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PubMed1990

HIV infection and health policy.

The epidemic of human immunodeficiency virus (HIV) infection has given an urgency to health policy dilemmas that have long been brewing. By exacerbating long-standing problems, the epidemic has surpassed what we find tolerable and has pressured politicians and health officials to find solutions. Whether the approaches they take will substantially contribute to solving the underlying problems is unclear. Many persons engaged in health policy believe that in responding to the AIDS crisis we may be defining our society for future historians. Judgement may be passed on how compassionately we care for those who are sick, how effectively we choose our public health measures, and how creatively we apply our scientific knowledge. This paper addresses six challenges that face policymakers: (a) protecting people from discrimination, (b) designing testing and screening programs, (c) developing safe and effective antiviral drugs, (d) planning for future vaccine trials, (e) organizing and delivering health care to sufferers of HIV infection, and (f) financing such health care.

Delivery of Health Care↗
PubMed1982

Factors influencing participation in a rubella vaccination program.

During the course of a 7-day voluntary rubella vaccination program conducted at a large community-teaching hospital, 718 hospital workers were vaccinated, an overall vaccination rate of 29%. During and after the vaccination campaign, physicians, employees, and students were surveyed as to their reasons for accepting or rejecting rubella vaccine. Prior to the campaign few hospital workers realized that rubella vaccination was of importance in their case. Although paycheck notices, newsletters, and poster displays were all effective in publicizing the campaign, hospital workers most frequently cited discussions with other workers as the major factor leading to their acceptance of vaccination. The belief that a history of rubella, diagnosed clinically, was adequate assurance of immunity was common among physicians and employees and was the major obstacle to greater success in the campaign. Vaccine reactions were infrequent and mild and did not lead to excessive employee absenteeism.

Cost-Benefit Analysis↗
PubMedDate not supplied

A rubella vaccination program for women entering the U.S. Army.

A voluntary rubella vaccination program for female basic trainees was initiated on April 21, 1975, at Fort Jackson, S.C. A total of 29,852 women were tested for rubella titers between April 21, 1975, and December 31, 1977, and 6,167 were found to be nonimmune. An average of 53 percent of the susceptible women were vaccinated. The best results were obtained from August 1 to December 31, 1977, when 67 percent of the susceptible women were vaccinated. During this period, blood specimens for rubella titer and for pregnancy testing were obtained simultaneously. This procedure reduced the number of referrals to the Obstetrics-Gynecology Clinic, as well as the amount of training time lost when pregnancy testing and rubella titer testing were done on separate days. Despite the vaccination program, however, rubella epidemics occurred among female trainees at Fort Jackson in 1975, 1976, and 1977. A significant number of women are still susceptible to rubella. To reduce morbidity and the risk of congenital rubella syndrome, rubella titer testing and immunization of susceptibles should be considered for women-especially where they can be screened, counseled, and vaccinated en masse.

Family Planning Services↗
PubMed1992

Screening women of childbearing age for human immunodeficiency virus. A cost-benefit analysis.

In light of the increasing problem of perinatal human immunodeficiency virus (HIV) transmission, the issue of screening women for HIV is receiving considerable attention. We analyzed the costs and benefits of screening women of childbearing age for HIV. The analysis was based on a dynamic model of the HIV epidemic that incorporated disease transmission and progression, behavioral changes, and effects of screening and counseling. We found that the primary benefit of screening programs targeted to women of childbearing age lies not in the prevention of HIV infection in their newborns but in the prevention of infection in their adult contacts. Because of this benefit, screening medium- and high-risk women is likely to be cost-beneficial over a wide range of assumptions about program cost and behavioral changes in response to screening.

AIDS Serodiagnosis↗
PubMed1999

Antenatal HIV screening--knowledge, attitudes and practices of obstetricians in KKH.

