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Biomedical subjects

H V Fineberg

Publications and source records attributed to H V Fineberg.

At least 37 records · Page 2Linked to original sources
PubMed1991

Infections in HIV-infected travelers: risks and prevention.

OBJECTIVE: To review risks for infection and to outline strategies to protect the health of travelers infected with human immunodeficiency virus (HIV). DATA SOURCES: Original reports and summaries of the geographic distribution and frequency of infections as well as of special risks these infections impose on HIV-infected persons. The recommendations incorporate guidelines published by the Centers for Disease Control (CDC) and the World Health Organization. STUDY SELECTION: Sources containing the most recent, pertinent information. DATA SYNTHESIS: Infections of the gastrointestinal tract are common in all travelers to developing countries and are likely to be more frequent, severe, and difficult to treat in HIV-infected persons. Prominent among the respiratory tract infections that pose special risks to HIV-infected travelers are influenza, measles, and fungal infections with geographically focal distributions. The most common vector-borne infection, malaria, appears to present relatively little, if any, incremental risk to the HIV-infected traveler. Persons with HIV infection respond less vigorously to vaccines and have a higher frequency of adverse reactions to antimicrobial agents. Nevertheless, immunizations and chemoprophylaxis can reduce the risk for many travel-related infections. Additionally, there are protective measures that travelers can take to minimize exposure to pathogens. CONCLUSIONS: By understanding the risks for disease in different destinations, assessing patients' HIV status, counseling patients about travel plans and personal protective measures, appropriately using vaccines and chemoprophylaxis, as well as instituting early treatment of infection, physicians can help HIV-infected patients to preserve their health during travel.

Gastrointestinal Diseases↗
PubMed1991

Bleach programs for preventing AIDS among i.v. drug users: modeling the impact of HIV prevalence.

BACKGROUND: The growing importance of drug use as a mode of HIV transmission has led to increased attention to AIDS prevention among intravenous drug users (IVDUs). This analysis examines the effectiveness of bleach distribution, a program to prevent HIV transmission via shared needles. METHODS: We used a Markov model to assess the role of the initial HIV prevalence among drug users in determining the effectiveness of bleach programs. The model incorporates survey data on risk behaviors and published information describing HIV incubation and mortality. It predicts life expectancy for cohorts of IVDUs with and without a bleach program to estimate program effectiveness. RESULTS: We found that bleach programs can produce the greatest life-year savings in areas of low HIV prevalence. In the lowest prevalence scenario (0.02 initial prevalence), initiation of the program resulted in a projected savings of 2.3 life years per HIV-negative drug user, compared with 1.7 and 1.3 years under medium (0.25) and high (0.60) prevalence, respectively. CONCLUSIONS: While bleach programs are beneficial in all groups of IVDUs, these results highlight the advantages of introducing bleach programs early, when prevalence is still comparatively low in a drug-user population.

Acquired Immunodeficiency Syndrome↗
PubMed1990

Paying the medical cost of the HIV epidemic: a review of policy options.

The complex health care needs of people with HIV infection highlight inadequacies in our health care financing system and raise the question of how best to pay for care. AIDS requires a broad continuum of care to maintain high quality and reasonable costs. A simultaneous need is to assure access to care for patients with HIV infection who lack insurance or entitlement to health care benefits. We suggest new and practical payment mechanisms that can encourage the availability of comprehensive care for people with HIV infection. We suggest changes in state and federal payment policies that would make the cost of providing AIDS care more of a collective, community responsibility. We recommend mandated workplace insurance, extension of Medicaid eligibility to all with incomes below the federal poverty level, an opportunity for individuals with incomes to 200% of the poverty level to purchase Medicaid coverage, mechanisms to encourage public and private agencies to pay for continued health insurance after loss of employment, and a shortened waiting period for Medicare disability.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Estimating prevalence of HIV infection: considerations in the design and analysis of a national seroprevalence survey.

