John Kulig - Academia.edu (original) (raw)
Papers by John Kulig
WHAT'S KNOWN ON THIS SUBJECT: Primary care settings provide an important venue for early detectio... more WHAT'S KNOWN ON THIS SUBJECT: Primary care settings provide an important venue for early detection of substance use and intervention, but adolescent screening rates need improvement. Screening and brief interventions appear effective in reducing adult problem drinking but evidence for effectiveness among adolescents is needed. WHAT THIS STUDY ADDS: A computer-facilitated system for screening, feedback, and provider brief advice for primary care can increase adolescent receipt of substance use screening across a variety of practice settings, and shows promise for reducing adolescents' use of alcohol and cannabis. abstract OBJECTIVE: Primary care providers need effective strategies for substance use screening and brief counseling of adolescents. We examined the effects of a new computer-facilitated screening and provider brief advice (cSBA) system. METHODS: We used a quasi-experimental, asynchronous study design in which each site served as its own control. From 2005 to 2008, 12-to 18-year-olds arriving for routine care at 9 medical offices in New England (n = 2096, 58% females) and 10 in Prague, Czech Republic (n = 589, 47% females) were recruited. Patients completed measurements only during the initial treatment-as-usual study phase. We then conducted 1-hour provider training, and initiated the cSBA phase. Before seeing the provider, all cSBA participants completed a computerized screen, and then viewed screening results, scientific information, and true-life stories illustrating substance use harms. Providers received screening results and " talking points " designed to prompt 2 to 3 minutes of brief advice. We examined alcohol and cannabis use, initiation, and cessation rates over the past 90 days at 3-month follow-up, and over the past 12 months at 12-month follow-up. RESULTS: Compared with treatment as usual, cSBA patients reported less alcohol use at follow-up in New England (3-month rates 15.5% vs 22.9%, adjusted relative risk ratio [aRRR] = 0.54, 95% confidence interval 0.38– 0.77; 12-month rates 29.3% vs 37.5%, aRRR = 0.73, 0.57–0.92), and less cannabis use in Prague (3-month rates 5.5% vs 9.8%, aRRR = 0.37, 0.17– 0.77; 12-month rates 17.0% vs 28.7%, aRRR = 0.47, 0.32–0.71). CONCLUSIONS: Computer-facilitated screening and provider brief advice appears promising for reducing substance use among adolescent primary care patients.
Adolescent medicine (Philadelphia, Pa.), 2003
Journal of Adolescent Health Care, 1983
Sporadic cases of anorexia nervosa in the male patient have been described. We present three case... more Sporadic cases of anorexia nervosa in the male patient have been described. We present three cases of weight loss in adolescent males. The first is a typical case of primary anorexia nervosa. The second illustrates weight loss in the competitive adolescent athlete. The third was mistakenly thought to have primary anorexia nervosa. At autopsy, he had regional enteritis. These patients are compared to call attention to the differential diagnosis of anorexia nervosa in the adolescent male.
Australian Occupational Therapy Journal, 2008
Archives of Pediatrics & Adolescent Medicine, 1995
To explore through a pilot study the relationship between appropriateness (medical necessity) and... more To explore through a pilot study the relationship between appropriateness (medical necessity) and variations in pediatric hospital admission rates across several communities in the Boston (Mass) area for two common pediatric conditions with extremely variable admission rates: pneumonia and bronchitis/asthma. We identified five communities in the greater Boston area with high, average, and below-average ratios of observed to expected admissions for the study conditions. Diagnosis-specific, criteria-based utilization review instruments were developed by community-based pediatricians and applied by trained nurse reviewers to medical records. ADMISSIONS STUDIED: All admissions for pneumonia (diagnosis related group [DRG] 91) and bronchitis/asthma (DRG 98) of study area residents younger than 18 years to participating hospitals during fiscal year 1986. For each area, we calculated age-adjusted admission rates, age-adjusted observed to expected ratios, and rates of inappropriate admissions. We tested the hypothesis that admission rates and inappropriateness rates were directly related. We deemed 9.4% of pneumonia admissions and 4.4% of bronchitis/asthma admissions inappropriate. Rates of inappropriate admissions were not significantly associated with admission rates in this local pilot study for either study condition at P < .05. However, in one community both rates were high for both conditions. Feedback of findings to the key local hospital there resulted in sharp decreases in admission rates for DRGs 91 and 98 in subsequent years. Our results suggest that higher pediatric admission rates may not be associated with higher rates of inappropriateness. Further research is needed, with a larger number of communities, to differentiate practice patterns more precisely and explore patient and family preferences.
