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Biomedical subjects

S C Morton

Publications and source records attributed to S C Morton.

At least 37 records · Page 2Linked to original sources
PubMed2001

A comparison of unmet needs for dental and medical care among persons with HIV infection receiving care in the United States.

OBJECTIVE: Oral health conditions associated with HIV disease are frequently more severe than those of the general population, making access to both dental and medical care important. Using the domains specified in the Behavioral Model of Health Services Use, this paper examines the correlates of unmet needs for dental and medical care in a nationally representative sample of patients with HIV. METHODS: This investigation is a cross-sectional study using baseline data from the HIV Cost and Services Utilization Study (HCSUS), the first nationally representative study of persons in care for HIV. Using probability-based techniques, 4,042 people were randomly selected in January 1996, and 2,864 (71%) completed a structured interview that included questions on unmet needs for dental and medical care. Regression analysis was used to identify variables associated with having unmet needs for dental care only, medical care only, and both medical and dental care. RESULTS: Of the estimated 230,900 people in treatment for HIV in the United States, approximately 58,000 had unmet medical or dental needs based on self-reported data. Unmet dental needs were more than twice as prevalent as unmet medical needs (32,900 vs 14,300), and 11,600 people were estimated to have both types of unmet needs. Multinomial logit regression showed that persons with low income had increased odds of reporting unmet needs for both dental and medical care. The uninsured and those insured by Medicaid without dental benefits had more than three times the odds of having unmet needs for both types of care than did the privately insured. CONCLUSIONS: To serve both the dental and medical needs of diverse populations affected by HIV disease, greater coordination of services is needed. In addition, state insurance programs for people with HIV should consider the feasibility of expanding their benefit structure to include dental care benefits.

Adult↗
PubMed2001

Evidence assessment of management of acute otitis media: I. The role of antibiotics in treatment of uncomplicated acute otitis media.

CONTEXT: In 1995, >5 million episodes of acute otitis media (AOM) accounted for $3 billion in health care expenditures. OBJECTIVES: To synthesize the literature on the natural history of AOM, the effectiveness of antibiotic treatment in uncomplicated AOM, and the relative effectiveness of specific antibiotic regimens. DATA SOURCES: Seven electronic databases for articles published between 1966 and March 1999 and reference lists in proceedings, published articles, reports, and guidelines. STUDY SELECTION: Two physicians independently assessed each article. Studies addressing AOM in children 4 weeks to 18 years old were included; those addressing children with immunodeficiencies or craniofacial abnormalities were excluded. Randomized, controlled trials (RCTs) were used to assess antibiotic effectiveness, and RCTs and cohort studies were used to assess the natural history of AOM. Among the 3491 citations identified, 80 (2.3%) met our inclusion criteria. DATA EXTRACTION: Two physicians independently abstracted data and assessed the quality of studies using a validated scale for RCTs and 8 quality components for cohort studies. DATA SYNTHESIS: Random-effects estimates of pooled absolute rate differences of outcomes were derived, and heterogeneity of both the rates and rate differences was assessed. Children with AOM not treated with antibiotics experienced a 1- to 7-day clinical failure rate of 19% (95% confidence interval: 0.10-0.28) and few suppurative complications. When patients were treated with amoxicillin, the 2- to 7-day clinical failure rate was reduced to 7%, a 12% (95% confidence interval: 0.04-0.20) reduction. Adverse effects, primarily gastrointestinal, were more common among children on cefixime than among those on ampicillin or amoxicillin. They were also more common among children on amoxicillin-clavulanate than among those on azithromycin. CONCLUSIONS: The majority of uncomplicated cases of AOM resolve spontaneously without apparent suppurative complications. Ampicillin or amoxicillin confers a limited therapeutic benefit. There is no evidence to support any particular antibiotic regimens as more effective at relieving symptoms. Certain antibiotics are more likely than others to cause diarrhea and other adverse events.

Acute Disease↗
PubMed2001

Evidence assessment of management of acute otitis media: II. Research gaps and priorities for future research.

