Search

Background: Critical illness increases the risk for poor mental health outcomes among both patients and their informal caregivers, especially their surrogate decision-makers. Surrogates who must make life-and-death medical decisions on behalf of incapacitated patients may experience additional distress. EMPOWER (Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience) is a novel cognitive-behavioral, acceptance-based intervention delivered in the intensive care unit (ICU) setting to surrogate decision-makers designed to improve both patients' quality of life and death and dying as well as surrogates' mental health., Methods: Clinician stakeholder and surrogate participant feedback (n = 15), as well as results from an open trial (n = 10), will be used to refine the intervention, which will then be evaluated through a multisite randomized controlled trial (RCT) (n = 60) to examine clinical superiority to usual care. Feasibility, tolerability, and acceptability of the intervention will be evaluated through self-report assessments. Hierarchical linear modeling will be used to adjust for clustering within interventionists to determine the effect of EMPOWER on surrogate differences in the primary outcome, peritraumatic stress. Secondary outcomes will include symptoms of post-traumatic stress disorder, prolonged grief disorder, and experiential avoidance. Exploratory outcomes will include symptoms of anxiety, depression, and decision regret, all measured at 1 and 3 months from post-intervention assessment. Linear regression models will examine the effects of assignment to EMPOWER versus the enhanced usual care group on patient quality of life or quality of death and intensity of care the patient received during the indexed ICU stay assessed at the time of the post-intervention assessment. Participant exit interviews will be conducted at the 3-month assessment time point and will be analyzed using qualitative thematic data analysis methods., Discussion: The EMPOWER study is unique in its application of evidence-based psychotherapy targeting peritraumatic stress to improve patient and caregiver outcomes in the setting of critical illness. The experimental intervention will be strengthened through the input of a variety of ICU stakeholders, including behavioral health clinicians, physicians, bereaved informal caregivers, and open trial participants. Results of the RCT will be submitted for publication in a peer-reviewed journal and serve as preliminary data for a larger, multisite RCT grant application., Trial Registration: ClinicalTrials.gov, NCT03276559 . Retrospectively registered on 8 September 2017.

Unhealthy substance use is associated with increased rates of STDs, including HIV. Within three high-risk New York City (NYC) sexual health clinics between 2008 and 2012 (n = 146,657), 17% of patients screened positive for a current SUD but only 5.3% ever received prior treatment. The goal of Project Renew was to expand the reach of substance use early intervention services within and across sexual health clinics citywide and decrease substance use, poor mental health, and risky sexual behavior. To accomplish this goal, Screening, Brief Intervention, and Referral to Treatment (SBIRT), an evidence-based substance use early intervention model, was implemented in all eight NYC sexual health clinics February 2012-January 2015. Clinic patients were screened for substance misuse using the AUDIT/DAST-10, and those who screened positive were eligible for on-site brief intervention. Overall, 130,597 substance misuse screenings were conducted (66,989, or 51%, positive), and 17,474 on-site brief interventions and 1238 referrals were provided (not unique to individual patients). A 10% sample of 14,709 unique patients who screened positive were interviewed using a federal data collection tool at baseline and six months later to assess changes in substance use, sexual risk behaviors, mental health, and health status (n = 1328). At six-month follow-up, patients reported reduced substance use, less sexual activity, improved overall health, and fewer days of depression and anxiety compared to measures at baseline (p < 0.05). Based on positive results, Project Renew SBIRT services have been sustained, ensuring essential care which may help prevent acquisition of HIV/STDs among a large population of high-risk New Yorkers., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: This article reports the integration and outcomes of implementing intervention services for substance use disorder (SUD) in three New York City public sexually transmitted disease (STD) clinics., Methods: The screening, brief intervention, and referral to treatment (SBIRT) service model was implemented in the STD clinics in 2008. A relational database was developed, which included screening results, service dispositions, face-to-face interviews with 6-month follow-ups, and treatment information., Results: From February 2008 to the end of September 2012, 146,657 STD clinic patients 18 years or older were screened for current or past substance use disorders; 15,687 received a brief intervention; 954 received referrals to formal substance abuse treatment; 2082 were referred to substance abuse support services such as Alcoholics Anonymous (AA), and 690 were referred to mental health, social or HIV awareness services. Intervention services delivered through SBIRT resulted in improvements in multiple outcomes at 6 month follow-up. Patients who received interventions had reduced SUD risks, fewer mental health problems, and fewer unprotected sexual contacts., Conclusion: Delivery of SUD services in a public health setting represents a significant policy and practice change and benefits many individuals whose SUDs might otherwise be overlooked. Intervention services for substance use disorder were integrated and highly utilized in the STD setting. Further research needs to focus on the long-term impact of SUD interventions in the STD setting, their cost effectiveness, and the extent they are financially sustainable under the new healthcare law.

