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Biomedical subjects

Martin T Schechter

Publications and source records attributed to Martin T Schechter.

At least 55 records · Page 3Linked to original sources
PubMed2003

Alcohol use and incarceration adversely affect HIV-1 RNA suppression among injection drug users starting antiretroviral therapy.

We conducted this study among HIV-infected injection drug users to determine the effect of self-reported alcohol use and prior incarceration at the time of initiating antiretroviral therapy on subsequent HIV-1 RNA suppression. We examined the demographics, recent incarceration history, and drug and alcohol use history from the Vancouver Injection Drug User Study (VIDUS) questionnaire closest to the date of initiating antiretroviral therapy. We linked these data to the HIV/AIDS Drug Treatment Program. There were 234 VIDUS participants who accessed antiretroviral therapy through the Drug Treatment Program from August 1, 1996, to July 31, 2001. In terms of illicit drug use, 196 (84%) reported injecting heroin and cocaine at the time of initiating antiretroviral therapy. Multiple logistic regression revealed that in the 6 months prior to initiating antiretroviral therapy, alcohol use (adjusted odds ratio [AOR] 0.32; 95% CI 0.13-0.81) and incarceration (AOR 0.22; 95% CI 0.09-0.58) were independently associated with lower odds of HIV-1 RNA suppression. Factors positively associated with HIV-1 RNA suppression included: adherence (AOR 1.27; 95% CI 1.06-1.51); lower baseline HIV-1 RNA (AOR 1.30; 95% CI 1.01-1.66); highly active antiretroviral therapy (AOR 4.10; 95% CI 1.56-10.6); months on therapy (AOR 1.1; 95% CI 1.06-1.14). Among HIV-infected injection drug users who were on antiretroviral therapy, any alcohol use and incarceration in the 6 months prior to initiating antiretroviral therapy were negatively associated with achieving HIV-1 RNA suppression. In addition to addiction treatment for active heroin and cocaine use, the identification and treatment of alcohol problems should be supported in this setting. As well, increased outreach to HIV-infected drug users recently released from prison to ensure continuity of care needs to be further developed.

Adult↗
PubMed2002

Socioeconomic status, access to triple therapy, and survival from HIV-disease since 1996.

BACKGROUND: In the era before highly active antiretroviral therapy (HAART), socioeconomic status was associated with survival from HIV disease. We have explored socioeconomic status, access to triple therapy (HAART), and mortality in the context of a universal healthcare system. METHODS: We evaluated 1408 individuals who initiated double or triple therapy between 1 August 1996 and 31 December 1999, and were followed until 31 March 2000. Cumulative HIV-related mortality rates were estimated using Kaplan-Meier methods and Cox proportional hazards regression. RESULTS: In the overall Cox model, we found that adherence [risk ratio (RR) 0.83; per 10% increase], CD4 cell count (RR 1.53; per 100 cell decrease), and lower socioeconomic status (RR 2.19; high versus low), were associated with HIV-related mortality. However, socioeconomic status was not significant among patients prescribed triple therapy in a stratified analysis, or in a sub-analysis restricted to patients prescribed HAART in the initial regimen. When we investigated if inequitable access to HAART by socio-economic status could explain the discrepancy, we found that persons in the lower socio-economic strata were less likely to be prescribed triple therapy even after adjustment for clinical characteristics. CONCLUSION: In a universal healthcare system, socioeconomic status was strongly associated with HIV-related mortality. When we investigated possible explanations for this association, we found that individuals of lower socioeconomic status were less likely to receive triple therapy after adjustment for clinical characteristics. Our findings highlight the need for the monitoring of therapeutic guidelines to ensure equitable access, as treatment strategies are updated.

Adult↗
PubMed2002

Leaving hospital against medical advice among HIV-positive patients.

