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Biomedical subjects

M D Stein

Publications and source records attributed to M D Stein.

At least 73 records · Page 4Linked to original sources
PubMed1995

Physicians' utilization of health care.

OBJECTIVE: To describe how physicians attend to their own health care needs. SETTING: Rhode Island. PARTICIPANTS: A random sample of Blue Cross/Blue Shield providers. The 306 respondents (67% of 458) primarily (92%) had MD or DO degrees. The nonphysician providers were chiropractors, dentists, optometrists, and podiatrists. DESIGN: A mailed survey provided data describing the respondents' medical conditions and utilization of formal and informal care during a three-year period. Questions asked about provider visits, physical examinations, preventive and diagnostic tests, and medication use. The respondents indicated whether services had been initiated by themselves or by another physician. MAIN RESULTS: The physicians' overall use of formal health services was low; their number of office visits was a fourth of the national average. Two-thirds of the respondents reported having a primary care physician, and one-third had sought informal care. The respondents' use of preventive services was high. During the three-year period, 82% of the women physicians had received a Pap test, and 81% of the women physicians over the age of 40 years had received mammography. Cholesterol levels were checked for more than two-thirds of all the respondents. Medical examinations and laboratory tests tended to be ordered by another physician, although self-prescribing was not uncommon. Furthermore, 61% of the respondents had self-prescribed at least one medication. CONCLUSIONS: Physicians' care-seeking behavior covers a broad spectrum, ranging from self-care, to informal consultation, to formal treatment by another physician. Physicians appear to be low users of formal services overall, but high users of preventive care.

Adult↗
PubMed1995

Tropism of varicella-zoster virus for human CD4+ and CD8+ T lymphocytes and epidermal cells in SCID-hu mice.

To investigate the cell tropism and pathogenicity of varicella-zoster virus (VZV) strains, we analyzed VZV replication by using SCID-hu mice that carry human fetal thymus/liver implants under the kidney capsule or as subcutaneous fetal skin implants. MRC-5 cells infected with wild-type VZV or the Oka strain, used in the live attenuated varicella vaccine, were injected into the implants. The implants were surgically removed 2, 7, 14, and 21 days postinfection. The VZV titer from infected thymus/liver implants peaked on day 7 for the wild-type strain and on day 14 for the Oka strain. Histological analysis showed necrotic areas characterized by thymocyte depletion and fibrosis. VZV protein synthesis was detectable by immunohistochemical staining in the necrotic areas and in distant regions that did not show cytopathic changes, and VZV DNA was detected by in situ hybridization in the same distribution. Fluorescence-activated cell sorting analysis of thymocytes harvested at day 7 postinfection showed that VZV proteins were expressed in CD4+, CD8+, and CD4+ CD8+ T cells; VZV was cultured from each T-cell subpopulation. The Oka strain had tropism for human cell types similar to that of wild-type VZV. T lymphocytes released infectious VZV, which is a novel and important observation about the replication of this otherwise highly cell associated virus. VZV-infected skin implants exhibited microscopic epidermal lesions that were indistinguishable histologically from the characteristic lesions of varicella. These experiments demonstrate a unique tropism of VZV for human T lymphocytes, explaining its capacity to cause viremia in natural disease, and demonstrate the value of the SCID-hu model for studies of VZV pathogenesis.

Animals↗
PubMed1995

A Comparative study of ePTFE periodontal membranes with and without decalcified freeze-dried bone allografts for the regeneration of interproximal intraosseous defects.

A comparative study which evaluated two treatment modalities for regeneration of interproximal periodontal lesions was conducted. Eleven pairs of advanced periodontal lesions in 11 human subjects (6 male and 5 female) were treated in a split mouth design with expanded polytetrafluoroethylene (ePTFE) interproximal membranes alone (control) in one lesion and ePTFE interproximal membranes in combination with decalcified freeze-dried bone (test) in the other lesion. At 1 year post-treatment, both treatment modalities revealed a significant increase in clinical attachment levels from baseline (2.0 +/- 1.37 mm test, 2.0 +/- 0.88 mm control) with no significant differences between the two modalities. When the amount of new bone formed in these lesions was assessed using re-entry procedures, a significant difference in new bone formation from baseline was found only for lesions treated with ePTFE alone (0.4 +/- 0.78 mm test, 1.3 +/- 0.96 mm control). It was concluded that at 1 year post-treatment, significant clinical attachment gains could be obtained by the use of ePTFE barriers with or without DFDBA. Statistically significant results in bone fill were only found when ePTFE barriers were used alone.

