role, and social functioning; mental health; health perception and bodily pain. The primary drugs used were alcohol 38%, cocaine 38%, heroin 24%. Reliability coefficients for the MOS scales ranged from 0.70 to 0.92. Users of these three drugs had similar profiles among the health components. Sociodemographic characteristics in combination explained 2-7% of score variance. Alcohol and other drug use had little effect on physical or role function scores. Health perception and pain subscale scores were low. We conclude the MOS survey is a reliable measure of function and well being in this population. Like other chronic diseases, alcohol and drug use have powerful effects on quality of life.

Adult↗
PubMed1997

Victimization among substance-abusing women. Worse health outcomes.

BACKGROUND: Although women with a history of victimization are known to have increased somatic symptoms, health care utilization, and substance abuse, the health effects of victimization on substance-abusing women are uncertain. OBJECTIVE: To examine whether a history of victimization among substance-abusing women is associated with more medical problems or emergency department visits. METHODS: Interview data were collected from 2322 women seeking publicly funded addiction treatment from September 1992 to January 1996. We compared women with a lifetime history of physical or sexual abuse with those without such a history by bivariate and multivariable analyses. Variables included episodic medical disease, chronic medical disease, recent emergency department visits, substance abuse characteristics, and demographic data. RESULTS: The prevalence of victimization was 42%. In bivariate analyses, the following variables had significant association with victimization histories: episodic medical disease, recent emergency department visit, chronic medical disease, primary care physician's awareness of substance abuse history, ethnicity, and lower income. Alcohol and crack cocaine users had higher prevalence of victimization compared with heroin or noncrack cocaine users (P = .001). In the logistic regression, the following variables remained independently and significantly associated with victimization: episodic medical disease (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.70-2.73), physician awareness of substance abuse (OR, 1.78; 95% CI, 1.42-2.23), emergency department visit (OR, 1.57; 95% CI, 1.22-2.03), chronic medical disease (OR, 1.51; 95% CI, 1.19-1.92), and lower income. CONCLUSION: Victimization in urban, poor, substance-abusing women is associated with more medical disease and health care utilization. Interventions that focus on the interconnected problems these women face may more effectively affect this challenging population.

Adult↗
PubMed1997

Screening in special populations: a "case study" of recent Vietnamese immigrants.

PURPOSE: To determine how the medical and social profile of a particular special population, Vietnamese immigrants, should be used to tailor screening protocols that differ from those designed for the general population. PATIENTS AND METHODS: A consecutive series of Vietnamese immigrants living in the United States for less than 6 months were evaluated by interviewer-administered standardized questionnaire and medical record review. A total of 99 new Vietnamese immigrants (47 women and 52 men) aged 19 to 71 years presenting for primary care to two neighborhood health centers between October 1994 and June 1995 were identified. Data collected included smoking status, alcohol use (CAGE questionnaire), depression (Vietnamese Depression Scale [VDS]), PPD status, stool ova and parasites, hepatitis B and syphilis serologies. RESULTS: Overall, 32% were smokers and significantly more men than women smoked (54% vs. 9%) (P < .00001). Although 24% of patients used alcohol, none responded positively to any of the CAGE questions. Using the VDS, 17% (17 of 99) were depressed; age 40 and older was the only sociodemographic factor associated with depression (P < .00001). Ova or parasites were found in 51% (41 of 80), and 63% of those infected (26 of 41) required treatment for pathogenic infections. Seventy percent (66 of 94) tested positive on the tuberculin skin test (PPD), and antituberculous medication was recommended in 39% (37 of 94). Eighty-three percent (80 of 96) had been exposed to hepatitis B, and 14% (13 of 96) were chronic hepatitis B carriers. CONCLUSIONS: Caring for special populations provides an opportunity to institute appropriate unique screening tests not recommended for the general population. In the case of new Vietnamese immigrants, routine screening protocols should include the following: testing for tuberculosis by PPD, stool ova and parasite examinations, hepatitis B serologies, and assessment for depression and smoking status. The CAGE questionnaire may not be an effective instrument for detecting alcohol abuse in this particular population.

Adult↗
PubMed1997

Brief interventions with substance-abusing patients.