AIM OF STUDY: To determine the knowledge, attitudes and practices of obstetricians with regards to HIV screening in pregnant women. METHOD: This is a cross-sectional study based on a questionnaire survey of all obstetricians in KKH from January to August 1997. MAIN OUTCOME MEASURES: Obstetricians' knowledge and beliefs of HIV epidemiology and HIV perinatal transmission, and attitudes and practices with regards to antenatal HIV screening. RESULTS: Forty-one (77.4%) obstetricians responded to the survey. At the time of the survey, only 43.9% of the respondents had offered the HIV serology test to their patients with only 17.1% and 19.5% providing pre-test and post-test counselling respectively. Seventy-eight percent of them were aware of reports that zidovudine could reduce the vertical HIV transmission rate. All the respondents felt that HIV testing should be performed in pregnant women. The majority (70.7%) felt that antenatal HIV testing should be voluntary rather than mandatory and 56.1% felt that the patients' civil rights and confidentiality could be more assured if HIV testing is voluntary than if it was mandatory. Most respondents (56.1%) felt that antenatal HIV screening should be universally offered rather than targeted to those with risk factors. Most obstetricians did not feel comfortable (58.5%) or competent (80.5%) to manage HIV infection in pregnancy. Those who felt competent were more likely to feel comfortable, more likely to have provided HIV test in the clinic, and less likely to opt out of caring for an HIV-infected patient. CONCLUSION: The majority of the surveyed obstetricians would support a program of voluntary antenatal HIV screening that is universally offered to all pregnant women. The feelings of discomfort and incompetence of the obstetricians towards caring for an HIV-infected pregnant woman need to be addressed further. There is a need for continuing medical education to help obstetricians keep abreast with the advances in HIV screening and its management.

AIDS Serodiagnosis↗
PubMed2005

Hatch hunts for hospitals. Minnesota is now the main stage in U.S. debate over uninsured billing as a third group of hospitals sign pacts with state officials.

Minnesota has become the main stage in the debate over uninsured billing. Forthe third month in a row, state authorities have signed agreements with hospitals to expand discount programs and limit debt-collection efforts. The latest deal means about 75% of admissions there will be covered by such pacts. "We saw this as a positive response to a major public challenge," said Terence Pladson, left, of CentraCare.

Financial Management, Hospital↗
PubMed1987

Ethics in worksite health programming: who is served?

As relatively new innovations in the workplace, employee assistance and wellness/health promotion programs have not yet established clear identities. Thus ethical practices have not been fully considered or discussed. Based on extensive research experience with employee assistance programs, ethical issues are considered at three levels. Of primary concern are ethical issues affecting the individual employee, of which the scope of perceived or expected service relationships between employees and EAP coordinators is critical. There are tendencies to transfer models of community or private practice to the worksite, but the relationships both prescribed and implied at the worksite require that a different pattern of clinical relationships obtain. At the organizational level, it is critical for the worksite practitioners to be conscious of their authority in translating scientific data into recommended practices at the worksite and in transforming equivocal data and health practices into organizational norms. Finally, at the level of interorganizational relationships the worksite health program practitioner needs to be aware of the risks of becoming drawn into overly intimate relationships with external organizations who may come to benefit by special treatment that such relationships generate.

Behavior Control↗
PubMed1990

Blood and plasma donations among a cohort of intravenous drug users.

We evaluated the blood and plasma donation histories of a cohort of 2921 intravenous drug users in Baltimore, Md, and correlated these histories with their human immunodeficiency virus (HIV) serologic status, numbers of CD4 lymphocytes in the peripheral blood, and stigmata of intravenous drug use (scarred veins). Of the 793 intravenous drug users (27.1%) who had donated blood or plasma, 652 (82.2%) donated after they had started using intravenous drugs. Most subjects donated at commercial plasma centers, where they were paid $10 to $15 per donation. Although the HIV-1 seroprevalence of the entire cohort was 24.1%, the HIV-1 seroprevalence among those reporting plasma or blood donations declined progressively with time, from 17.1% in those who last donated in 1985 to 3.6% in those who last donated in 1988-1989. Many of the 437 intravenous drug users who had donated plasma or blood since 1985, when screening for HIV-1 was initiated, had not been notified and counseled about their HIV test results. Current programs to exclude individuals with a history of intravenous drug use from the plasma donor pool should be reevaluated and improved.

Baltimore↗
PubMed1989

Attitude of hospital personnel toward hepatitis B vaccination.