OBJECTIVES: To report research gaps and priorities of future research identified during an evidence assessment process on the management of acute otitis media (AOM). METHODS: A conceptual framework for management of AOM was developed to guide the evidence assessment. An 11-member technical expert panel guided the selection of key questions, prioritization of influencing factors, development of scope, definition of AOM, and search strategy through polling processes and conference calls. Quality of clinical trials was evaluated using established scales. Outcome measures were abstracted from each study. RESULTS: A total of 3461 titles and abstracts were screened, and 760 full-length articles were reviewed. Of the 760 articles, 80 studies addressed the key questions. In defining AOM, 42 (52.5%) of the 80 studies included the middle-ear effusion component, only 2 (2.5%) included the rapid onset component, and 26 (32.5%) included the signs/symptoms of inflammation component. None of the 80 studies used all 3 components. Of the 74 controlled trials, 39 (53%) were of acceptable quality (Jadad score of 3 or higher). The technical experts did not agree in the ranking of the importance of the 41 influencing factors (Kendall's coefficient of concordance was 0.0022). Another poll also indicated diverse opinions of the experts on the importance of 7 key questions derived from the conceptual framework (Kendall coefficient of concordance is 0.21). Furthermore, our review found that the type and definition of outcome measure varied. CONCLUSIONS: Despite the large body of literature on AOM, its quality is uneven and its findings are not generalizable. Future research should try to answer all key questions and investigate all risk factors in well-designed, scientific studies.

Acute Disease↗
PubMed2000

Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.

OBJECTIVE: Because of the pressure for timely, informed decisions in public health and clinical practice and the explosion of information in the scientific literature, research results must be synthesized. Meta-analyses are increasingly used to address this problem, and they often evaluate observational studies. A workshop was held in Atlanta, Ga, in April 1997, to examine the reporting of meta-analyses of observational studies and to make recommendations to aid authors, reviewers, editors, and readers. PARTICIPANTS: Twenty-seven participants were selected by a steering committee, based on expertise in clinical practice, trials, statistics, epidemiology, social sciences, and biomedical editing. Deliberations of the workshop were open to other interested scientists. Funding for this activity was provided by the Centers for Disease Control and Prevention. EVIDENCE: We conducted a systematic review of the published literature on the conduct and reporting of meta-analyses in observational studies using MEDLINE, Educational Research Information Center (ERIC), PsycLIT, and the Current Index to Statistics. We also examined reference lists of the 32 studies retrieved and contacted experts in the field. Participants were assigned to small-group discussions on the subjects of bias, searching and abstracting, heterogeneity, study categorization, and statistical methods. CONSENSUS PROCESS: From the material presented at the workshop, the authors developed a checklist summarizing recommendations for reporting meta-analyses of observational studies. The checklist and supporting evidence were circulated to all conference attendees and additional experts. All suggestions for revisions were addressed. CONCLUSIONS: The proposed checklist contains specifications for reporting of meta-analyses of observational studies in epidemiology, including background, search strategy, methods, results, discussion, and conclusion. Use of the checklist should improve the usefulness of meta-analyses for authors, reviewers, editors, readers, and decision makers. An evaluation plan is suggested and research areas are explored.

Epidemiology↗
PubMed2000

Lack of progress in labor as a reason for cesarean.

OBJECTIVE: To estimate the prevalence of lack of progress in labor as a reason for cesarean delivery and to compare published diagnostic criteria with the labor characteristics of women with this diagnosis. METHODS: We reviewed medical records and did a postpartum telephone survey to collect data from 733 women who delivered full-term, nonbreech infants by unplanned cesarean between March 1993 and February 1994. These were a subset of 2447 births sampled at delivery from 30 hospitals in Los Angeles County and Iowa. We measured the proportion of unplanned cesareans done for lack of progress in labor, the cervical dilatation at the time of cesarean, length of the second stage, and slope of the active phase among the women. We estimated the proportion of these cesareans that conformed to the ACOG criteria for the diagnosis of lack of progress. RESULTS: Lack of progress was a reason for 68% of unplanned, vertex cesareans. At least 16% of the subjects who had cesareans for lack of progress were in the latent phase of labor according to ACOG criteria. The second stage was not prolonged in 36% of the women who delivered at 10 cm. CONCLUSION: Lack of progress in labor is a dominant reason for cesarean delivery. Many cesareans are done during the latent phase of labor, and in the second stage of labor when it is not prolonged. These practices do not conform to published diagnostic criteria for lack of progress.

Adolescent↗
PubMed2000

HIV-infected parents and their children in the United States.

OBJECTIVES: This study sought to determine the number, characteristics, and living situations of children of HIV-infected adults. METHODS: Interviews were conducted in 1996 and early 1997 with a nationally representative probability sample of 2864 adults receiving health care for HIV within the contiguous United States. RESULTS: Twenty-eight percent of infected adults in care had children. Women were more likely than men to have children (60% vs 18%) and to live with them (76% vs 34%). Twenty-one percent of parents had been hospitalized during the previous 6 months, and 10% had probably been drug dependent in the previous year. Parents continued to have children after being diagnosed with HIV: 12% of all women conceived and bore their youngest child after diagnosis, and another 10% conceived before but gave birth after diagnosis. CONCLUSIONS: Clinical and support services for people affected by the HIV epidemic should have a family focus.

