Economic analysis of financial incentives for smoking cessation during pregnancy and postpartum.

Higgins and colleagues' recently-completed randomized controlled trial and pooled data with 4 related trials of smoking cessation in pregnant women in Vermont (USA) showed that abstinence-contingent financial incentives (FI) increased abstinence over control conditions from early pregnancy through 24-weeks postpartum. Control conditions were best practices (BP) alone in the recent trial and payments provided independent of smoking status (noncontingently) in the others. This paper reports economic analyses of abstinence-contingent FI. Merging trial results with maternal and infant healthcare costs from all Vermont Medicaid deliveries in 2019, we computed incremental cost-effectiveness ratios (ICERs) for quality-adjusted life years (QALYs) and compared them to established thresholds. The healthcare sector cost (±standard error) of adding FI to BP averaged $634.76 ± $531.61 per participant. Based on this trial, the increased probability per BP + FI participant of smoking abstinence at 24-weeks postpartum was 3.17%, the cost per additional abstinent woman was $20,043, the incremental health gain was 0.0270 ± 0.0412 QALYs, the ICER was $23,511/QALY gained, and the probabilities that BP + FI was very cost-effective (ICER≤$65,910) and cost-effective (ICER≤$100,000) were 67.9% and 71.0%, respectively. Based on the pooled trials, the corresponding values were even more favorable-8.89%, $7138, 0.0758 ± 0.0178 QALYs, $8371/QALY, 98.6% and 99.3%, respectively. Each dollar invested in abstinence-contingent FI over control smoking-cessation programs yielded $4.20 in economic benefits in the recent trial and $11.90 in the pooled trials (very favorable benefit-cost ratios). Medicaid and commercial insurers may wish to consider covering financial incentives for smoking abstinence as a cost-effective service for pregnant beneficiaries who smoke. Trial Registration: ClinicalTrials.gov identifier: NCT02210832.

Using an experimental tobacco marketplace to pilot test the substitutability of JUUL e-cigarettes and other alternative nicotine and tobacco products for conventional cigarettes among vulnerable populations.

The Experimental Tobacco Marketplace (ETM) is an online research marketplace where increasing the cost of cigarettes is used to investigate the substitutability of other fixed-price tobacco products such as electronic nicotine delivery systems (ENDS). The ETM is useful for modeling effects of potential policy changes on use of various concurrently available products. To our knowledge, the ETM has not been used to investigate substitutability of newer generation e-cigarettes or populations at increased risk for smoking, heavy smoking, nicotine dependence, and smoking-attributable adverse effects. In the current pilot study, participants were 30 adult daily smokers with socioeconomic disadvantage or comorbid psychiatric conditions (substance-use disorder or mental illness). In each session, cigarette prices increased ($0.12, $0.25, $0.50, $1.00. and $2.00 per cigarette) while prices for alternative products remained fixed. Across three ETM sessions, either all products, all products except little cigars and cigarillos (LCCs), or all products except ENDS (JUUL e-cigarettes) were available. Linear regression was performed on individual participant data using log-transformed cigarette price to determine demand and substitution. Cigarette demand decreased as price increased across sessions (significantly non-zero slopes, ps ≤ 0.0001). When all products were available, ENDS substitution increased as cigarette price increased (significantly non-zero slope, p = .016). When LCCs were unavailable, ENDS again were a significant substitute (p = .008). When ENDS were unavailable, LCCs did not substitute (ps ≥ 0.48). In all sessions, participants rarely purchased other products (e.g., snus). Overall, ENDS were the most robust substitute for cigarettes, further underscoring the potential importance of ENDS availability on the impact of tobacco regulatory policies.

Relating individual differences in the reinforcing value of smoking and dependence severity to nicotine exposure levels in vulnerable populations.

Cigarette smoking is overrepresented in populations with psychiatric conditions and socioeconomic disadvantage. Greater understanding of the role of reinforcement and nicotine dependence in smoking among vulnerable populations may facilitate development of better targeted interventions to reduce smoking. Prior research demonstrated that individual differences in the reinforcing value of smoking and nicotine-dependence severity predicted total nicotine-exposure in vulnerable populations. The present study uses multivariate regression to address two aims: (1) Quantify the degree to which the reinforcing value of smoking, assessed using the Cigarette Purchase Task (CPT), and dependence severity assessed using the Fagerström Test of Nicotine Dependence and Brief Wisconsin Inventory of Smoking Dependence Motives (B-WISDM) each account for individual differences in cotinine-plus-3'-hydroxycotinine (COT+3HC) levels. (2) Explore whether there is overlap in the variance accounted for by the CTP, FTND, and B-WISDM. Participants were 628 adults with co-morbid psychiatric conditions or socioeconomic disadvantage who smoked daily. The CPT, FTND, and B-WISDM models accounted for 23.76%, 32.45%, and 29.61% of the variance in COT+3HC levels, respectively. Adding CPT to the FTND model failed to increase the variance accounted for and adding it to the B-WISDM model did so by only 1.2% demonstrating considerable overlap in the variance in nicotine exposure levels accounted for by these three instruments. These results provide new knowledge on the relationship between individual differences in the reinforcing value of smoking and nicotine-exposure levels and suggest differences in reinforcing value may underpin a considerable portion of the variance in nicotine exposure accounted for by dependence severity.