BACKGROUND: Hospital discharge against medical advice, especially among substance-abusing populations, is a frustrating problem for health care providers. Because of the high prevalence of injection drug use among HIV-positive patients admitted to hospital in Vancouver, we explored the factors associated with leaving hospital against medical advice in this population. METHODS: We reviewed records for all HIV/AIDS patients admitted to St. Paul's Hospital, Vancouver, between Apr. 1, 1997, and Mar. 1, 1999. After identifying the first ("index") admission during this period, we followed the patients' records for 1 year. Multivariate models were applied to identify the determinants of discharge against medical advice and to estimate the impact of such discharge on readmission rate, readmission frequency and length of stay in hospital. RESULTS: Of 981 index admissions among HIV/AIDS patients, 125 (13%) of the patients left the hospital against medical advice. Departure on the day on which welfare cheques were issued and a history of injection drug use were significant predictors of leaving against medical advice. After adjusting for sex, age, severity of illness, injection drug use and homelessness, we found that patients leaving against medical advice were readmitted more frequently than those who were formally discharged (frequency ratio 1.25, 95% confidence interval [CI] 1.11-1.42), were more likely to be readmitted with a related diagnosis within 30 days (odds ratio 5.00, 95% Cl 3.04-8.24) and had significantly longer lengths of stay in the follow-up period. INTERPRETATION: Discharge against medical advice among HIV-positive patients was associated with frequent readmissions with the same diagnosis. Preventing such discharges is likely to benefit patients (by improving their health status) and the health care system (by reducing unnecessary readmissions).

Adult↗
PubMed2002

Satellite needle distribution among injection drug users: policy and practice in two canadian cities.

Access to clean needles and syringes through needle exchange programs (NEPs) has reduced both high-risk behaviors and the transmission of blood-borne infections among injection drug users (IDUs). However, policies regarding "needle-for-needle" exchange versus unrestricted needle distribution remain controversial. The objective of this study was to compare sources of needles, trends in needle distribution, and the practice of satellite needle distribution (SND) among IDUs in Vancouver and Montreal. SND was defined as receiving a new syringe from another individual through trading, purchasing, borrowing, or being given the syringe outright, or supplying a syringe to another individual through trading, selling, lending, or giving a syringe outright. This was practiced by 46% of IDUs in Vancouver and 50% of IDUs in Montreal. SND was associated with borrowing used injection equipment (adjusted OR [AOR], 2.62; 95% CI: 1.85-3.71), conducting bulk needle exchanges (AOR, 1.85; 95% CI: 1.34-2.54), being married or in a common-law relationship (AOR, 1.85; 95% CI: 1.34-2.54), and regular visits to the NEP (> weekly) (AOR, 1.54; 95% CI: 1.17-2.13). In Vancouver, SND was also associated with borrowing used needles (AOR, 2.07; 95% CI: 1.22-3.52). In these two cities, despite different distribution policies, almost half of the participants reported SND, and this was associated with high risk sharing. The practice of SND appears to be an important mechanism for needle acquisition, especially for those at highest risk for HIV and hepatitis C transmission.

Canada↗
PubMed2002

Females experiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth who use injection drugs.

OBJECTIVES: To compare sociodemographic, drug-related, and sexual risk variables between young (13-24 years of age) and older (> or =25 years of age) injection drug users (IDUs); and to determine HIV prevalence and associated risk factors for HIV infection among young IDUs. METHODS: Data were collected through the Vancouver Injection Drug Users Study (VIDUS). To date, over 1400 Vancouver area IDUs have been enrolled and observed during follow-up. Sociodemographic, drug-related, and sexual risk variables were compared between younger and older IDUs using nonparametric methods. Mantel-Haenszel and logistic regression methods were used to compare HIV-positive and HIV-negative female youth. RESULTS: Younger injectors (N = 232) were more likely to be female; work in the sex trade; report condom use; inject heroin daily; smoke crack cocaine daily; and need help injecting. HIV prevalence at baseline among the youth was 10%. HIV prevalence was associated with female gender; history of sexual abuse; engaging in survival sex; injecting heroin daily; injecting speedballs (a mixture of heroin and cocaine) daily; and having numerous lifetime sexual partners. CONCLUSION: Our data show that HIV positivity among young IDUs is concentrated among females engaged in dual sexual and drug-related risk exposure categories. Over half the HIV-positive youth were Aboriginal (a classification used by the federal government in Canada to include native peoples of all ethnic groups). Targeted interventions that take into account sexual and drug risk for young female and Aboriginal peoples are urgently needed.