During a 1-yr period (November 1985-86), a free-of-charge vaccination program against hepatitis B was offered to 809 of the 1200 medical workers in a 650-bed general and regional hospital in Israel. Three hundred and eighteen (39.3%) accepted the offer and were vaccinated. The higher rates of acceptance were among cleaning personnel (96.3%) and student nurses (63.9%). The lower rates of acceptance were among physicians (46.5%) and nurses (24.9%). Different types of fear, as well as lack of knowledge, were the reasons responsible for 73.3% of all refusals. More specific and continuous health educational efforts among high-risk groups should be initiated for voluntary vaccination programs in Israel.

Attitude of Health Personnel↗
PubMed2002

Voluntary saccadic eye movements in humans studied with a double-cue paradigm.

In the classic double-step paradigm, subjects are required to make a saccade to a visual target that is briefly presented at one location and then shifted to a new location before the subject has responded. The saccades in this situation are "reflexive" in that they are made in response to the appearance of the target itself. In the present experiments we adapted the double-step paradigm to study "voluntary" saccades. For this, several identical targets were always visible and subjects were given a cue to indicate that they should make a saccade to one of them. This cue was then changed to indicate another of the targets before the subject had responded: double-cue (DC) paradigm. The saccadic eye movements in our DC paradigm had many features in common with those in the double-step paradigm and we show that apparent differences can be attributed to the spatio-temporal arrangements of the cues/targets rather than to any intrinsic differences in the programming of these two kinds of eye movements. For example, a feature of our DC paradigm that is not seen in the usual double-step paradigm is that the second cue could cause transient delays of the initial saccade, and these delays still occurred when the second cue was reflexive--provided that it was at the fovea (as in our DC paradigm) and not in the periphery (as in the usual double-step paradigm). Thus, the critical factor for the delay was the retinal (foveal) location of the second cue/target--not whether it was cognitive or reflexive--and we argue that the second cue/target is here acting as a distractor. We conclude that the DC paradigm can be used to study the programming of voluntary saccades in the same way that the double-step paradigm can be used to study reflexive saccades.

Cognition↗
PubMed1994

Maternal-newborn human immunodeficiency virus infection in Harlem.

OBJECTIVE: To determine the prevalence of human immunodeficiency virus type 1 (HIV-1) infection and its association with illicit drug use for mothers being delivered of infants at an inner-city municipal hospital. METHODS: We anonymously tested the umbilical cord blood for HIV-1 antibody of 98.1% (2971/3028) of singleton infants with birth weight greater than 500 g born during 1989 and linked the results to a maternal-infant database from which all identifying information had been removed. RESULTS: Overall, HIV-1 seroprevalence was 3.3% (99/2971). Among HIV-1-seropositive mothers, 79% (78/99) gave no history of ever using injected drugs. Seropositivity for HIV-1 was independently associated with history of maternal cocaine use during pregnancy (odds ratio, 3.55; 95% confidence interval, 2.18, 5.78), history of ever using injected drugs (odds ratio, 6.02; 95% confidence interval, 3.14, 11.6), positive serologic test result for syphilis during pregnancy (odds ratio, 3.37; 95% confidence interval, 1.94, 5.88), and increasing maternal age per year (odds ratio, 1.04; 95% confidence interval, 1.00, 1.09). Voluntary testing programs failed to identify 71% (70/99) of all HIV-1-infected women. Infants placed into foster care were eight times more likely to be HIV-1 seropositive than those discharged to their mothers. CONCLUSIONS: Most HIV-1-infected mothers seem to have acquired the infection via heterosexual transmission rather than via injected drug use. Associations of maternal HIV-1 infection with cocaine use, syphilis, and increasing age probably operate through behaviors that increase maternal risk of exposure to an HIV-1-infected sexual partner or, in the case of syphilis, also through biologic factors that may predispose to HIV-1 transmission. The failure of voluntary testing to identify most HIV-1-infected mothers provides a strong rationale for routine HIV-1 testing during pregnancy and in the newborn period.

AIDS Serodiagnosis↗
PubMed1982

Some cognitive effects of frontal-lobe lesions in man.