Journal of Adolescent Health, 1998
Pediatric dermatology
Adults with psoriasis have a greater risk of developing metabolic syndrome (MetS) and cardiovascu... more Adults with psoriasis have a greater risk of developing metabolic syndrome (MetS) and cardiovascular disease (CVD), but few studies have investigated the prevalence of MetS and other risk factors for CVD in children with psoriasis. In an assessor-blinded study, 20 children ages 9-17 years with a current or previously documented history of psoriasis involving 5% or more of their body surface area or psoriatic arthritis were compared with a cohort of age- and sex-matched controls with benign nevi, warts, or acne. MetS, our primary endpoint, was defined by the presence of abnormal values in at least three of the following measures: triglycerides, high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), waist circumference, and blood pressure. Secondary endpoints included high-sensitivity C-reactive protein (hs-CRP), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C). Thirty percent (6/20) of children with psoriasis met the criteria for MetS, compa...
Substance Abuse, 2007
To assess adolescents&amp... more To assess adolescents' preferences for substance abuse screening in primary medical care settings. Twelve- to 18-year-old patients (N = 2133) arriving for routine care at a network of primary care sites completed an interview that included demographic items, the CRAFFT screen, and a questionnaire assessing preferences for screening method (paper questionnaire, computer, oral interview by nurse or doctor). A subgroup (n = 222) completed the CRAFFT directly on the computer. Across the entire sample, paper was the screening administration method most preferred (mean rank (MR) = 2.92, 95%CI 2.87-2.96) vs. computer (MR = 2.38, 2.33-2.43), nurse (MR = 2.43, 2.39-2.47), and doctor (MR = 2.30, 2.25-2.35). Among the participants who received the screening on the computer, however, computer (MR = 3.08, 95%CI 2.42-2.52) was statistically tied with paper (MR = 2.88, 2.75-3.02) and both were ranked significantly higher than nurse (MR = 2.06, 1.94-2.17) and doctor (MR = 1.98, 1.82-2.14). The findings were similar for participants' reports of being "very likely" to be honest when answering substance abuse screening questions. Adolescents should ideally be screened for substance abuse using paper or computer questionnaires.
Southern Medical Journal, 2007
Previous studies indicate that religiousness is associated with lower levels of substance use amo... more Previous studies indicate that religiousness is associated with lower levels of substance use among adolescents, but less is known about the relationship between spirituality and substance use. The objective of this study was to determine the association between adolescents' use of alcohol and specific aspects of religiousness and spirituality. Twelve- to 18-year-old patients coming for routine medical care at three primary care sites completed a modified Brief Multidimensional Measure of Religiousness/Spirituality; the Spiritual Connectedness Scale; and a past-90-days alcohol use Timeline Followback calendar. We used multiple logistic regression analysis to assess the association between each religiousness/spirituality measure and odds of any past-90-days alcohol use, controlling for age, gender, race/ethnicity, and clinic site. Timeline Followback data were dichotomized to indicate any past-90-days alcohol use and religiousness/spirituality scale scores were z-transformed for analysis. Participants (n = 305) were 67% female, 74% Hispanic or black, and 45% from two-parent families. Mean +/- SD age was 16.0 +/- 1.8 years. Approximately 1/3 (34%) reported past-90-day alcohol use. After controlling for demographics and clinic site, Religiousness/Spirituality scales that were not significantly associated with alcohol use included: Commitment (OR = 0.81, 95% CI 0.36, 1.79), Organizational Religiousness (OR = 0.83, 95% CI 0.64, 1.07), Private Religious Practices (OR = 0.94, 95% CI 0.80, 1.10), and Religious and Spiritual Coping--Negative (OR = 1.07, 95% CI 0.91, 1.23). All of these are measures of religiousness, except for Religious and Spiritual Coping--Negative. Scales that were significantly and negatively associated with alcohol use included: Forgiveness (OR = 0.55, 95% CI 0.42-0.73), Religious and Spiritual Coping--Positive (OR = 0.67, 95% CI 0.51-0.84), Daily Spiritual Experiences (OR = 0.67, 95% CI 0.54-0.84), and Belief (OR = 0.76, 95% CI 0.68-0.83), which are all measures of spirituality. In a multivariable model that included all significant measures, however, only Forgiveness remained as a significant negative correlate of alcohol use (OR = 0.56, 95% CI 0.41, 0.74). Forgiveness is associated with a lowered risk of drinking during adolescence.