Comparing participant estimated demand intensity on the cigarette Purchase Task to consumption when usual-brand cigarettes were provided free.

Accumulating evidence suggests that the hypothetical Cigarette Purchase Task (CPT), especially its demand Intensity index (i.e., estimated cigarettes participants would smoke if free), is associated with individual differences in smoking risk. Nevertheless, few studies have examined the extent to which hypothetical CPT demand Intensity may differ from consumption when participants are provided with free cigarettes. That topic is the overarching focus of the present study. Participants were 745 adult smokers with co-morbid psychiatric conditions or socioeconomic disadvantage. CPT was administered for usual-brand cigarettes prior to providing participants with seven days of their usual-brand cigarettes free of cost and consumption was recorded daily via an Interactive Voice Response (IVR) System. Demand Intensity was correlated with IVR smoking rate (rs 0.670-0.696, ps < 0.001) but estimates consistently exceeded IVR smoking rates by an average of 4.4 cigarettes per day (ps < 0.001). Importantly, both measures were comparably sensitive to discerning well-established differences in smoking risk, including greater cigarettes per day among men versus women (F(1,732) = 18.74, p < 0.001), those with versus without opioid-dependence (F(1,732) = 168.37, p < 0.001), younger versus older adults (F(2,730) = 32.93, p < 0.001), and those with lower versus greater educational attainment (F(1,732) = 38.26, p < 0.001). Overall, CPT demand Intensity appears to overestimate consumption rates relative to those observed when participants are provided with free cigarettes, but those deviations are systematic (i.e., consistent in magnitude and direction, Fs all <1.63; ps > 0.19 for all interactions with subgroups). This suggests that demand Intensity was sensitive to established group differences in smoking rate, supporting its utility as an important measure of addiction potential.

Examining effects of unit price on preference for reduced nicotine content cigarettes and smoking rate.

Cigarette preference increases as a function of greater nicotine content, but manipulating cost can shift preference. The aims of the present study are to model whether (1) the behavioral-economic metric unit price (cost/reinforcer magnitude) accounts for preference shifts and (2) whether preference shifts toward reduced nicotine content are associated with smoking reductions. In a multisite study between 2015 and 2016, 169 daily smokers from vulnerable populations completed two concurrent-choice conditions examining preference for smoking normal (15.8 mg/g) and reduced (0.4 mg/g) nicotine content cigarettes. In Condition 1, both products were available at 10 responses/choice. In Condition 2, availability of the 0.4 mg/g dose remained at 10 responses/choice while the 15.8 mg/g dose was available on a progressive-ratio (PR) schedule wherein response cost increased following each choice. Unit prices were calculated by dividing dose by response requirement. Results were analyzed using ANOVA and binomial tests (p < .05). Participants preferred the 15.8 over 0.4 mg/g dose in Condition 1, but shifted preference to the 0.4 mg/g dose in Condition 2 (p < .001) immediately before the point in the PR progression where unit price for 15.8 dose exceeded unit price for the 0.4 dose (p < .001). This shift was associated with a reduction in smoking (p < .001). The unit price of nicotine appears to underpin cigarette product preference and may provide a metric for predicting preference and potentially impacting it through tobacco regulations. These results also demonstrate that reduced compared to normal nicotine content cigarettes sustain lower smoking rates discernible even under acute laboratory conditions and in vulnerable populations.

Potential Moderating Effects of Psychiatric Diagnosis and Symptom Severity on Subjective and Behavioral Responses to Reduced Nicotine Content Cigarettes.