Brief interventions to change alcohol use have proven effective in different primary care settings. Current data show decreases in consumption as well as a decreased utilization of some health resources and decreased mortality. The process of changing drinking or substance abuse behavior requires a series of predictable steps. The key to changing behavior is ambivalence about current behavior. Understanding the stages of behavioral change and assessing the patient's readiness to change are important for effective interventions. Brief interventions include giving the patient feedback about a behavior, clearly recommending a change in behavior, presenting options to achieve this change, checking and responding to the patient's reaction, and providing follow-up care. Effective interventions help develop the patient's sense of motivation and self-efficacy for behavioral change. In approaching a patient with a substance abuse problem, using techniques of motivational enhancement is more effective than a confrontational approach.

Alcohol Drinking↗
PubMed1997

Managed care of substance abuse disorders. Implications for generalist physicians.

Given the rapidly changing landscape of both private and public health plan programs, it is foolhardy to suggest that a definitive characterization of managed care and substance abuse issues can be made. Among other topics, this article discusses goals of managed care organizations, managed care models, and physicians' roles in managed care.

Cost Control↗
PubMed1997

Factors associated with HIV testing among sexually active adolescents: a Massachusetts survey.

OBJECTIVE: To assess sexually active adolescents' knowledge, attitudes, and behaviors associated with human immunodeficiency virus (HIV) testing and to determine the factors important in their decision to obtain voluntary HIV testing. DESIGN: Anonymous, random, digit-dial telephone survey undertaken in 1993. SETTING: Massachusetts households. PARTICIPANTS: Adolescents, 16 to 19 years of age. RESULTS: Of the 567 adolescents surveyed who had sexual intercourse within the past year, 127 (22%) had received HIV testing, with 54 (10%) stating that this testing was for personal reasons. A "great deal" or "some" worry about getting HIV/acquired immunodeficiency syndrome (AIDS) was expressed by 51%, and 56% felt that it was at least a little likely that they will get AIDS. Misconceptions were common about aspects of HIV testing: 35% did not believe or did not know that the HIV test results were kept in confidence, 19% thought that AIDS testers informed partners if the results were positive, and 30% did not think that the HIV test was very accurate. Although 92% (452/490) had seen a physician in the past year, only 30% (136/452) had ever discussed AIDS with a doctor. Multivariable analysis identified five factors as independently associated with voluntary adolescent HIV testing: 1) having had more than one sexual partner within the past year [odds ratio (OR): 2.9; 95% confidence interval (CI): 1.5, 5.5]; 2) believing that condoms are only somewhat effective at preventing the spread of AIDS (OR: 2. 6; 95% CI: 1.4, 4.8); 3) having discussed AIDS with a doctor (OR: 2. 6; 95% CI: 1.4, 4.8); 4) not having had a teacher discuss AIDS (OR: 2.2; 95% CI: 1.2, 4.2); and 5) believing that a positive test result means one has AIDS as opposed to carrying the virus (OR: 2.0; 95% CI: 1.1, 3.7). High-risk behavior of infrequent condom use and a history of a sexually transmitted disease were not significantly associated with voluntary HIV testing. CONCLUSION: Among sexually active Massachusetts adolescents, voluntary HIV testing is uncommon. Teens who have had multiple sexual partners and who do not believe condoms are effective in preventing transmission were most likely to have been tested. Issues requiring clearer communication to patients include the testing process, its availability, and confidentiality. Physicians can play an influential role in the promotion of HIV testing by discussing HIV risk behaviors with patients and offering those at risk voluntary HIV counseling and testing.

AIDS Serodiagnosis↗
PubMed1997

Physician unawareness of serious substance abuse.

PURPOSE: To describe and assess the prevalence of perceived physician unawareness of serious substance abuse. PATIENTS AND METHODS: We report an observational study with validation of multivariable results of data collected by interview from persons presenting for addictions treatment in the public system who reported having a physician. RESULTS: Of 3,253 patients interviewed, 87% (2,843) responded to the question about having a physician. Of 1,440 patients who stated that they had physicians, 45% (651) reported that the physician who cared for them was unaware of their substance abuse. In multivariable logistic regressions adjusting for sociodemographics, health status, and substance abuse histories, the following patient characteristics were found to be independently associated with physician unawareness of substance abuse and were confirmed in a validation analysis (OR = Odds Ratio, CI = 95% Confidence Interval); no prior episodic medical illness (OR = 1.98, CI = 1.35-2.92), no health insurance (OR = 1.89, CI = 1.33-2.70), no prior mental health treatment (OR = 1.75, CI = 1.06-2.88), no chronic medical illness (OR = 1.69, CI = 1.18-2.40), no prior substance abuse treatment (OR 1.64, CI 1.17-2.31), and no prior detoxification (OR = 1.54, CI = 1.14-2.22). CONCLUSIONS: Forty-five percent of patients with substance abuse serious enough to prompt a presentation for treatment stated that the physician who cared for them was unaware of their substance abuse. Patients without health insurance, a history of medical illness, or prior substance abuse or mental health treatment were more likely to have reported physician unawareness. Even among substance abusing patients requesting addiction treatment, many perceive that their physicians do not recognize their substance abuse.

