CASE OF PAUL S. Upon arrival at the office, you receive a telephone call from Mrs S. Over the wee... more CASE OF PAUL S. Upon arrival at the office, you receive a telephone call from Mrs S. Over the weekend her normally "well-behaved" 14-year-old son Paul, together with a group of school friends, were found by the police at a construction site in the process of spray-painting nicknames, slogans, and "obscene language" on a newly built concrete wall. Several bottles of beer, cigarette papers, loose tobacco, and a small quantity of marijuana were found nearby. Although he began to cry when his parents arrived at the police station to arrange his release, Paul has been "uncommunicative and sullen" ever since, refusing even to attend school today. Paul and his parents must appear before the Juvenile Court in two days, and Mrs S. would like you, as Paul9s pediatrician for 14 years, to "see what9s wrong" with Paul before then. Among the various options that you might initially choose, how would you decide whether or not to: —refer Paul to a teenage drug rehabilitation program, —arrange an adolescent psychiatric consultation for Paul because of his sudden change in behavior, —have Paul come to see you at the office, to be followed by a meeting with his parents, —reassure Mrs S. over the telephone that Paul is a normal healthy teenager, —inform the school guidance counselor of the reason for Paul9s absence and request information concerning his school performance and activities.
The human immunodeficiency virus (HIV) epidemic may portend disaster or may become an opportunity... more The human immunodeficiency virus (HIV) epidemic may portend disaster or may become an opportunity for learning some of the basic lessons of medicine for those entering the ranks of health care workers in the 1990s. At present, a small cadre of health care professionals have dedicated themselves exclusively to the care of HIV-infected people. Although their number has increased in the past 8 years, they still represent a tiny fraction of total health care professionals. As they age or burn out, who will be there to take their places? 1 Major academic medical centers on the East and West coasts have not filled residency training slots with the candidates of their choice for the past several years. One of the reasons given by candidates and feared by training directors is the acquired immunodeficiency syndrome (AIDS) epidemic. The muchpublicized strain on existing resources, the emotional drain caused by caring for terminally
Although adolescent sexual behavior has become a focal point for debate among family members, edu... more Although adolescent sexual behavior has become a focal point for debate among family members, educators, and health providers, the percent of young people who have their first intercourse experience in adolescence has not increased dramatically in the past decade. 1 The mass media has reflected the increased awareness of adolescent sexual behavior. One important issue that has arisen is whether certain of the attitudes and behaviors surrounding teenage sexuality are started by the media or if the media merely reflects the beliefs and attitudes already held in a community. By assessing the effect of the media on changing belief systems as well as on education of populations in such sexually related areas as venereal disease control, one could analyze the potential impact of publicity on adolescent sexual behavior. The general conclusion of investigators in the field of mass communication is that the messages in the media merely reinforce attitudes that
We know how to prevent HIV infection, and in some countries successful programs are operating. In... more We know how to prevent HIV infection, and in some countries successful programs are operating. In her commentary, Hein outlines two prevention trials described in this issue of Science (a research article by the NIMH Multisite HIV Prevention Trial Group and a Viewpoint by Phoolcharoen) and discusses the relative failure of the United States to successfully implement AIDS intervention strategies.