INTRODUCTION: Given FDA's authority to implement a cigarette nicotine reduction policy, possible outcomes of this regulation must be examined, especially among those who may be most affected, such as those with comorbid psychiatric disorders. METHODS: In this secondary analysis of a multisite, randomized, clinical laboratory study, we used analyses of variance to examine the effects of nicotine dose (0.4, 2.4, 5.2, and 15.8 mg/g of tobacco), depressive and anxiety diagnoses (depression only, anxiety only, both, or neither), and depressive and anxiety symptom severity on cigarette choice, smoke exposure, craving, and withdrawal across three vulnerable populations: socioeconomically disadvantaged women of reproductive age, opioid-dependent individuals, and those with affective disorders (n = 169). RESULTS: Diagnosis and symptom severity largely had no effects on smoking choice, total puff volume, or CO boost. Significant main effects on craving and withdrawal were observed, with higher scores in those with both anxiety and depression diagnoses compared with depression alone or no diagnosis, and in those with more severe depressive symptoms (p's < .001). These factors did not interact with nicotine dose. Cigarettes with <15.8 mg/g nicotine were less reinforcing, decreased total puff volume, and produced significant but lower magnitude and shorter duration reductions in craving and withdrawal than higher doses (p's < .01). CONCLUSIONS: Reducing nicotine dose reduced measures of cigarette addiction potential, with little evidence of moderation by either psychiatric diagnosis or symptom severity, providing evidence that those with comorbid psychiatric disorders would respond to a nicotine reduction policy similarly to other smokers. IMPLICATIONS: Thus far, controlled studies in healthy populations of smokers have demonstrated that use of very low nicotine content cigarettes reduces cigarette use and dependence without resulting in compensatory smoking. These analyses extend those findings to a vulnerable population of interest, those with comorbid psychiatric disorders. Cigarettes with very low nicotine content were less reinforcing, decreased total puff volume, and produced significant but lower magnitude and shorter duration reductions in craving and withdrawal than higher doses. These nicotine dose effects did not interact with psychiatric diagnosis or mood symptom severity suggesting that smokers in this vulnerable population would respond to a nicotine reduction strategy similarly to other smokers.

The nonallergic asthma of obesity. A matter of distal lung compliance.

RATIONALE: The pathogenesis of asthma in obesity is poorly understood, but may be related to breathing at low lung volumes. OBJECTIVES: To determine if lung function in obese patients with asthma and control subjects would respond differently to weight loss. METHODS: Lung function was evaluated by conventional clinical tests and by impulse oscillometry in female late-onset, nonallergic patients with asthma and control subjects before, and 12 months after, bariatric surgery. MEASUREMENTS AND MAIN RESULTS: Patients with asthma (n = 10) had significantly lower FEV1 (79.8 ± 10.6 vs. 95.5 ± 7.0%) and FVC (82.4 ± 13.2 vs. 93.7 ± 8.9%) compared with control subjects (n = 13). There were no significant differences in FRC or TLC at baseline. Twelve months after surgery, control subjects had significant increases in FEV1 (95.5 ± 7.0 to 100.7 ± 5.9), FVC (93.6 ± 8.9 to 98.6 ± 8.3%), FRC (45.4 ± 18.5 to 62.1 ± 15.3%), and TLC (84.8 ± 15.0 to 103.1 ± 15.3%), whereas patients with asthma had improvement only in FEV1 (79.8 ± 10.6 to 87.2 ± 11.5). Control subjects and patients with asthma had a significantly different change in respiratory system resistance with weight loss: control subjects exhibited a uniform decrease in respiratory system resistance at all frequencies, whereas patients with asthma exhibited a decrease in frequency dependence of resistance. Fits of a mathematical model of lung mechanics to these impedance spectra suggest that the lung periphery was more collapsed by obesity in patients with asthma compared with control subjects. CONCLUSIONS: Weight loss decompresses the lung in both obese control subjects and patients with asthma, but the more pronounced effects of weight loss on lung elastance suggest that the distal lung is inherently more collapsible in people with asthma.

Examining Associations Between Baseline Health-Related Quality of Life and Depression and Physical Functioning Improvement Following Pulmonary Rehabilitation.