PEDIATRICS, 2004
In 1952, Hsia et al 1 reported that 50% of infants with erythroblastosis fetalis in whom the tota... more In 1952, Hsia et al 1 reported that 50% of infants with erythroblastosis fetalis in whom the total serum bilirubin (TSB) was> 30 mg/dL developed kernicterus. The authors further reported that kernicterus did not occur in> 200 consecutive cases of erythroblastosis ...
Medical Clinics of North America, 2000
The 1990s in medicine have been characterized by the development of various clinical guidelines t... more The 1990s in medicine have been characterized by the development of various clinical guidelines to assist in the diagnosis, classification, and management of common disorders. Among the most frequent presenting complaints of adolescent patients are asthma, headaches, and fatique. In an era of managed care and brief clinical encounters, application of standardized guidelines, modified appropriately for adolescents, is likely to improve clinical outcomes, including patient and parent satisfaction. In each of these disorders, engaging the adolescent patient as a partner in planning and implementing management is crucial to success.
The Journal of Pediatrics, 1980
Journal of Pediatric and Adolescent Gynecology, 2001
Journal of Adolescent Health, 1998
The purpose of this study was to identify the behavioral, psychosocial, and demographic predictor... more The purpose of this study was to identify the behavioral, psychosocial, and demographic predictors of self-reported weapon carrying among secondary school students who attend urban public schools. Self-reported weapon carrying was measured in a schoolwide anonymous health survey conducted in two demographically comparable high schools in 1992, in Boston, Massachusetts. Indicators of self-perception, depression, stressful life events, and adolescent risk behaviors of substance use and sexual behavior, along with self-reported weapon carrying, were measured. The students in both schools were racially heterogeneous, with the majority of about 80% from black or Hispanic backgrounds. A predictive model was developed using a forward stepwise logistic regression model in one inner-city high school, and tested in a second high school. Self-reported lifetime weapon carrying was 32% overall. The major predictors of weapon carrying among urban secondary school students are a combination of demographic, psychosocial, behavioral, and school-related factors. This analysis indicates consistency in eight markers predictive of weapon carrying: lower age, male gender, regular marijuana use, sexual experience, having witnessed a crime, having skipped school, suicidal ideation, and having hit or "beat up" someone. Race parental education, and family composition were not significant predictors. Significant predictors of weapon carrying were marijuana use and sexual experience, each of which was consistently high in both schools. The model-building and validation presented in this study provide empirical evidence for three important conclusions. First, weapon carrying is associated with multiple and interrelated factors which include demographic, psychosocial, behavioral, and school-related characteristics of high school-age adolescents. Second, students with more risk factors are more likely to carry a weapon, suggesting that the variables are independent markers. Third, this study identified marijuana use and being sexually experienced as both highly predictive of weapon carrying. Implications of this study for prevention point to the need for comprehensive multidisciplinary services in high school that include mental health counseling as well as health education efforts aimed at behavior change.