Adolescent↗
PubMed2000

Principles of metaanalysis.

Metaanalysis is a relatively new tool to help make evidence based decisions. This technique involves the systematic examination of available evidence on a given clinical topic, and the summary of that evidence using statistical techniques that pool data from multiple studies to yield a single result. We briefly discuss the principal steps in a metaanalysis: identifying all the studies; assessing the studies for quality; organizing the studies into subgroups; and summarizing the results.

Humans↗
PubMed1999

Identifying adolescents at risk for hard drug use: racial/ethnic variations.

PURPOSE: To examine early risk factors for initiation of hard drug use by 10th grade in a sample of adolescents drawn from diverse high schools and communities, compares the results across different racial/ethnic groups, and to evaluate the predictive performance of a user-friendly risk scale against the more complex logistic model. METHODS: Using longitudinal data from 4347 adolescents from California and Oregon, we developed and cross-validated logistic and additive prediction models for non-Hispanic white students (the largest group) and assessed how well each model worked for black, Hispanic, and Asian adolescents. We also developed a best logistic model for each group. Predictor variables were measured at Grade 7; the hard drug use outcome was measured at Grade 10. RESULTS: Major risk factors for initiation of hard drug use included early marijuana and cigarette use, deviant behavior, poor parent-child communication, being offered drugs, and prodrug attitudes and intentions. White adolescents had the most risk factors, followed by Hispanics, Asians, and Blacks. Specific risk factors played more important roles for some groups than others. Early marijuana use provided the strongest warning signal for all groups except Blacks, while exposure to drug offers increased the risk for all but Hispanic youth. Poor communication with parents was particularly important for Hispanic and Asian adolescents, whereas doing poorly in school was a key predictor only for Asians. Social influences to use drugs and intentions to use them were the only predictors for Blacks. Although family disruption and limited parental education were associated with an increase in risk for white adolescents, the latter had the opposite effect for Hispanics and Blacks. The simple additive model worked almost as well as the most complicated logistic model in predicting hard drug use for each group except Blacks. CONCLUSIONS: These results suggest that curbing early initiation of marijuana and cigarettes and reducing prodrug influences and attitudes may dampen initiation of other substances for most youth. They also suggest that drug prevention programs need to be sensitive to differences across racial/ethnic groups and that using social background characteristics as indicators of risk can be very misleading. Carefully constructed risk scales based on simple additive models could help guide program development and provide clinicians with useful information about a troubled adolescent's likely trajectory.

Adolescent↗
PubMed1999

Systematic review of risk factors for urinary tract infection in adults with spinal cord dysfunction.

Recurrent urinary tract infections (UTIs) occur frequently in persons with neurogenic bladders due to spinal cord dysfunction, resulting in increased morbidity and cost. The authors conducted a systematic review to identify risk factors for UTI using controlled clinical trials, cohort, and cross-sectional studies that assessed risk factors for UTI and included bacteriuria or UTI as an outcome. Twenty-two studies met the inclusion criteria. Quality assessment revealed important methodological deficiencies. Two studies provide evidence supporting increased bladder residual volume as a risk factor. Most of the retrieved studies investigated method of drainage with the consistent finding that persons using intermittent catheterization had fewer infections than those with indwelling catheters. There is conflicting evidence over the value of sterile or "no touch" catheter techniques compared with clean intermittent catheterization. There is insufficient evidence to assess risk due to psychosocial, behavioral, and hygiene factors; sex; level of function; and time since injury.

Adult↗
PubMed1999

A new paradigm for alcohol use in older persons.

BACKGROUND: Current paradigms for conceptualizing alcohol-related problems typically focus on persons who are abusing or dependent on alcohol. These paradigms may not apply to older drinkers whose alcohol use, regardless of consumption-level, can cause problems because of age-related changes in physiology and interactions with increased morbidity, medication use, and functional limitations. OBJECTIVE: We convened an expert panel# to develop clinical indications of harmful, hazardous, and nonhazardous drinking in persons 65 years of age and older. RESEARCH DESIGN AND SUBJECTS: Nine panelists with expertise in psychiatry, geriatrics, internal medicine, and alcohol research were provided with epidemiological data and a published explicit literature review of alcohol use in the elderly. The RAND/UCLA two-round panel method was used to develop the indications. After the second round, the authors wrote a draft statement that was circulated to the panelists whose comments were incorporated into a final document. RESULTS: Panelists agreed on 215 scenarios in which older peoples' use of alcohol either alone or in the presence of chronic medical conditions, medication use, symptoms, smoking, and functional limitations are hazardous or harmful. Panelists' ratings of risk did not differ significantly between persons aged 65 to 74 years and those aged 75 years and older. CONCLUSION: Alcohol use may be hazardous or harmful for older persons, particularly in conjunction with physical or emotional illnesses, medication use, functional limitations, smoking, and driving after drinking. When asking about alcohol use in older persons, clinicians need to be aware of these factors to assist in identifying and managing potential or actual alcohol-related problems.