A national survey to estimate prevalence of HIV infection would provide a useful addition to available information about the current status and future prospects of the AIDS epidemic in the United States. Both design and interpretation of a prevalence study should make use of existing information about the biology and epidemiology of AIDS. In conjunction with such information, a survey would help increase the accuracy of prevalence estimates and aid in making projections, despite the possibility that participation rates will differ in infected and uninfected individuals.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Education to prevent AIDS: prospects and obstacles.

A number of obstacles thwart effective education to prevent AIDS in the United States. These include the biological basis and social complexity of the behaviors that must be changed, disagreement about the propriety of educational messages to prevent AIDS, uncertainty about the degree of risk to the majority of Americans, and dual messages of reassurance and alarm from responsible officials. Long-term protection of an individual from infection requires extreme changes in risk-taking behavior. Partial shifts toward safer practices may be epidemiologically important in retarding the rate and extent of spread of infection. Though some striking changes in behavior have occurred, especially in homosexual populations in areas with high prevalence of AIDS, educational efforts to date have succeeded more in raising awareness and knowledge about AIDS than in producing sufficient changes in behavior. The United States has yet to mount a nationwide comprehensive, intensive, and targeted education program to prevent AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1987

Compulsory premarital screening for the human immunodeficiency virus. Technical and public health considerations.

The effectiveness of a mandatory premarital screening program was examined as a means of curtailing the spread of the human immunodeficiency virus (HIV) infection in the United States. The epidemiology of the HIV, the technical characteristics of tests for antibodies to HIV, and the logistic, economic, and legal implications of such a program were considered. In one year, universal premarital screening in the United States currently would detect fewer than one tenth of 1% of HIV-infected individuals at a cost of substantially more than +100 million. More than 100 infected individuals would be told that they were probably not infected, and there would likely be more than 350 false-positive results. Public education, counseling of individuals, and discretionary testing can be important tools in reducing the spread of HIV infection, but mandatory premarital screening in a population with a low prevalence of infection is a relatively ineffective and inefficient use of resources.

Acquired Immunodeficiency Syndrome↗
PubMed1987

A cost-effectiveness model for coronary thrombolysis/reperfusion therapy.

A model was designed to examine the relations between incremental costs and benefits of coronary thrombolysis/reperfusion therapy. The model allows for the study of intravenous and intracoronary streptokinase, intravenous tissue plasminogen activator and primary angioplasty. Three strategies for the management of reocclusion are also compared. It was found that each of the following four variables can be responsible for a 2- to 15-fold variation in the costs per additional survivor: 1) the quantity of jeopardized myocardium, 2) the duration of coronary occlusion before the onset of therapy, 3) the time required from the onset of therapy until reperfusion is achieved, and 4) the reocclusion management strategy. Therapeutic strategies involving intravenous administration of thrombolytic agents were found to be consistently more cost effective than were strategies involving intracoronary administration of thrombolytic agents and primary angioplasty. In patients with a large or moderate-sized infarct, proper selection of intravenous protocols and reocclusion management strategies leads to costs of $7,000 to $100,000/additional survivor, costs that are similar to those of many generally accepted medical practices. Substantially higher costs per additional survivor are incurred with the routine use of thrombolytic therapy in patients with a small infarct or the routine use of coronary artery bypass surgery to reduce the risk of reocclusion after successful thrombolytic therapy. Decisions regarding which patients should receive thrombolysis/reperfusion therapy depend on society's willingness to pay for its incremental benefits.

Angioplasty, Balloon↗
PubMed1987

Clinical evaluation: how does it influence medical practice?