Journal of Adolescent Health, 1994
WHAT'S KNOWN ON THIS SUBJECT: Primary care settings provide an important venue for early detectio... more WHAT'S KNOWN ON THIS SUBJECT: Primary care settings provide an important venue for early detection of substance use and intervention, but adolescent screening rates need improvement. Screening and brief interventions appear effective in reducing adult problem drinking but evidence for effectiveness among adolescents is needed. WHAT THIS STUDY ADDS: A computer-facilitated system for screening, feedback, and provider brief advice for primary care can increase adolescent receipt of substance use screening across a variety of practice settings, and shows promise for reducing adolescents' use of alcohol and cannabis. abstract OBJECTIVE: Primary care providers need effective strategies for substance use screening and brief counseling of adolescents. We examined the effects of a new computer-facilitated screening and provider brief advice (cSBA) system. METHODS: We used a quasi-experimental, asynchronous study design in which each site served as its own control. From 2005 to 2008, 12-to 18-year-olds arriving for routine care at 9 medical offices in New England (n = 2096, 58% females) and 10 in Prague, Czech Republic (n = 589, 47% females) were recruited. Patients completed measurements only during the initial treatment-as-usual study phase. We then conducted 1-hour provider training, and initiated the cSBA phase. Before seeing the provider, all cSBA participants completed a computerized screen, and then viewed screening results, scientific information, and true-life stories illustrating substance use harms. Providers received screening results and " talking points " designed to prompt 2 to 3 minutes of brief advice. We examined alcohol and cannabis use, initiation, and cessation rates over the past 90 days at 3-month follow-up, and over the past 12 months at 12-month follow-up. RESULTS: Compared with treatment as usual, cSBA patients reported less alcohol use at follow-up in New England (3-month rates 15.5% vs 22.9%, adjusted relative risk ratio [aRRR] = 0.54, 95% confidence interval 0.38– 0.77; 12-month rates 29.3% vs 37.5%, aRRR = 0.73, 0.57–0.92), and less cannabis use in Prague (3-month rates 5.5% vs 9.8%, aRRR = 0.37, 0.17– 0.77; 12-month rates 17.0% vs 28.7%, aRRR = 0.47, 0.32–0.71). CONCLUSIONS: Computer-facilitated screening and provider brief advice appears promising for reducing substance use among adolescent primary care patients.
Adolescent medicine (Philadelphia, Pa.), 2003
Journal of Adolescent Health Care, 1983
Sporadic cases of anorexia nervosa in the male patient have been described. We present three case... more Sporadic cases of anorexia nervosa in the male patient have been described. We present three cases of weight loss in adolescent males. The first is a typical case of primary anorexia nervosa. The second illustrates weight loss in the competitive adolescent athlete. The third was mistakenly thought to have primary anorexia nervosa. At autopsy, he had regional enteritis. These patients are compared to call attention to the differential diagnosis of anorexia nervosa in the adolescent male.
Australian Occupational Therapy Journal, 2008
Archives of Pediatrics & Adolescent Medicine, 1995
To explore through a pilot study the relationship between appropriateness (medical necessity) and... more To explore through a pilot study the relationship between appropriateness (medical necessity) and variations in pediatric hospital admission rates across several communities in the Boston (Mass) area for two common pediatric conditions with extremely variable admission rates: pneumonia and bronchitis/asthma. We identified five communities in the greater Boston area with high, average, and below-average ratios of observed to expected admissions for the study conditions. Diagnosis-specific, criteria-based utilization review instruments were developed by community-based pediatricians and applied by trained nurse reviewers to medical records. ADMISSIONS STUDIED: All admissions for pneumonia (diagnosis related group [DRG] 91) and bronchitis/asthma (DRG 98) of study area residents younger than 18 years to participating hospitals during fiscal year 1986. For each area, we calculated age-adjusted admission rates, age-adjusted observed to expected ratios, and rates of inappropriate admissions. We tested the hypothesis that admission rates and inappropriateness rates were directly related. We deemed 9.4% of pneumonia admissions and 4.4% of bronchitis/asthma admissions inappropriate. Rates of inappropriate admissions were not significantly associated with admission rates in this local pilot study for either study condition at P < .05. However, in one community both rates were high for both conditions. Feedback of findings to the key local hospital there resulted in sharp decreases in admission rates for DRGs 91 and 98 in subsequent years. Our results suggest that higher pediatric admission rates may not be associated with higher rates of inappropriateness. Further research is needed, with a larger number of communities, to differentiate practice patterns more precisely and explore patient and family preferences.