Aged↗
PubMed1999

Utilization of mental health and substance abuse services among homeless adults in Los Angeles.

OBJECTIVES: Even though psychiatric disorders are disproportionately present among the homeless, little is known about the extent to which homeless people receive treatment for those problems or the factors that are associated with receiving treatment. This article examines utilization and predictors of mental health and substance abuse treatment among a community-based probability sample of homeless adults. METHODS: The data analyzed here were collected through face-to-face interviews with 1,563 homeless individuals. Bivariate analyses examined differences between homeless men and women in (1) the prevalence of major mental illnesses and substance dependence and (2) utilization of inpatient and outpatient treatment services for those with specific diagnoses. Logistic regression analyses identified predictors of mental health treatment among those with chronic mental illness and substance abuse treatment among those with recent substance dependence. RESULTS: Two-thirds of these homeless adults met criteria for chronic substance dependence, whereas 22% met criteria for chronic mental illness, with substantial overlap between those two disorders: 77% of those with chronic mental illness were also chronic substance abusers. Only one-fifth of each of those two groups reported receiving treatment for those disorders within the last 60 days. Mental health service utilization was predicted largely by factors related to need (eg, diagnosis, acknowledgment of a mental health problem), whereas substance abuse service utilization was predicted by myriad additional factors, reflecting, in part, critical differences in the organization and financing of these systems of care. CONCLUSIONS: More attention must be directed at how to better deliver appropriate mental health and substance abuse services to homeless adults.

Adolescent↗
PubMed1999

The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States.

OBJECTIVES: To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data. DESIGN: Survey of a nationally representative sample of 2,864 adults receiving HIV care. MAIN INDEPENDENT VARIABLES: Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick. MAIN OUTCOME MEASURES: Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale. RESULTS: More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access. CONCLUSIONS: Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

Adult↗
PubMed1999

National probability samples in studies of low-prevalence diseases. Part II: Designing and implementing the HIV cost and services utilization study sample.

OBJECTIVE: The design and implementation of a nationally representative probability sample of persons with a low-prevalence disease, HIV/AIDS. DATA SOURCES/STUDY SETTING: One of the most significant roadblocks to the generalizability of primary data collected about persons with a low-prevalence disease is the lack of a complete methodology for efficiently generating and enrolling probability samples. The methodology developed by the HCSUS consortium uses a flexible, provider-based approach to multistage sampling that minimizes the quantity of data necessary for implementation. STUDY DESIGN: To produce a valid national probability sample, we combined a provider-based multistage design with the M.D.-colleague recruitment model often used in non-probability site-specific studies. DATA COLLECTION: Across the contiguous United States, reported AIDS cases for metropolitan areas and rural counties. In selected areas, caseloads for known providers for HIV patients and a random sample of other providers. For selected providers, anonymous patient visit records. PRINCIPAL FINDINGS: It was possible to obtain all data necessary to implement a multistage design for sampling individual HIV-infected persons under medical care with known probabilities. Taking account of both patient and provider nonresponse, we succeeded in obtaining in-person or proxy interviews from subjects representing over 70 percent of the eligible target population. CONCLUSIONS: It is possible to design and implement a national probability sample of persons with a low-prevalence disease, even if it is stigmatized.

Data Collection↗
PubMed1998

The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium.

BACKGROUND AND METHODS: In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas. RESULTS: During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than $10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were $5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were $6.7 billion, which is about $20,000 per patient per year. CONCLUSIONS: In this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Cesarean childbirth and psychosocial outcomes: a meta-analysis.

A comprehensive literature review with meta-analysis examines the differences between vaginal and cesarean delivery on 23 psychosocial outcomes of childbirth. The most robust findings suggest that cesarean mothers, compared with mothers who delivered vaginally, expressed less immediate and long-term satisfaction with the birth, were less likely ever to breast-feed, experienced a much longer time to first interaction with their infants, had less positive reactions to them after birth, and interacted less with them at home. Some differences were also found between unplanned and planned cesarean sections; none were found between birthing methods for maternal confidence for infant caretaking soon after birth, maternal anxiety in the hospital and at home, maternal stress at home, maternal return to work, and continuation of breast-feeding once begun. Implications of these findings for theory, research, and childbirth practice are discussed.

Breast Feeding↗