JAMA: The Journal of the American Medical Association, 1999
Patients with the greatest health care needs may have the least ability to read and comprehend in... more Patients with the greatest health care needs may have the least ability to read and comprehend information needed to function successfully as patients. To examine the scope and consequences of poor health literacy in the United States, characterize its implications for patients and physicians, and identify policy and research issues. The 12 members of the Ad Hoc Committee on Health Literacy, American Medical Association Council on Scientific Affairs, were selected by a key informant process as experts in the field of health literacy from a variety of backgrounds in clinical medicine, medical and health services research, medical education, psychology, adult literacy, nursing, and health education. Literature review using the MEDLINE database for January 1966 through October 1, 1996, searching Medical Subject Heading (MeSH) reading combined with text words health or literacy in the title, abstract, or MeSH. A subsequent search using reading as a search term identified articles published between 1993 and August 1998. Authors of relevant published abstracts were asked to provide manuscripts. Experts in health services research, health education, and medical law identified proprietary and other unpublished references. Consensus among committee members was reached through review of 216 published articles and additional unpublished manuscripts and telephone and Internet conferencing. All committee members approved the final report. Patients with inadequate health literacy have a complex array of communications difficulties, which may interact to influence health outcome. These patients report worse health status and have less understanding about their medical conditions and treatment. Preliminary studies indicate inadequate health literacy may increase the risk of hospitalization. Professional and public awareness of the health literacy issue must be increased, beginning with education of medical students and physicians and improved patient-physician communication skills. Future research should focus on optimal methods of screening patients to identify those with poor health literacy, effective health education techniques, outcomes and costs associated with poor health literacy, and the causal pathway of how poor health literacy influences health.
Between 1973 and 1976, laparoscopy was performed on 50 girls aged 12 to 18 years old for evaluati... more Between 1973 and 1976, laparoscopy was performed on 50 girls aged 12 to 18 years old for evaluation of abdominal pain severe enough to warrant hospitalization. In nine patients, a pelvic mass was suspected on physical examination or ultrasonography. Twenty-three patients had histories of previous episodes of salpingitis, but negative cultures at time of admission. Eighteen patients had no significant past medical history and normal physical findings. Laparoscopy established a diagnosis in 28 of the 50 patients, and in the 32 patients in whom a specific preoperative diagnosis was entertained, laparoscopy proved it to be incorrect in 15. In all cases where laparoscopy resulted in specific treatment, the symptoms were relieved. There was no morbidity or mortality.
The frequency of self-discovered breast masses in adolescent females has not previously been desc... more The frequency of self-discovered breast masses in adolescent females has not previously been described. The histologic diagnosis rather than the means of detection has been the focus of previous surveys. Seven characteristics of 95 patients admitted from 1968-1979 for the evaluation of a breast mass were delineated. The mean age at hospitalization was 15.9 years (range 12-20). The delay from detection to hospitalization was 7.2 months (range 0.5-72). In 77 cases the mass was detected by the patient; 11 were found during a physician examination, 4 by a family member, and 3 by an unrecorded source. Diagnoses were fibroadenoma (71), abscess (11), cyst (9), lipoma (2), and cystosarcoma phyllodes (2). The median length of the masses was 2.6 cm, width 2.3 cm, with a median mass area (diameter x length) of 6 cm2. When patients were compared for age, delay in hospitalization, means of detection, family history, and mass size, the girls with abscesses were younger and had a shorter time delay before hospitalization. Self-discovery was the means of detection in 77 of 95 (81%). The means of detection is an important factor to consider in weighing the merits of teaching breast self-examination procedures to adolescent females.
A kinetic model for imipramine (IMI) has been developed, based upon a study of 16 teenagers who r... more A kinetic model for imipramine (IMI) has been developed, based upon a study of 16 teenagers who received IMI 4-5 mg/kg/day for treatment of a major depressive disorder. Serial measurements of plasma concentrations of IMI, desmethylimipramine (DMI), 2-hydroxy-IMI, and 2-hydroxy-DMI were made. Mean residence times, volumes of distribution, clearances of IMI and DMI, and rate constants for formation and elimination of the hydroxy metabolites were determined from a multicompartment model fitted to the concentration-time data. Mean residence time for DMI was significantly longer than for IMI (47.1 +/- 21.2 vs. 13.4 +/- 4.8 h, p less than 0.001). A different volume of distribution for IMI and DMI was not supported by the data. Clearance of DMI was considerably slower than that of IMI (0.67 +/- 0.45 vs. 2.18 +/- 1.33 l(kg.h), p less than 0.001). A statistically significant increase in mean residence time with increasing age during adolescence was found (r = 0.57, p less than 0.05).