Journal of Adolescent Health, 1998
Pediatric dermatology
Adults with psoriasis have a greater risk of developing metabolic syndrome (MetS) and cardiovascu... more Adults with psoriasis have a greater risk of developing metabolic syndrome (MetS) and cardiovascular disease (CVD), but few studies have investigated the prevalence of MetS and other risk factors for CVD in children with psoriasis. In an assessor-blinded study, 20 children ages 9-17 years with a current or previously documented history of psoriasis involving 5% or more of their body surface area or psoriatic arthritis were compared with a cohort of age- and sex-matched controls with benign nevi, warts, or acne. MetS, our primary endpoint, was defined by the presence of abnormal values in at least three of the following measures: triglycerides, high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), waist circumference, and blood pressure. Secondary endpoints included high-sensitivity C-reactive protein (hs-CRP), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C). Thirty percent (6/20) of children with psoriasis met the criteria for MetS, compa...
Substance Abuse, 2007
To assess adolescents&amp... more To assess adolescents' preferences for substance abuse screening in primary medical care settings. Twelve- to 18-year-old patients (N = 2133) arriving for routine care at a network of primary care sites completed an interview that included demographic items, the CRAFFT screen, and a questionnaire assessing preferences for screening method (paper questionnaire, computer, oral interview by nurse or doctor). A subgroup (n = 222) completed the CRAFFT directly on the computer. Across the entire sample, paper was the screening administration method most preferred (mean rank (MR) = 2.92, 95%CI 2.87-2.96) vs. computer (MR = 2.38, 2.33-2.43), nurse (MR = 2.43, 2.39-2.47), and doctor (MR = 2.30, 2.25-2.35). Among the participants who received the screening on the computer, however, computer (MR = 3.08, 95%CI 2.42-2.52) was statistically tied with paper (MR = 2.88, 2.75-3.02) and both were ranked significantly higher than nurse (MR = 2.06, 1.94-2.17) and doctor (MR = 1.98, 1.82-2.14). The findings were similar for participants' reports of being "very likely" to be honest when answering substance abuse screening questions. Adolescents should ideally be screened for substance abuse using paper or computer questionnaires.
Southern Medical Journal, 2007
Previous studies indicate that religiousness is associated with lower levels of substance use amo... more Previous studies indicate that religiousness is associated with lower levels of substance use among adolescents, but less is known about the relationship between spirituality and substance use. The objective of this study was to determine the association between adolescents' use of alcohol and specific aspects of religiousness and spirituality. Twelve- to 18-year-old patients coming for routine medical care at three primary care sites completed a modified Brief Multidimensional Measure of Religiousness/Spirituality; the Spiritual Connectedness Scale; and a past-90-days alcohol use Timeline Followback calendar. We used multiple logistic regression analysis to assess the association between each religiousness/spirituality measure and odds of any past-90-days alcohol use, controlling for age, gender, race/ethnicity, and clinic site. Timeline Followback data were dichotomized to indicate any past-90-days alcohol use and religiousness/spirituality scale scores were z-transformed for analysis. Participants (n = 305) were 67% female, 74% Hispanic or black, and 45% from two-parent families. Mean +/- SD age was 16.0 +/- 1.8 years. Approximately 1/3 (34%) reported past-90-day alcohol use. After controlling for demographics and clinic site, Religiousness/Spirituality scales that were not significantly associated with alcohol use included: Commitment (OR = 0.81, 95% CI 0.36, 1.79), Organizational Religiousness (OR = 0.83, 95% CI 0.64, 1.07), Private Religious Practices (OR = 0.94, 95% CI 0.80, 1.10), and Religious and Spiritual Coping--Negative (OR = 1.07, 95% CI 0.91, 1.23). All of these are measures of religiousness, except for Religious and Spiritual Coping--Negative. Scales that were significantly and negatively associated with alcohol use included: Forgiveness (OR = 0.55, 95% CI 0.42-0.73), Religious and Spiritual Coping--Positive (OR = 0.67, 95% CI 0.51-0.84), Daily Spiritual Experiences (OR = 0.67, 95% CI 0.54-0.84), and Belief (OR = 0.76, 95% CI 0.68-0.83), which are all measures of spirituality. In a multivariable model that included all significant measures, however, only Forgiveness remained as a significant negative correlate of alcohol use (OR = 0.56, 95% CI 0.41, 0.74). Forgiveness is associated with a lowered risk of drinking during adolescence.