Adult↗
PubMed1996

Beyond CAGE. A brief clinical approach after detection of substance abuse.

Generalist physicians should incorporate alcohol and drug abuse detection and brief intervention in the care of their patients. A suggestion of alcohol or drug abuse or a positive response to the CAGE questions deserves further assessment such as clarification about adverse consequences, inquiry about loss of control, determination of the patient's perception of the substance use, and an assessment of the patient's readiness to change behavior. Brief intervention with the patient in the clinical setting about alcohol or drug use can be effective. Motivational interviewing, a directive, patient-centered counseling style for enhancing motivation for change, can make brief interventions more effective by incorporating the patient's readiness to address alcohol or drug use. A useful clinical approach is presented that is tailored to the patient's stage of readiness to change alcohol or drug abuse behavior.

Attitude to Health↗
PubMed1996

The substance-using human immunodeficiency virus patient: approaches to outpatient management.

Individuals with a substance use disorder who are infected with human immunodeficiency virus (HIV) provide physicians with challenging issues for both medical management and drug treatment. Using a case presentation format, we present an overview of some of the major issues involved in delivering effective primary care for these individuals. A detailed medical and substance use history is critical to sort common complaints that can be seen both in HIV infection and with drug use. Physicians must be able to recognize withdrawal syndromes and differentiate those signs and symptoms that may be attributed to specific drugs. A two-phase model of drug abuse treatment takes into account both detoxification and maintenance of abstinence. Primary care physicians should be able to initiate the process of substance abuse treatment and refer the patient to appropriate substance abuse programs when necessary. Pharmacological approaches to long-term abstinence with heroin addiction include methadone, LAAM, and naltrexone. While clinically challenging, HIV-infected substance users can be successfully managed using the general principles of primary care.

Adult↗
PubMed1994

Management of hospitalized intravenous drug users: role of the internist.

Intravenous drug users present significant clinical challenges to internists. In this paper, we review common clinical dilemmas faced by internists when managing intravenous drug users in the inpatient hospital setting. Articles were identified through a MEDLINE search and bibliographies of published articles. Studies and reviews were selected for information relevant to the management of hospitalized intravenous drug users. Seventy-three papers were selected for this review. We summarize data and information from the relevant literature concerning common presenting medical problems (fever, musculoskeletal pain, and dyspnea), the importance of knowing patients' HIV status, common behavioral issues, special concerns of women, and the diagnosis and management of drug withdrawal in intravenous drug users. We also offer recommendations for hospital discharge planning. With appropriate knowledge of the epidemiology and management of important medical and substance use problems among intravenous drug users, internists may more effectively care for them in the hospital setting.

Dyspnea↗
PubMed1994

Factors associated with initiation of primary medical care for HIV-infected persons.

PURPOSE: To examine the degree of immune dysfunction of human immunodeficiency virus (HIV)-infected patients at the time of presentation and to identify factors associated with early and late initial primary medical care for HIV infection as measured by CD4+ lymphocyte count. PATIENTS AND METHODS: Two hundred fifty-one consecutive outpatients without prior primary care for HIV infection were assessed at a municipal hospital HIV intake clinic (derivation group). Sociodemographic and clinical variables were examined for their association with CD4+ cell count on presentation in bivariate and stepwise linear regression analyses. Variables of interest were examined in 123 similar patients at a second site to assess the generalizability of our findings (validation group). RESULTS: In the derivation group, 30% of patients presented for initial primary care with CD4+ cell counts less than 200/mm3, 51% had counts from 201/mm3 to 500/mm3, and only 19% had counts greater than 500/mm3. Twenty-seven percent of patients had delayed seeking medical care for longer than 1 year and 12%, for more than 2 years after an initial positive HIV serologic evaluation. Three variables were significant and independent predictors of CD4+ cell count on presentation: Haitian ethnicity (P = 0.05) and HIV-related symptoms (P = 0.005) were associated with lower CD4+ cell counts; and female sex (P = 0.009) was associated with higher CD4+ cell counts. With HIV-related symptoms excluded from the model, a history of cocaine use was also a significant predictor for higher CD4+ cell count (P = 0.02). In the validation group, which included few Haitians, results for female sex and HIV-related symptoms showed a similar association. CONCLUSIONS: Most HIV-infected patients presented for primary care with advanced immune dysfunction. A substantial percentage of patients waited over a year to initiate medical care after testing positive for HIV. Haitian patients presented later for primary HIV care as measured by CD4+ cell count. Women presented with significantly higher CD4+ cell counts than did men. Since few characteristics examined could clearly identify the majority of late-presenting HIV-infected patients, improved general and targeted efforts are needed to link all HIV-infected people with primary medical care before the development of advanced disease.