According to the World Health Organization, half of the 14 million people with human immunodefici... more According to the World Health Organization, half of the 14 million people with human immunodeficiency virus (HIV) worldwide were infected between the ages of 15 and 24 years. However, details about HIV-positive (HIV+) youths' risk-related behavior and social context have not been previously reported. Objectives. To outline detailed sexual and drug use practices, social and psychological status of HIV + youth compared with a cohort of HIV-negative (HIV-) youth; and to examine the ability of the health belief and risk-taking models to predict sexual and drug use acts of HIV + youth. Methods. HIV testing was conducted on and a 207-item structured interview covering HIV risk-related acts, protective factors and background information was administered to 72 HIV + and 1142 HIV - adolescents aged 13 through 21 years receiving care in an adolescent clinical care unit of a large medical center in New York City. Data were analyzed for adolescents reporting sexual intercourse (71 HIV + and...
It is clear from the evidence that a growing number of adolescents are acquiring HIV infection an... more It is clear from the evidence that a growing number of adolescents are acquiring HIV infection and developing AIDS. The impact this epidemic will have on all teenagers is overwhelming. Given the high prevalence of risk-related sexual behaviors, many adolescents are likely to become HIV infected, thus requiring extensive medical and psychosocial services. Other adolescents will lose a parent, relative, or friend to AIDS, and these adolescents will similarly require special services and psychological counseling. Thus, there is an immediate need for the development of methods for (1) providing all adolescents with age-appropriate and culturally relevant interventions for prevention and risk reduction, (2) identifying high-risk adolescents and triaging them to different levels of care and risk reduction counseling, and (3) providing ongoing medical and psychosocial treatments. Accessing adolescents at risk for HIV infection will require networking between the health care system and youth-serving and community-based agencies, particularly agencies servicing high-risk adolescents. We must begin addressing these needs now, in order to prevent further infection and to provide appropriate care for those adolescents who are or will become infected with HIV.
CASE OF PAUL S. Upon arrival at the office, you receive a telephone call from Mrs S. Over the wee... more CASE OF PAUL S. Upon arrival at the office, you receive a telephone call from Mrs S. Over the weekend her normally "well-behaved" 14-year-old son Paul, together with a group of school friends, were found by the police at a construction site in the process of spray-painting nicknames, slogans, and "obscene language" on a newly built concrete wall. Several bottles of beer, cigarette papers, loose tobacco, and a small quantity of marijuana were found nearby. Although he began to cry when his parents arrived at the police station to arrange his release, Paul has been "uncommunicative and sullen" ever since, refusing even to attend school today. Paul and his parents must appear before the Juvenile Court in two days, and Mrs S. would like you, as Paul9s pediatrician for 14 years, to "see what9s wrong" with Paul before then. Among the various options that you might initially choose, how would you decide whether or not to: —refer Paul to a teenage drug rehabilitation program, —arrange an adolescent psychiatric consultation for Paul because of his sudden change in behavior, —have Paul come to see you at the office, to be followed by a meeting with his parents, —reassure Mrs S. over the telephone that Paul is a normal healthy teenager, —inform the school guidance counselor of the reason for Paul9s absence and request information concerning his school performance and activities.