PEDIATRICS, 2004
In 1952, Hsia et al 1 reported that 50% of infants with erythroblastosis fetalis in whom the tota... more In 1952, Hsia et al 1 reported that 50% of infants with erythroblastosis fetalis in whom the total serum bilirubin (TSB) was> 30 mg/dL developed kernicterus. The authors further reported that kernicterus did not occur in> 200 consecutive cases of erythroblastosis ...
Medical Clinics of North America, 2000
The 1990s in medicine have been characterized by the development of various clinical guidelines t... more The 1990s in medicine have been characterized by the development of various clinical guidelines to assist in the diagnosis, classification, and management of common disorders. Among the most frequent presenting complaints of adolescent patients are asthma, headaches, and fatique. In an era of managed care and brief clinical encounters, application of standardized guidelines, modified appropriately for adolescents, is likely to improve clinical outcomes, including patient and parent satisfaction. In each of these disorders, engaging the adolescent patient as a partner in planning and implementing management is crucial to success.
The Journal of Pediatrics, 1980
Journal of Pediatric and Adolescent Gynecology, 2001
Journal of Adolescent Health, 1998
The purpose of this study was to identify the behavioral, psychosocial, and demographic predictor... more The purpose of this study was to identify the behavioral, psychosocial, and demographic predictors of self-reported weapon carrying among secondary school students who attend urban public schools. Self-reported weapon carrying was measured in a schoolwide anonymous health survey conducted in two demographically comparable high schools in 1992, in Boston, Massachusetts. Indicators of self-perception, depression, stressful life events, and adolescent risk behaviors of substance use and sexual behavior, along with self-reported weapon carrying, were measured. The students in both schools were racially heterogeneous, with the majority of about 80% from black or Hispanic backgrounds. A predictive model was developed using a forward stepwise logistic regression model in one inner-city high school, and tested in a second high school. Self-reported lifetime weapon carrying was 32% overall. The major predictors of weapon carrying among urban secondary school students are a combination of demographic, psychosocial, behavioral, and school-related factors. This analysis indicates consistency in eight markers predictive of weapon carrying: lower age, male gender, regular marijuana use, sexual experience, having witnessed a crime, having skipped school, suicidal ideation, and having hit or "beat up" someone. Race parental education, and family composition were not significant predictors. Significant predictors of weapon carrying were marijuana use and sexual experience, each of which was consistently high in both schools. The model-building and validation presented in this study provide empirical evidence for three important conclusions. First, weapon carrying is associated with multiple and interrelated factors which include demographic, psychosocial, behavioral, and school-related characteristics of high school-age adolescents. Second, students with more risk factors are more likely to carry a weapon, suggesting that the variables are independent markers. Third, this study identified marijuana use and being sexually experienced as both highly predictive of weapon carrying. Implications of this study for prevention point to the need for comprehensive multidisciplinary services in high school that include mental health counseling as well as health education efforts aimed at behavior change.
Journal of Adolescent Health, 1994