Adult↗
PubMed1994

Improving medical residents' attitudes toward HIV-infected persons through training in an HIV staging and triage clinic.

PURPOSE: To assess the effect of a weekly outpatient clinic for staging and triage of newly identified human-immunodeficiency-virus (HIV)-infected patients on medical residents' attitudes and knowledge regarding care of HIV-infected persons. METHOD: Twenty-one second- and third-year medical residents who participated in the Diagnostic Evaluation Unit (DEU) of Boston City Hospital's Clinical AIDS Program from July 1991 through December 1991 were matched with a control group of 20 residents. Both groups of residents were asked to anonymously complete self-administered questionnaires before, immediately after, and three months following the DEU rotation. Responses were compared using repeated measures analysis of variance, two-tailed t-tests, and chi-square analysis. RESULTS: Compared with the controls, the DEU residents showed an increased sense of feeling adequately trained to provide primary care to HIV-infected patients immediately after the rotation (p = .0002), which was sustained at the three-month follow-up (p < .001). Compared with the controls, the DEU residents also showed improved general attitudes toward treating persons with acquired immune deficiency syndrome, which persisted at the three-month follow-up, although these changes were not significant. CONCLUSION: The experience in an HIV staging and triage clinic had a positive effect on the confidence and attitudes of the medical residents. Similar training experiences may increase the willingness and capacity of physicians to provide primary care to HIV-infected persons.

Analysis of Variance↗
PubMed1994

Initial assessment of patients infected with human immunodeficiency virus: the yield and cost of laboratory testing.

Our objective was to determine the yield and cost of standardized laboratory testing of HIV-infected patients entering medical care after testing positive for HIV. An HIV staging and referral clinic in a municipal public hospital was our site for a cross-sectional study, and 308 patients were evaluated in the clinic between February 1, 1990 and October 1, 1991. Patients underwent standardized laboratory testing, including hematologic studies, serum chemistries, infectious disease serologies, and chest radiographs. The percentage of abnormal results for each test was determined. Abnormal results were stratified as mild or severe. They were also examined with regard to whether injection drug users or other patient subgroups had higher percentages of abnormalities. Changes and Medicare reimbursements for the tests were also determined. There were substantial numbers of abnormalities in all types of laboratory testing. Only 3% of patients had normal CD4 lymphocyte counts; 85% had counts of < 500/mm3, and 35% were < 200/mm3. Forty-four percent of patients had at least one abnormal hematologic study; 8% were severe. Nearly 75% had abnormal liver function tests; 20% of these were severe abnormalities. Fifteen percent of patients were PPD-positive, and > 50% were anergic. Fourteen percent had a positive nonspecific test for syphilis, and 7% had a positive confirmatory test. Fourteen percent of patients had an abnormal chest radiograph.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Sociodemographic determinants in the hospitalization decision: evaluation of an emergency department interhospital transfer policy.

STUDY OBJECTIVES: To evaluate an emergency department's "treat and transfer" policy during a two-month period of reduced inpatient capacity by determining the number and characteristics of transferred patients not admitted as planned to the receiving hospital. DESIGN: Matched case-control analysis. SETTING: Public hospital adult ED. TYPE OF PARTICIPANTS: Patients transferred to other hospitals for admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twelve percent of patients (16 of 135) were not admitted after transfer during the first month, and 8% during the two-month period. Only IV drug use was found to be significantly associated with an increased risk of discharge without admission (odds ratio = 9.5; 95% confidence interval, 1.9 to 47.8). CONCLUSION: Patients transferred from the public hospital ED resulted in admission to the receiving hospital in 92% of transfers. A history of IV drug use was the only characteristic found to be associated with discharge without admission to the accepting hospital.

Adolescent↗