The human immunodeficiency virus (HIV) epidemic may portend disaster or may become an opportunity... more The human immunodeficiency virus (HIV) epidemic may portend disaster or may become an opportunity for learning some of the basic lessons of medicine for those entering the ranks of health care workers in the 1990s. At present, a small cadre of health care professionals have dedicated themselves exclusively to the care of HIV-infected people. Although their number has increased in the past 8 years, they still represent a tiny fraction of total health care professionals. As they age or burn out, who will be there to take their places? 1 Major academic medical centers on the East and West coasts have not filled residency training slots with the candidates of their choice for the past several years. One of the reasons given by candidates and feared by training directors is the acquired immunodeficiency syndrome (AIDS) epidemic. The muchpublicized strain on existing resources, the emotional drain caused by caring for terminally
Although adolescent sexual behavior has become a focal point for debate among family members, edu... more Although adolescent sexual behavior has become a focal point for debate among family members, educators, and health providers, the percent of young people who have their first intercourse experience in adolescence has not increased dramatically in the past decade. 1 The mass media has reflected the increased awareness of adolescent sexual behavior. One important issue that has arisen is whether certain of the attitudes and behaviors surrounding teenage sexuality are started by the media or if the media merely reflects the beliefs and attitudes already held in a community. By assessing the effect of the media on changing belief systems as well as on education of populations in such sexually related areas as venereal disease control, one could analyze the potential impact of publicity on adolescent sexual behavior. The general conclusion of investigators in the field of mass communication is that the messages in the media merely reinforce attitudes that
We know how to prevent HIV infection, and in some countries successful programs are operating. In... more We know how to prevent HIV infection, and in some countries successful programs are operating. In her commentary, Hein outlines two prevention trials described in this issue of Science (a research article by the NIMH Multisite HIV Prevention Trial Group and a Viewpoint by Phoolcharoen) and discusses the relative failure of the United States to successfully implement AIDS intervention strategies.
JAMA: The Journal of the American Medical Association, 1999
Patients with the greatest health care needs may have the least ability to read and comprehend in... more Patients with the greatest health care needs may have the least ability to read and comprehend information needed to function successfully as patients. To examine the scope and consequences of poor health literacy in the United States, characterize its implications for patients and physicians, and identify policy and research issues. The 12 members of the Ad Hoc Committee on Health Literacy, American Medical Association Council on Scientific Affairs, were selected by a key informant process as experts in the field of health literacy from a variety of backgrounds in clinical medicine, medical and health services research, medical education, psychology, adult literacy, nursing, and health education. Literature review using the MEDLINE database for January 1966 through October 1, 1996, searching Medical Subject Heading (MeSH) reading combined with text words health or literacy in the title, abstract, or MeSH. A subsequent search using reading as a search term identified articles published between 1993 and August 1998. Authors of relevant published abstracts were asked to provide manuscripts. Experts in health services research, health education, and medical law identified proprietary and other unpublished references. Consensus among committee members was reached through review of 216 published articles and additional unpublished manuscripts and telephone and Internet conferencing. All committee members approved the final report. Patients with inadequate health literacy have a complex array of communications difficulties, which may interact to influence health outcome. These patients report worse health status and have less understanding about their medical conditions and treatment. Preliminary studies indicate inadequate health literacy may increase the risk of hospitalization. Professional and public awareness of the health literacy issue must be increased, beginning with education of medical students and physicians and improved patient-physician communication skills. Future research should focus on optimal methods of screening patients to identify those with poor health literacy, effective health education techniques, outcomes and costs associated with poor health literacy, and the causal pathway of how poor health literacy influences health.
Between 1973 and 1976, laparoscopy was performed on 50 girls aged 12 to 18 years old for evaluati... more Between 1973 and 1976, laparoscopy was performed on 50 girls aged 12 to 18 years old for evaluation of abdominal pain severe enough to warrant hospitalization. In nine patients, a pelvic mass was suspected on physical examination or ultrasonography. Twenty-three patients had histories of previous episodes of salpingitis, but negative cultures at time of admission. Eighteen patients had no significant past medical history and normal physical findings. Laparoscopy established a diagnosis in 28 of the 50 patients, and in the 32 patients in whom a specific preoperative diagnosis was entertained, laparoscopy proved it to be incorrect in 15. In all cases where laparoscopy resulted in specific treatment, the symptoms were relieved. There was no morbidity or mortality.