Background: Expedited partner therapy (EPT) for Chlamydia trachomatis (Ct) reduces repeat Ct infection and was legalized in New York State in 2009. It is a practice in which a Ct-infected index patient delivers medication or a prescription directly to sex partner(s), without those partners receiving medical evaluation. There have been few evaluations of EPT implementation assessing acceptance and uptake among index patients. We measured EPT acceptance among index patients, identified predictors of accepting EPT, and described reasons for declining EPT., Methods: We conducted a retrospective analysis using electronic medical records from patients attending New York City Department of Health and Mental Hygiene STD clinics from July 2011 to October 2012. A multivariable model examined the associations between accepting EPT and patient and clinic-level characteristics., Results: Overall, 54.8% (1076/1964) of index patients accepted EPT when offered (55.9% of males and 54.4% of females [P = 0.55]). Predictors of EPT acceptance included having a male provider offer EPT (adjusted odds ratio, 1.43; 95% confidence interval, 1.12-1.83). Index patients who had a partner present at the clinic during the treatment visit were less likely to accept EPT (adjusted odds ratio, 0.28; 95% confidence interval, 0.20-0.40). Among 888 patients who refused EPT, common reasons were as follows: "partner in clinic today for treatment" (26.3% [234/888]), "no longer with partner" (25.0% [222/888]), "partner already treated" (20.3% [180/888]), and "prefer medication be delivered by clinician" (19.6% [174/888]). Expedited partner therapy acceptance did not differ by patient age, sex, or race. Excluding persons whose partners were already treated and persons whose partners were in the clinic for treatment, EPT acceptance rates were 69.4%., Conclusions: Expedited partner therapy acceptance rates were high among index patients whose partners were not otherwise treated.

Background: Methamphetamine and other drug use has been documented among men who have sex with men (MSM). Patterns of use may be influenced by point of recruitment into these studies., Purpose: The aim of this study is to describe patterns of methamphetamine and other drug use and to delineate psychosocial and demographic factors which accompany these patterns of use in a sample of MSM attending gyms in New York City., Methods: Active recruitment strategies were implemented to ascertain a sample of 311 MSM. Participants completed a one-time survey regarding both health risks and health promotion., Results: Methamphetamine use in the last 6 months was reported by 23.8% of men. Inhalation and smoking were the most common modes of administration, and 84% of men reported more than one mode of use. Study participants also indicated a variety of other substances used, including but not limited to alcohol, inhalant nitrates, and 3,4 methylenedioxymethamphetamine (MDMA). Compared to nonusers, methamphetamine users were more likely to report being black or Latino, depressed, HIV-positive, perceiving more benefits of unprotected sex, and understanding masculinity in sexual terms., Conclusions: These data suggest that health-risk behaviors are common among MSM who are regularly using a gym and are indicative of the complexities of health issues for this segment of the population.

In January 1998, an outbreak of influenza A occurred on our adult bone marrow transplant unit. Aggressive infection control measures were instituted to halt further nosocomial spread. A new, more rigorous approach was implemented for the 1998/99 influenza season and was extremely effective in preventing nosocomial influenza at our institution.