Adolescent↗
PubMed2002

Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.

BACKGROUND: Coronary thrombosis and pulmonary thromboembolism are common causes of cardiac arrest. We assessed whether the administration of tissue plasminogen activator (t-PA) during cardiopulmonary resuscitation would benefit patients with cardiac arrest and pulseless electrical activity of unknown or presumed cardiovascular cause. METHODS: Patients who were older than 16 years of age and who had more than one minute of pulseless electrical activity that was unresponsive to initial therapy outside the hospital or in the emergency department were eligible. Patients were randomly assigned to receive 100 mg of t-PA or placebo intravenously over a 15-minute period in a double-blind fashion. Standard resuscitation was then continued for at least 15 minutes. The primary outcome was survival to hospital discharge. RESULTS: During the study period, 1583 patients with cardiac arrest were treated and 233 patients were enrolled (117 in the t-PA group and 116 in the placebo group). The characteristics of the patients in the two groups were similar. One patient in the t-PA group survived to hospital discharge, as compared with none in the placebo group (absolute difference between groups, 0.9; 95 percent confidence interval, -2.6 to 4.8; P=0.99). The proportion of patients with return of spontaneous circulation was 21.4 percent in the t-PA group and 23.3 percent in the placebo group (absolute difference between groups, -1.9; 95 percent confidence interval, -12.6 to 8.8; P=0.85). CONCLUSIONS: We found no evidence of a beneficial effect of fibrinolysis in patients with cardiac arrest and pulseless electrical activity of unknown or presumed cardiovascular cause. Our study had limited statistical power, and it remains unknown whether there is a small treatment effect or whether selected subgroups may benefit.

Cardiopulmonary Resuscitation↗
PubMed2002

Factors associated with persistent high-risk syringe sharing in the presence of an established needle exchange programme.

Vancouver has experienced an explosive HIV epidemic despite the presence of a needle exchange programme (NEP). We sought possible explanations for high-risk syringe sharing among Vancouver injection drug users over the period January 1999 to October 2000. Overall, 14% of participants reported high-risk sharing. Although acquiring needles exclusively from the NEP was independently associated with less sharing, we identified several risk factors for persistent sharing, including difficulty accessing sterile needles, bingeing, and frequent cocaine injection.

British Columbia↗
PubMed2002

Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver.

BACKGROUND: In 1997, we found a higher prevalence of HIV among female than among male injection drug users in Vancouver. Factors associated with HIV incidence among women in this setting were unknown. In the present study, we sought to compare HIV incidence rates among male and female injection drug users in Vancouver and to compare factors associated with HIV seroconversion. METHODS: This analysis was based on 939 participants recruited between May 1996 and December 2000 who were seronegative at enrolment with at least one follow-up visit completed, and who were studied prospectively until March 2001. Incidence rates were calculated using the Kaplan-Meier method. The Cox proportional hazards regression model was used to identify independent predictors of time to HIV seroconversion. RESULTS: As of March 2001, seroconversion had occurred in 110 of 939 participants (64 men, 46 women), yielding a cumulative incidence rate of HIV at 48 months of 13.4% (95% confidence interval [CI] 11.0%-15.8%). Incidence was higher among women than among men (16.6% v. 11.7%, p = 0.074). Multivariate analysis of the female participants' practices revealed injecting cocaine once or more per day compared with injecting less than once per day (adjusted relative risk [RR] 2.6, 95% CI 1.4-4.8), requiring help injecting compared with not requiring such assistance (adjusted RR 2.1, 95% CI 1.1-3.8), having unsafe sex with a regular partner compared with not having unsafe sex with a regular partner (adjusted RR 2.9, 95% CI 0.9-9.5) and having an HIV-positive sex partner compared with not having an HIV-positive sex partner (adjusted RR 2.7, 95% CI 1.0-7.7) to be independent predictors of time to HIV seroconversion. Among male participants, injecting cocaine once or more per day compared with injecting less than once per day (adjusted RR 3.3, 95% CI 1.9-5.6), self-reporting identification as an Aboriginal compared with not self-reporting identification as an Aboriginal (adjusted RR 2.5, 95% CI 1.4-4.2) and borrowing needles compared with not borrowing needles (adjusted RR 2.0, 95% CI 1.1-3.4) were independent predictors of HIV infection. INTERPRETATION: HIV incidence rates among female injection drug users in Vancouver are about 40% higher than those of male injection drug users. Different risk factors for seroconversion for women as opposed to men suggest that sex-specific prevention initiatives are urgently required.