This paper reviews reports of the effects of clinical evaluations on physician awareness and behavior. Among the reviewed papers, there are 28 studies of the effect of specific randomized clinical trials (RCTs) on 19 different medical practices. After analyzing these 28 papers, there remain two (7%) where the RCT has clear implications for practice, where the pattern of practice reported quantitatively over time conforms fully to the RCT findings, where the RCT preceded the change in the pattern of practice, and where findings from the RCT differ from the results of other forms of evaluation. The majority of the reviewed papers do not support an inference that RCTs have a strong, direct influence in changing established clinical practices. Clinical evaluation is one among many factors bearing on changes in medical practices. Improving the care of patients requires both improved methods of evaluation and more effective translation of the results of evaluation into practice. Evaluations are likely to exert a greater impact on medical practices if they are buttressed by attention to other controllable factors, like channels of communication and environmental constraints and incentives, that affect the adoption and abandonment of medical practices.

Awareness↗
PubMed1984

Care of patients with a low probability of acute myocardial infarction. Cost effectiveness of alternatives to coronary-care-unit admission.

We conducted a cost-effectiveness analysis to examine the clinical and economic consequences of alternatives to admission to a coronary-care unit for patients who have a relatively low probability of acute myocardial infarction. Despite the fact that all our assumptions were slanted to favor the current standard policy of admission to a coronary-care unit, our analysis shows that admission to an intermediate-care unit providing resuscitative facilities and prophylactic lidocaine is highly cost effective. For patients with about a 5 per cent probability of infarction, admission to a coronary-care unit would cost $2.04 million per life saved and $139,000 per year of life saved, as compared with intermediate care. For the expected number of such patients annually in the United States, the cost would be $297 million to save 145 lives. At probabilities of infarction up to about 20 per cent, the incremental cost to save a year of life by choosing a coronary-care unit over an intermediate-care unit would be higher than the estimated cost of saving a year of life by treating a 40-year-old man with mild hypertension. Our results suggest that many patients who have a low risk of acute myocardial infarction would be appropriate candidates for admission to an intermediate-care unit.

Ambulatory Care↗
PubMed1984

Variation and information in white blood cell differential counts.

The magnitude and sources of variation in the white blood cell (WBC) count and differential count affect their information content and clinical value. This study describes components of variation in the WBC count and differential, estimates the magnitude of each component, and uses computer simulations to compare the information conveyed by the total WBC count and by the WBC differential count, expressed as the number of each type of cell and as the percentage of each cell type. Biologic variation is much greater than statistical sampling variation in differential WBC counts, even when a relatively small number of cells is classified. The commonly reported neutrophil percentage is inferior both to the neutrophil count and to the total WBC count in its ability to detect neutrophilia and to detect recovery from elevated levels. This conclusion holds for single as well as for sequential WBC differential determinations and regardless of the level of test result at which the clinician considers disease to be present. The total WBC count and the neutrophil count differ little in performance, so a neutrophilic patient's return to normal levels can safely be detected and monitored by relying on the less expensive total WBC count and foregoing repeated requests for differential counts.

Bacterial Infections↗
PubMed1984

Preferences for health outcomes. Comparison of assessment methods.

This study compared standard gamble (SG), time trade-off (TTO), and category scaling (CS) methods for assessing preferences among hypothetical outcomes of coronary artery bypass surgery. High correlations among assessment methods, as found in some previous studies, do not assure the absence of systematic differences in rating obtained by different methods. This study used analysis of variance to test for differences among the three assessment methods. Questionnaire responses were obtained from 67 of 109 physicians participating in a postgraduate course on clinical decision making, following a lecture and workshop on utility theory. SG and CS were used to rate multivariate combinations of angina (none, moderate, and severe) and survival (0, 5, and 10 years); and SG, TTO, and CS were used to rate univariate outcomes with angina (none, moderate, and severe) for the remainder of their life expectancy. SG ratings were higher than TTO ratings, which were higher than CS ratings (p less than 0.001 for all comparisons). Multivariate responses revealed a significant interaction between angina and survival dimensions using CS, but not using SG. We conclude that these methods are not interchangeable and that differences between SG and CS require a more complex explanation than differences in attitude toward risk.

Angina Pectoris↗