Faculty Bibliography

OBJECTIVE: To evaluate whether training primary care clinicians in maintenance care for patients who have changed their drinking influences practice behavior. DESIGN: We randomized 15 physician and 3 mid-level clinicians in 2 primary care offices in a 2:1 design. The 12 intervention clinicians received a total of 2 (1/4) hours of training in the maintenance care of alcohol problems in remission, a booster session, study materials and chart-based prompts at eligible patients' visits. Six controls provided usual care. Screening forms in the waiting rooms identified eligible patients, defined as those who endorsed: 1 or more items on the CAGE questionnaire or that they had an alcohol problem in the past; that they have 'made a change in their drinking and are trying to keep it that way'; and that they drank <15 (men) or <10 (women) drinks per week in the past month. Exit interviews with patients evaluated the clinician's actions during the visit. RESULTS: Of the 164 patients, 62% saw intervention clinicians. Compared with patients of control clinicians, intervention patients were more likely to report that their clinician asked about their alcohol history (odds ratio, 2.8; 95% confidence interval, 1.3, 5.8). Intervention clinicians who asked about the alcohol history were more likely to assess prior and planned alcohol treatment, assist through offers for prescriptions and treatment referral, and receive higher satisfaction ratings for the visit. CONCLUSIONS: Systemic prompts and training in the maintenance care of alcohol use disorders in remission might increase primary care clinicians' inquiries about the alcohol history as well as appropriate assessment and intervention after an initial inquiry

Reviews the book, Sexing the body: Gender politics and the construction of sexuality by Anne Fausto-Sterling (2000). This book is frankly political, advocating a world where diversity in gender and sexual identity is valued over conformity. Achieving such a world requires destabilizing the current view that our notions of gender and sex reflect the natural order of things. The author seeks a paradigm shift; the existence and social viability of intersexual bodies is the first challenge to the 'normal science' of gender and sex. She needs to further persuade us that current scientific stories about gender and sex do not sufficiently account for the facts, or even describe the 'facts' correctly. The second half of the book pursues this agenda. The author's gift as a scientist is to recount the many, often inconsistent, facts and also the various interpretations of these facts, and her major achievement as an interdisciplinary writer is to show how, amidst all the inconsistency, there is room for a new interpretation of both what it means to be a certain kind of person, and how such persons come into being.

Reviews the book Madhouse: A Tragic Tale of Megalomania and Modern Medicine by Andrew Scull. Scull's writing style will be easily accessible to a lay reader and his choice of title and his prose in the opening chapters suggest that it is a lay audience he is after. For this project 20 years in the making, Scull has unearthed facts and fashioned a story out of them that has all the elements of a page turner: the antihero, Dr. Henry Cotton, a sociopathic physician whose grandiosity only magnifies his badness as he literally butchers his patients; the long-suffering heroine, Dr. Phyllis Greenacre, a brilliant psychiatrist who despite long odds rises to become a star of the psychoanalytic community, who holds the truth about Dr. Cotton but is stifled by forces beyond her control; Dr. Adolf Meyer, the morally inept superior, who offers Chamberlain-like appeasement to the monstrous Dr. Cotton while ignoring and at times nearly betraying the fragile genius of the heroine, Dr. Greenacre. And it is a long story, with twists and turns, near happy endings and near tragic moments. The ending of this story is ultimately morally complicated, and left this reader's mind whirring with possibilities, replaying each moment and each confrontation, wondering if it could have gone differently

To better characterize fluent and nonfluent variants of primary progressive aphasia (PPA). Although investigators have recognized both fluent and nonfluent patients with PPA, the clinical and neuroimaging features of these variants have not been fully defined. We present clinical and neuropsychological data on 47 PPA patients comparing the fluent (n=21) and nonfluent (n=26) subjects. We further compared language features with PET/SPECT data available on 39 of these patients. Compared to the nonfluent PPA patients, those with fluent PPA had greater impairment of confrontational naming and loss of single word comprehension. They also exhibited semantic paraphasic errors and loss of single word comprehension. Patients with nonfluent PPA were more likely to be female, were more often dysarthric, and exhibited phonological speech errors in the absence of semantic errors. No significant differences were seen with regard to left hemisphere abnormalities, suggesting that both variants result from mechanisms that overlap frontal, temporal, and parietal regions. Of the language measures, only semantic paraphasias were strongly localized, in this case to the left temporal lobe. Fluent and nonfluent forms of PPA are clinically distinguishable by letter fluency, single word comprehension, object naming, and types of paraphasic errors. Nevertheless, there is a large amount of overlap between dysfunctional anatomic regions associated with these syndromes

Surveys of physicians' attitudes regarding the therapeutic value of marijuana are rare. Drawing on a national sample of family physicians, general internists, obstetrician-gynecologists, psychiatrists, and addiction specialists, 960 (adjusted response rate 66%) offered opinions about the legal prescription of marijuana as medical therapy. Thirty-six percent believed prescribed marijuana should be legal and 26% were neutral to the proposition. Non-moralistic attitudes toward substance use were significantly associated with support for physician prescription, as was internal medicine and obstetrics-gynecology specialization. Physicians are, in general, less supportive than the general American public regarding the use of medical marijuana

The sequelae of hepatitis B virus infection include fulminant liver failure, chronic liver disease, hepatocellular carcinoma, and death. The hepatitis B vaccine is efficacious, safe, and cost-effective, but has been consistently underutilized in high-risk adults despite long-standing recommendations. Instituting routine hepatitis B vaccination for high-risk adults in settings such as prisons and jails, sexually transmitted disease clinics, drug treatment centers, and needle exchange programs could prevent up to 800 cases of hepatitis, and 10 deaths from hepatitis, per 10,000 vaccinations, with an overall cost savings. Low rates of completion of the three-dose series and lack of funding for adult immunizations have always been challenges to offering hepatitis B vaccines to high-risk adults. However, there is benefit to an incomplete vaccination series, and high-risk populations are accessible for follow-up vaccination outside of traditional medical settings. A clear national objective and federal funding for vaccinating high-risk adults are needed

We compared the sociodemographic, drug use, and social support characteristics of injection drug users (IDUs) who reported at least 6 months having not 'shared needles or works' (zero sharing risk) with those who reported recent equipment sharing. 187 AUDIT-positive (>8), active IDUs were recruited between February 1998 and October 1999 from a needle exchange program in Providence, RI. The sample was 64% male and 87% white, with a mean age of 36 years, and 32% of subjects reported zero sharing risk in the prior 6 months. Variables having significant (P<.05) associations with zero sharing risk included: older age, lower heroin use frequency, lower cocaine use, and increased frequency of needle exchange visits. As social support from friends increased, the likelihood of sharing decreased. Subjects with substance-using friends or partners were significantly more likely to share than those without such associations (OR = 9.4; P<.05). Social support and social network composition influenced sharing behaviors in active, out-of-treatment drug injectors. Interventions that mobilize social support may increase the possibility of zero sharing, an important public health goal