Background: Several outbreaks of rotavirus gastroenteritis have occurred in hospitals and day care centers. In the spring of 1997, an outbreak of rotavirus occurred on our pediatric unit. Aggressive infection control measures were instituted, and potential lapses in infection control were assessed., Methods: Memorial Sloan-Kettering Cancer Center is a 434-bed cancer hospital in New York City. The pediatric unit is a 42-bed ward with both bone marrow transplant patients and non-bone marrow transplant oncology patients. Nosocomially acquired rotavirus was defined as diarrhea, vomiting, or gastrointestinal upset with onset 48 hours or more after hospital admission, accompanied by a positive enzyme immunoassay for rotavirus antigen., Results: Between February 24 and April 4, 1997, 8 patients on the pediatric unit had nosocomial rotavirus. Aggressive infection control measures were instituted. Patients with rotavirus were cohorted and placed on contact precautions (strict handwashing, gloves, and gown). Investigation by the infection control team revealed that communal toys in the playroom were not being cleaned according to the weekly protocol., Conclusions: An outbreak of nosocomial rotavirus occurred on our pediatric oncology unit. Shared toys may have served as fomites in the transmission of rotavirus.

Recent reports have suggested that maternal antibodies to specific epitopes of the variable region 3 (V3 loop) of gp120 of HIV-1 might protect against perinatal transmission. In an attempt to confirm these findings, sera from 34 HIV-1-seropositive mothers, representing 13 episodes of mother-to-infant transmission and 23 episodes of non-transmission (two mothers had two pregnancies each during the study period), were tested for the presence of antibodies to various regions of the gp120 V3 loop. Synthetic peptides were generated from HIV-1MN. Of the four peptides tested by enzyme-linked immunosorbent assay (ELISA), only antibody to the C53 peptide (Env310-322, principal neutralizing determinant) was present in maternal sera. Antibody to the C53 sequence was present in 11 specimens from transmitting mothers and 21 from non-transmitting mothers (84.6 and 91.3%, respectively, P = 0.6). No reactivity was detected against the C51, C57, or C58 peptide sequences, located on the sides of the V3 loop. In an antigen-limited ELISA, only two specimens from transmitting mothers and two specimens from non-transmitting mothers had detectable 'high-affinity' antibodies to C53 at low antigen concentrations (15.4 and 8.7%, respectively; P = 0.6). Our results do not support previous reports that epitope-specific antibodies to the V3 loop peptides protect against perinatal transmission. Further research is required to determine whether any specific maternal humoral response might influence HIV-1 perinatal transmission.

To identify risk factors for human immunodeficiency virus (HIV) infection in intravenous drug users, we undertook a study of the seroprevalence of HIV antibody in 452 persons enrolled in a methadone-treatment program in the Bronx, New York. The seroprevalence of HIV was 39.4 percent overall, 49.1 percent in blacks, 41.8 percent in Hispanics, and 17.2 percent in non-Hispanic whites (P less than 0.001 for all comparisons). The presence of HIV antibody was associated with the number of injections per month (P less than 0.001), the percentage of injections with used needles (P less than 0.001), the average number of injections with cocaine per month (P less than 0.001), and the percentage of injections with needles that were shared with strangers or acquaintances (P less than 0.001), a practice that was more common among blacks and Hispanics than among whites. The number of heterosexual sex partners who used intravenous drugs was associated with HIV infection in women (P less than 0.004) and was the only risk factor found for users who had not injected drugs after 1982 (P less than 0.05). The presence of HIV antibody was independently associated with being black or Hispanic (adjusted odds ratio, 4.56; 95 percent confidence interval, 2.65 to 8.14), a more recent year of the last injection of drugs (adjusted odds ratio, 1.24; 95 percent confidence interval, 1.13 to 1.35), the percentage of injections of drugs that took place in "shooting galleries" (adjusted odds ratio, 1.49; 95 percent confidence interval, 1.19 to 1.88), having sex partners who used intravenous drugs (adjusted odds ratio 1.24; 95 percent confidence interval, 1.06 to 1.45), and low income (adjusted odds ratio, 1.55; 95 percent confidence interval, 1.10 to 2.17). We conclude that differences in both the social setting of drug use and behavior related to injection carry different risks for infection with HIV and may explain, in part, the higher seroprevalence of HIV among blacks and Hispanics. In addition, we found that heterosexual activity was an independent risk factor for drug users.