The study of patients undergoing unilateral frontal-lobe excisions for the relief of focal epilepsy has revealed specific cognitive disorders that appear against a background of normal functioning on many intellectual, perceptual and memory tasks. Lesions that invade the frontal eye field cause subtle impairments of voluntary oculomotor control, which reveal themselves as an inability to suppress an initial glance at a potentially distracting stimulus. After frontal lobectomy in either hemisphere, deficits are found quite consistently on motor-differentiation tasks (Konorski 1972) in which the subject must learn to produce different responses to different, randomly presented, environmental signals. More directly related to the concept of planning are those sequential tasks in which the subject is free to choose his own order of responding, but must not make the same response twice. Here the left frontal lobe plays the major role, a finding consistent with the notion of left-hemisphere dominance for the programming of voluntary actions. In contrast, the right frontal lobe appears to be more critically involved in monitoring the temporal sequence of externally ordered events, although the verbal or non-verbal nature of the stimuli remains a relevant factor.

Adult↗
PubMed2002

"Trial" prescriptions to reduce drug wastage: results from Canadian programs and a community demonstration project.

OBJECTIVE: To determine the acceptability of a program to avoid drug wastage through "trial" prescriptions. STUDY DESIGN: Cross-sectional survey, followed by a 9-month demonstration project. METHODS: Consultants to trial prescription programs operated by 2 public- and 3 private-sector drug plans in Canada were surveyed. All of the trial prescription programs were voluntary. The demonstration project involved 215 English-speaking adults who filled a "new" prescription for an angiotensin-converting enzyme inhibitor, beta-blocker, or calcium channel blocker (CCB) in 1 of 16 Peterborough, Ontario pharmacies. Patients received a 7-day supply of medication and a reminder card on which the dispensing pharmacist recorded the mutually agreed date and time the patient would be contacted to assess the results of the "trial." Patients who tolerated the medication received the balance of their original prescription. RESULTS: Most patients (86%) who were offered trials in the demonstration project accepted them, and most (82%) who accepted them found them helpful. The proportion of patients who received the balance varied by program, ranging from 47.1% to 86.6%. The dollar value of the wastage avoided through trial prescriptions varied by drug class. This was driven largely by differences in the unit cost of the medications, but also to a lesser extent by larger prescriptions for CCBs. CONCLUSIONS: Trial prescriptions were acceptable to patients and, if focused on specific medications, could reduce the direct cost of drug wastage. More work is needed to define the conditions under which trial prescription programs are feasible for pharmacists and drug plans.

Aged↗
PubMed1994

Screening surgeons for HIV infection: assessment of a potential public health program.

OBJECTIVE: To develop a model to assess the impact of a program of testing surgeons for human immunodeficiency virus (HIV) on the risk of HIV acquisition by their patients. DESIGN: A Monte Carlo simulation model of physician-to-patient transmission of human immunodeficiency virus (HIV) infection using three different rates of physician-to-patient transmission per percutaneous exposure event (0.15%, 0.3%, 0.6%). Data from the model were developed from a review of the medical literature and from subjective probability estimates when data were not available. We used this model to estimate on a national basis the annual number of cases of HIV transmission from surgeons to patients with and without surgeon testing and practice limitations. RESULTS: The annual number of transmitted cases would range from 0.5 (+/- 0.3), assuming a surgeon HIV prevalence of 0.1% and a surgeon-to-patient transmission rate of 0.15%, to 36.9 (+/- 11.6), assuming a surgeon HIV prevalence of 2% and a surgeon-to-patient transmission rate of 0.6%. After one screening cycle, a mandatory screening program would be expected to reduce the annual transmissions to 0.05 (+/- 0.03) and 3.1 (+/- 1.1), respectively. CONCLUSION: Patients are at low risk of acquiring HIV infection from an infected physician during an invasive procedure. The potential costs of such a program extended beyond the costs of testing and counseling. In communities with high HIV prevalence, screening surgeons and limiting their practices may decrease patient access to care. A disability insurance program also would be required to protect surgeons and trainees performing invasive procedures. Screening surgeons for HIV infection would be a costly undertaking that would reduce but not completely eliminate this risk.

AIDS Serodiagnosis↗
PubMedDate not supplied

Public health measures for prevention and control of AIDS.