Adolescent↗
PubMed2002

Modified Delphi survey for decision analysis for prophylaxis of post-radiation osteonecrosis.

OBJECTIVES: to augment epidemiological data from the literature, assist Bayesian perspectives and a decision analytic framework for the minimization of post-radiation osteonecrosis (PRON; osteoradionecrosis) and its impacts in irradiated head and neck cancer patients. MATERIALS AND METHODS: a modified Delphi process survey of 15 international clinical experts was used to identify and assess outcome data and factors related to PRON risk, extraction, and factor suitability for formal decision analysis. Clinimetric pain and function outcome scales were created and assessed for relevance to quality of life. RESULTS AND CONCLUSIONS: expert opinion qualitative assessments were generally adequate and consistent between open- and close-ended items, but many quantitative (e.g. PRON risk rate) estimates were not. A research agenda advocated to validate the epidemiological database for minimization of PRON and decision analysis includes: adoption of a uniform definition of PRON, and ICD code for non-experimental databases; more detailed, consistent data reporting in articles; and quality of life studies.

Decision Support Techniques↗
PubMed2002

Opportunities for prevention: hepatitis C prevalence and incidence in a cohort of young injection drug users.

The objective of this study was to compare sociodemographic, drug, and sexual risk characteristics between hepatitis C virus (HCV) baseline positive and negative young (13-24 years) injection drug users (IDUs) and to determine prospective risk factors for HCV seroconversion among the youth. Data were collected through the Vancouver Injection Drug Users Study (VIDUS). To date, more than 1,400 Vancouver-area IDUs have been enrolled and followed up; 234 were aged 24 years and younger. Semiannually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for human immunodeficiency virus (HIV) and HCV. Univariate and multivariate logistic regression analyses were undertaken to investigate predictors of baseline HCV positivity. In the multivariate analyses, Cox regression models with time-dependent covariates were used to identify predictors of HCV seroconversion. Of the 232 young injectors, 107 (46%) were HCV positive at baseline and a further 37 HCV seroconverted during the study period for an incidence rate of 37.3 per 100 person-years. Baseline positivity was associated with Aboriginal ancestry, older age, greater number of years injecting drugs, recent incarceration, sex trade work, more than 100 lifetime sexual partners, a previous sexually transmitted disease, living in the IDU epicenter, and injection more than once per day of heroin, cocaine, and speedball. Factors independently associated with HCV seroconversion were having a partner who uses injection drugs, requiring help to inject, and injection of cocaine more than once daily. In conclusion, unlike older IDUs, more than one half of young injectors were HCV negative at recruitment. Thus, there is a window of opportunity for prevention. However, the incidence rate of HCV among these young IDUs is alarming, suggesting that the opportunity to intervene is exceedingly small.

Adolescent↗
PubMed2002

Risk-taking behaviors among injecting drug users who obtain syringes from pharmacies, fixed sites, and mobile van needle exchanges.