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

Injected-drug use: complications and costs in the care of hospitalized HIV-infected patients.

The aim of this study was to determine the contribution of injected-drug-use complications to the utilization of inpatient care by persons infected with human immunodeficiency virus (HIV). Retrospective chart review was done of all hospital admissions between January 1, 1991, and December 31, 1991, with outpatient records reviewed to establish CD4 counts within 3 months of the date of admission. The participants included 284 consecutive admissions (189 patients); admissions were divided into two groups according to the Center for Disease Control 1993 expanded AIDS definition: those with AIDS (CD4 count, < 200 cells/microliters) and those with early HIV disease (CD4 count, > 200 cells/microliters). Thirty percent of admissions occurred among persons with early HIV disease. Among 189 individuals admitted to the hospital, 84% were male, 62% were white, and 48% had injected drugs. Early HIV disease admissions were more likely to involve active injection-drug users (82% vs. 33%; p < 0.01). Admissions related to injected-drug use constituted 60% of early HIV disease hospitalizations, and this number rises to 72% if bacterial pneumonia is included as a substance abuse complication. Admissions related to injected-drug use constituted 27% of AIDS admissions; this number rises to 51% if bacterial pneumonia is included. Early HIV disease admissions were significantly shorter (9.9 vs. 12.6 days) and less expensive (mean charge, $9,592 vs. 12,873) than AIDS admissions but still accounted for 25% of inpatient HIV charges. Hospitalizations among HIV-infected persons early in the course of HIV disease are most often related to the medical complications of injected-drug use and account for a substantial expenditure of hospital resources.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia.

BACKGROUND: In making decisions about life-sustaining medical interventions, respect for patient autonomy has been widely advocated, yet little is known about what variables may compete with a physician's ability to honor patient requests in clinical situations. We investigated physician attitudes and behaviors about end-of-life decisions by means of a questionnaire that posed five hypothetical scenarios in which an elderly, competent, terminally ill patient made a request that, if agreed to by the physician, could result in the patient's death. METHODS: We surveyed 392 physicians in Rhode Island and asked them to decide (1) whether or not they would comply with a specific patient request, (2) the justifications they used in making their decision, and (3) whether they had been approached with such a request in their clinical practices. RESULTS: Two hundred fifty-six physicians (65%) responded. Of the respondents, 98% agreed not to intubate the patient in the face of worsening respiratory failure. Eighty-six percent agreed to give the patient a dose of narcotics that could cause respiratory compromise and death to treat his pain adequately. Fifty-nine percent agreed, once the patient was intubated without hope of coming off the respirator, to turn the respirator off. Nine percent agreed to give the patient a prescription for an amount of sleeping pills that would be lethal if taken all at once. Only 1% agreed to give the patient a lethal injection. When they complied with patient requests, physicians cited patient autonomy as the principle most important to their decision making. Physicians who would not comply with patient requests also, paradoxically, often cited this principle but agreed with it less strongly; others cited concerns about the ethical nature of the request, legal questions, and the perception that they were "killing the patient." Sixty-five percent of respondents had been asked by patients to turn off a respirator, and 12% had been asked to administer lethal injections. Twenty-eight percent of respondents indicated that they would comply with requests for lethal injection more frequently if such an action were legal. CONCLUSIONS: Difficult clinical decisions regarding potentially life-prolonging measures are commonly heard in clinical practice. Physicians value the concept of patient autonomy but place it in the context of other ethical and legal concerns and do not always accept specific actions derived from this principle.

Adult↗
PubMed1993

Who pays for published research?

OBJECTIVE: To determine the extent of unfunded research published in major medical journals. DESIGN: Review of original research completed in the United States and published in 23 official journals of internal medicine and neurology during 1 month in 1991. Investigators were contacted to confirm lack of funding. MAIN OUTCOME MEASURE: Percentage of unfunded, published original research. RESULTS: One hundred ninety-six articles were evaluated. There was at least one unfunded study in 78% of journals. Forty-five published studies (23%) were unfunded. Among those 45 studies, 7% were clinical trials, 9% were cohort studies, 18% were cross-sectional or case-control studies, 53% were case series, and 13% were surveys. Thirteen unfunded studies involved procedures that presumably were performed for research purposes and not as part of routine patient care. CONCLUSIONS: Nearly one quarter of original research published in major medical journals was unfunded. Seven percent of published research involved direct clinical costs that were not accounted for by the investigators. These costs may have been passed on to study participants or third-party payers.