The frequency of self-discovered breast masses in adolescent females has not previously been desc... more The frequency of self-discovered breast masses in adolescent females has not previously been described. The histologic diagnosis rather than the means of detection has been the focus of previous surveys. Seven characteristics of 95 patients admitted from 1968-1979 for the evaluation of a breast mass were delineated. The mean age at hospitalization was 15.9 years (range 12-20). The delay from detection to hospitalization was 7.2 months (range 0.5-72). In 77 cases the mass was detected by the patient; 11 were found during a physician examination, 4 by a family member, and 3 by an unrecorded source. Diagnoses were fibroadenoma (71), abscess (11), cyst (9), lipoma (2), and cystosarcoma phyllodes (2). The median length of the masses was 2.6 cm, width 2.3 cm, with a median mass area (diameter x length) of 6 cm2. When patients were compared for age, delay in hospitalization, means of detection, family history, and mass size, the girls with abscesses were younger and had a shorter time delay before hospitalization. Self-discovery was the means of detection in 77 of 95 (81%). The means of detection is an important factor to consider in weighing the merits of teaching breast self-examination procedures to adolescent females.
A kinetic model for imipramine (IMI) has been developed, based upon a study of 16 teenagers who r... more A kinetic model for imipramine (IMI) has been developed, based upon a study of 16 teenagers who received IMI 4-5 mg/kg/day for treatment of a major depressive disorder. Serial measurements of plasma concentrations of IMI, desmethylimipramine (DMI), 2-hydroxy-IMI, and 2-hydroxy-DMI were made. Mean residence times, volumes of distribution, clearances of IMI and DMI, and rate constants for formation and elimination of the hydroxy metabolites were determined from a multicompartment model fitted to the concentration-time data. Mean residence time for DMI was significantly longer than for IMI (47.1 +/- 21.2 vs. 13.4 +/- 4.8 h, p less than 0.001). A different volume of distribution for IMI and DMI was not supported by the data. Clearance of DMI was considerably slower than that of IMI (0.67 +/- 0.45 vs. 2.18 +/- 1.33 l(kg.h), p less than 0.001). A statistically significant increase in mean residence time with increasing age during adolescence was found (r = 0.57, p less than 0.05).
According to the World Health Organization, half of the 14 million people with human immunodefici... more According to the World Health Organization, half of the 14 million people with human immunodeficiency virus (HIV) worldwide were infected between the ages of 15 and 24 years. However, details about HIV-positive (HIV+) youths' risk-related behavior and social context have not been previously reported. Objectives. To outline detailed sexual and drug use practices, social and psychological status of HIV + youth compared with a cohort of HIV-negative (HIV-) youth; and to examine the ability of the health belief and risk-taking models to predict sexual and drug use acts of HIV + youth. Methods. HIV testing was conducted on and a 207-item structured interview covering HIV risk-related acts, protective factors and background information was administered to 72 HIV + and 1142 HIV - adolescents aged 13 through 21 years receiving care in an adolescent clinical care unit of a large medical center in New York City. Data were analyzed for adolescents reporting sexual intercourse (71 HIV + and...
It is clear from the evidence that a growing number of adolescents are acquiring HIV infection an... more It is clear from the evidence that a growing number of adolescents are acquiring HIV infection and developing AIDS. The impact this epidemic will have on all teenagers is overwhelming. Given the high prevalence of risk-related sexual behaviors, many adolescents are likely to become HIV infected, thus requiring extensive medical and psychosocial services. Other adolescents will lose a parent, relative, or friend to AIDS, and these adolescents will similarly require special services and psychological counseling. Thus, there is an immediate need for the development of methods for (1) providing all adolescents with age-appropriate and culturally relevant interventions for prevention and risk reduction, (2) identifying high-risk adolescents and triaging them to different levels of care and risk reduction counseling, and (3) providing ongoing medical and psychosocial treatments. Accessing adolescents at risk for HIV infection will require networking between the health care system and youth-serving and community-based agencies, particularly agencies servicing high-risk adolescents. We must begin addressing these needs now, in order to prevent further infection and to provide appropriate care for those adolescents who are or will become infected with HIV.
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