Needle-exchange programs (NEPs) have been shown to be effective in reducing harm related to injection drug use and to act as an important link between the injection drug using community and preventive/treatment services. Different needle-exchange distribution methods may reach different subpopulations of injecting drug users (IDUs). We undertook this study to characterize risk behaviors by primary source of clean needles accessed by IDUs in a city with pharmacy access and fixed and mobile exchange programs. We hypothesized there would be a gradient of risk across the three types of distribution. Data were collected from within the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort study. Participants who primarily obtained clean needles from pharmacies, fixed sites, or mobile exchange vans were compared using the Cochran-Armitage trend test to test for trends in increasing risk behaviors across the three types of distribution. Ordinal multivariate regression was used to adjust the associations for potential confounders. Results illustrate clear trends for increasing risk profiles from pharmacy to fixed site to mobile exchange vans. Van users were generally at higher risk than fixed-site and pharmacy users. Independent predictors of van use were fewer years injecting, difficulty finding needles, Aboriginal ethnicity, incarceration in the previous 6 months, and injecting cocaine daily. An important component of needle-exchange programs is outreach to access those who are at highest risk. Use of distribution beyond fixed sites will improve such outreach, thereby increasing program effectiveness and further preventing the transmission of blood-borne infections.

Adult↗
PubMedDate not supplied

Recent incarceration independently associated with syringe sharing by injection drug users.

OBJECTIVES: Few prospective studies are available on the relationship between incarceration and HIV risk among injection drug users (IDUs). The authors evaluated self-reported rates of syringe sharing and incarceration among a cohort of IDUs. METHODS: This study analyzed syringe lending by HIV-infected IDUs and syringe borrowing by HIV-negative IDUs among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with each outcome (syringe lending and borrowing) were evaluated using generalized estimating equations for binary outcomes. RESULTS: The study sample consisted of 1,475 IDUs who were enrolled into the VIDUS cohort from May 1996 through May 2002. At baseline, 1,123 (76%) reported a history of incarceration since they first began injecting drugs. Of these individuals, 351 (31%) reported at baseline that they had injected drugs while incarcerated. Among 318 baseline HIV-infected IDUs, having been incarcerated in the six months prior to each interview remained independently associated with syringe lending during the same period (adjusted odds ratio [OR]=1.33; 95% confidence interval [CI] 1.06, 1.69; p=0.015). Similarly, among the 1,157 baseline HIV-negative IDUs, having been incarcerated in the six months prior to each interview remained independently associated with reporting syringe borrowing during the same period (adjusted OR=1.26; 95% CI 1.12, 1.44; p<0.001). CONCLUSIONS: Incarceration was independently associated with risky needle sharing for HIV-infected and HIV-negative IDUs. This evidence of HIV risk behavior should reinforce public health concerns about the high rates of incarceration among IDUs.

Adult↗
PubMedDate not supplied

Health and socioeconomic status differences among antibody hepatitis C positive and negative transfusion recipients, 1986-1990.

OBJECTIVE: To characterize the socioeconomic and health status, disease symptoms of anti-HCV-positive and negative transfusion recipients. METHODS: A cross-sectional interviewer-administered survey of subjects identified through the British Columbia Blood Recipient Program. Study subjects were 18 years and over and had to have had a transfusion between August 1, 1986 and June 30, 1990 and completed an interview of satisfactory quality. Anti-HCV-positive subjects were those seeking monetary compensation from the provincial and Canadian governments and the comparison group was randomly selected from a pool of anti-HCV-negative subjects. The study was designed to detect an assumed difference of 20% in signs and symptoms between the two groups. Statistical comparisons were conducted using bivariate and multivariate logistic regression analyses. RESULTS: A total of 241 and 222 anti-HCV-positive and negative subjects were respectively interviewed and met the study's eligibility criteria. Results from the multivariate analysis indicated that anti-HCV-positive recipients were more likely to have two or more clinical symptoms (OR = 3.53; 95% CI: 1.44, 8.70), to be in worse health status as compared to ten years previous (OR = 1.60; 95% CI: 1.30, 1.96), to have a higher illness intrusiveness rating (OR = 1.35; 95% CI: 1.25, 1.46), and to be younger (OR = 0.97; 95% CI: 0.95, 0.98). CONCLUSION: Our results show that persons exposed to HCV were more likely to have had two or more clinical symptoms, be male, have worse health status as compared to ten years previous, have a higher illness intrusiveness rating, and be younger in age.

Aged↗