Periodicals as Topic↗
PubMed1993

Perceived needs and unmet needs for formal services among people with HIV disease.

This study presents estimates of the prevalence of perceived needs and unmet needs among people with HIV disease in the United States for six areas of community services: mental health, drug treatment, home care, housing, transportation, and entitlements. The prevalence of service needs and unmet needs within racial, gender, drug use history, and other subgroups was also examined. The study is based on a nonrandom cross-sectional sample of 907 people with HIV disease interviewed between November 1988 and May 1989 in nine major urban areas of the United States. Respondents reported high levels of need and unmet need across a variety of service areas. One third or more of all respondents reported a need for mental health services (57%), housing (39%), entitlements (34%), and transportation (32%). Within each of the six service areas, 40% or more reported unmet need. Women, people of color, and injected drug users were more likely to report unmet service need in a number of areas. Given the limitations of the sampling and the focus on current needs, these estimates may represent a lower bound on the magnitude of service need and unmet need within this population.

Activities of Daily Living↗
PubMed1993

Changes in the pattern of drug overdoses.

OBJECTIVE: To describe changes in the pattern of patients with drug overdoses hospitalized over the past two decades. DESIGN: Retrospective data review. SETTING: A 719-bed university-affiliated hospital. PATIENTS: All adults admitted to the hospital with drug overdoses in 1968, 1979, and 1989. PRIMARY OUTCOME MEASURES: Changes in demographics, drugs used, and discharge disposition. RESULTS: A majority of patients admitted with drug overdoses have had previous suicide attempts; and while women predominate, they make up a decreasing proportion of admissions over time (76% in 1968 to 52% in 1989 (p = 0.003). Benzodiazepines were the drugs most commonly used in 1979 and 1989, and cocaine has shown a marked increase in use over time, while barbiturate overdoses have progressively decreased. The use of two or more drugs is common and has been consistent over time, as has been the concomitant use of alcohol. The mortality rate has remained low at 1%, but mean length of stay has decreased dramatically from 6.6 days in 1979 to 3.2 days in 1989 (p < 0.001) and discharge disposition has shifted from out-patient to inpatient psychiatric care. CONCLUSIONS: The majority of patients admitted to a general acute care hospital following a drug overdose have a history of previous suicide attempts and are followed by a mental health professional. The changing pattern of drugs used over two decades reflects trends in drugs used in the community in general and by patients with mental illness in particular. Discharge disposition has changed over time and is related to patients' insurance status.

Adult↗
PubMed1993

Utilization of medical services by drug abusers in detoxification.

To establish the extent of health services, including inpatient, emergency room, and outpatient care utilized by illicit drug users during the previous year, we surveyed 77 drug abusers, who were not known to be HIV-positive, entering a detoxification unit and a comparison group of 70 drug nonusers. Over the previous year, drug abusers had a greater number of visits to their usual source of care, to emergency rooms, and to other sites than drug nonusers. Drug abusers were significantly more likely to have been hospitalized during the past year. Using a logistic model including sociodemographic factors, drug abusers were 2.3 times as likely to use an emergency room and 6.7 times as likely to be hospitalized as drug nonusers. We conclude that drug abusers are heavy users of health services compared to a group of drug nonusers.

Ambulatory Care↗
PubMed1993

The effects of guided tissue regeneration membrane placement on healthy periodontal sites.

This study investigates the effects of the placement of a bioresorbable Type I collagen barrier on clinically healthy sites. Ten human subjects, with at least one pair of matched periodontal defects included in a previous study, were investigated for the effect of guided tissue regeneration (GTR) membrane placement on adjacent healthy sites. Control sites consisted of open flap debridement, while experimental sites consisted of similar debridement procedures with placement of a collagen membrane for GTR. The membrane placement was designed to completely cover the periodontal defect, and therefore of necessity overlapped adjacent periodontally healthy sites. It is these healthy sites that are included in the present study. Standardized measurements of change in probing attachment levels were obtained at the time of surgery and 1 year later. The differences in change of clinical attachment levels (CAL) were compared utilizing the Student t-test for paired samples. The mean loss of CAL in the control sites was 1.00 +/- 1.179 mm, and in the test sites was 0.60 +/- 1.729 mm. When comparing the difference in changes of CAL in both test and control sites, there was no statistical significance. There was, however, a wide range of changes between individual sites, which might suggest a clinically meaningful change of CAL on an individual tooth basis. The results of this study suggest that the placement of a bioresorbable collagen barrier has no significant effect on CAL in healthy areas.

Adult↗