The grave challenge posed by the recent pandemic of acquired immunodeficiency syndrome is not the first time mankind has faced such a threat. Useful lessons may be drawn from the successful global Smallpox Eradication Program and applied to the current campaign in the areas of surveillance, strategy, operations, and evaluation. The most important epidemiologic characteristic of this new infection is the unprecedented observation that virtually all asymptomatic infected persons are infectious and will remain so indefinitely. In combatting this infection we should concentrate our efforts in the United States on preventing transmission from the estimated 1.5 million persons who are already infected. We must make the best use we can of all the tools we already have: public information, health education, counseling and serologic testing of persons at high risk, treatment and prevention of intravenous drug abuse, and serologic screening of organ and tissue donors. Adequate confidentiality of test results needs to be secured in order to promote voluntary testing as an important means of achieving behavorial change among persons who are most likely to have been exposed to the infections. Persons whose sexual or drug abuse behavior puts them at higher risk of infection are the highest priority target group. They should be sought at every opportunity, whether seen in public clinics or private practice, and advised to be tested. In order to focus on preventing sexual, parenteral, and perinatal transmission of the virus we must avoid numerous potential distractions and irrelevant issues: we don't have time for them.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department-based screening programs for HIV infection.

Personnel of inner-city emergency departments (EDs), which are frequently the only source of medical care for many patients, may be in a unique position to detect human immunodeficiency virus (HIV) infection earlier than personnel at other recommended screening sites. To assist development of ED-based screening strategies for HIV infection, we undertook a serosurvey of HIV infection in adult patients attending an ED during a 6-week period in 1992 using an identity-unlinked technique and compared our findings with data collected similarly in 1988. Of 1,606 patients, 183 (11.4%) were HIV-positive, compared with 6.0% in 1988. Seroprevalence rates of HIV infection among patients only at risk of heterosexual transmission increased more than fourfold (7% to 30.3%). CD4+ cell counts were higher in those patients with undiagnosed HIV infection than in those with known HIV infection. Targeting minority patients aged 25-44 years, intravenous drug users, and those patients at heterosexual risk would have identified 87% of patients with new HIV infection, while requiring screening of 41% of the study sample. Targeted voluntary screening programs in certain EDs would likely detect significant numbers of new early HIV infections.

Adolescent↗
PubMed1987

Readiness potential of cortical area 6 preceding self paced movement in Parkinson's disease.

The vertex Readiness Potential (RP) (Bereitschaftspotential) preceding self paced voluntary movements is reduced in duration and amplitude in patients with Parkinsonism. It cannot be used as an index for delayed initiation of movement. The negative potential is commonly replaced by a positive slow wave. In hemi-Parkinsonism, the abnormal RP is more apparent on moving the affected limb. The abnormal RP is related to the severity but not to the duration of Parkinsonism. Short-term fluctuations of akinesia and rigidity, spontaneous or caused by levodopa are associated with changes of RP duration and amplitude. The abnormality does not correlate with reaction or movement times. It is suggested that the Readiness Potential is a diffuse response of area 6 cortex (especially Supplementary Motor Area) evoked by pallido-thalamo-cortical afferents under dopaminergic control. It is not obligatory for pre-programming of voluntary movement. The authors postulate a dendritic potential of basket cells associated with a pallidal activated gate control of postural set.

Adult↗
PubMed1982

Public policy implications of human genetic technology: genetic screening.

As rapid advances in human genetic research are transferred into new areas of genetic technology, questions relating to the use of these techniques will escalate. This paper examines some of the policy concerns surrounding recent developments in genetic screening. It discusses the impetus and implications of genetic screening in general, examines various applications, and analyzes the costs and benefits of screening programs currently in existence. Special emphasis is placed on whether or not screening should be considered a matter of public health and mandated on those grounds. This paper argues against any compulsory screening programs except where the disease is easily identified, applicable across social groups, and treatable. While screening services for carriers of genetic disease and prenatal diagnosis should be made available and education programs should be expanded substantially, the burden of proof for involuntary programs is placed on the proponents. There is little public health justification at this time for mandatory screening though this does not preclude future public health demands. It is argued that the goals and justification of various human genetic technologies must be examined at this time due to the rapid advancement of the research as well as the ultimate benefits promised for humankind.

Cost-Benefit Analysis↗