PURPOSE: This study examined whether health-related quality of life (HRQL) and depression assessed prior to pulmonary rehabilitation (PR) participation (ie, at baseline) predicted change in 6-min walk distance (6MWD) from baseline to end of PR. METHODS: Patients with pulmonary disease were consecutively referred/enrolled in a PR program from 2009-2022 (N = 503). Baseline 6MWD was assessed along with self-report measures of HRQL (St George's Respiratory Questionnaire [SGRQ]) and depression (Geriatric Depression Scale [GDS]). The SGRQ total score was used to assess overall HRQL, and SGRQ subscales assessed pulmonary symptoms, activity limitations, and psychosocial impacts of pulmonary disease. Multiple linear regression was used to examine whether baseline SGRQ scores and depression predicted Δ6MWD. RESULTS: Baseline SGRQ total score ( F(1,389) = 8.4, P = .004) and activity limitations ( F(1,388) = 4.8, P = .03) predicted Δ6MWD. Patients with an SGRQ activity limitation score ≤ 25th percentile showed the most 6MWD improvement (mean = 79.7 m, SE = 6.7), and significantly more improvement than participants scoring between the 50-75th percentiles (mean = 54.4 m, SE = 6.0) or >75th percentile (mean = 48.7 m, SE = 7.5). Patients scoring between the 25-50th percentiles (mean = 70.2 m, SE = 6.1) did not differ significantly from other groups. The SGRQ symptoms and impacts subscales were unrelated to Δ6MWD ( F(1,388) = 1.2-1.9, P > .05), as was depression ( F(1,311) = 0.0, P  > .85). CONCLUSIONS: Patients with greater HRQL at baseline may experience greater physical functioning improvement following PR. Additional support for patients with lower HRQL (eg, adjunctive self-management interventions) may enhance PR outcomes, particularly for patients who report greater activity limitations. Alternatively, early referral to PR (ie, when less symptomatic) may also benefit physical function outcomes.

Prospectively assessed summer mood status in major depression, recurrent with seasonal pattern: Evidence for SAD's construct validity.

OBJECTIVE: Seasonal patterns are often undetectable in population-based depression studies, calling into question the existence of winter seasonal affective disorder (SAD). If SAD has construct validity, individuals with SAD should show spontaneous depression remission in the summer. Data are sparse on prospectively assessed summer mood status in confirmed SAD patients. METHOD: We conducted prospective summer followup of community adults who, the winter before, were diagnosed with Major Depression, Recurrent with Seasonal Pattern on the Structured Clinical Interview for DSM-IV Axis I Disorders, developed a current SAD episode on the Structured Interview Guide for the Hamilton Rating Scale for Depression-Seasonal Affective Disorder Version (SIGH-SAD), and enrolled in a clinical trial comparing group cognitive-behavioral therapy for SAD and light therapy. In July/August after treatment, 143/153 (93.5 %) participants provided data on the SIGH-SAD, the Beck Depression Inventory-Second Edition, and the Longitudinal Interval Followup Evaluation (LIFE). RESULTS: Summer mean depression scores were in the normal range, with the substantial majority in remission across different measures. On the LIFE, 113/143 (79.0 %) experienced complete summer remission, 19/143 (13.3 %) experienced partial summer remission, and 11/143 (7.7 %) had major depression in the summer. Depression scores were significantly lower at summer than post-treatment in both treatments, indicating incomplete treatment response. LIMITATIONS: This was a single-site study with a relatively homogeneous sample. CONCLUSIONS: Supporting construct validity for SAD, the substantial majority experienced complete summer remission, with a minority in partial remission and a very small minority in episode. Both treatments left residual symptoms at treatment endpoint compared to summer.

Lumbar multifidus muscle thickness does not predict patients with low back pain who improve with trunk stabilization exercises.

OBJECTIVE: To understand lumbar multifidus (LM) muscle activation as a clinical feature to predict patients with low back pain (LBP) who are likely to benefit from stabilization (STB) exercises. DESIGN: Prospective, cohort study. SETTING: Outpatient physical therapy clinics. PARTICIPANTS: Persons with LBP were recruited for this study. Subjects (N=25) were classified as either eligible to receive STB exercises or ineligible on the basis of current clinical prediction rules. INTERVENTIONS: Six weeks of STB treatment. MAIN OUTCOME MEASURES: Before and after treatment, subjects underwent rehabilitative ultrasound imaging to quantify LM-muscle activation and completed disability and pain questionnaires. Analyses were performed to examine the (1) relation between LM-muscle activation and current clinical features used to predict patients with LBP likely to benefit from STB exercises, (2) LM-muscle activation between the STB-eligible and STB-ineligible groups before and after STB treatment, and (3) relation between LM-muscle activation before STB treatment and (a) disability and (b) pain outcomes after treatment for both groups. RESULTS: No relation was found between LM-muscle activation and the number of clinical features. Before STB treatment, LM-muscle activation between the STB-eligible and STB-ineligible groups did not differ. After STB treatment, LM-muscle activation differed between the groups; however, this interaction was because the LM-muscle activation for the STB-eligible group decreased after treatment while that for the STB-ineligible group increased after treatment. Finally, only the STB-eligible group had a significant reduction in disability following treatment; however, no relation was found between LM-muscle activation before treatment and (a) disability or (b) pain outcomes after treatment in the STB-eligible group. CONCLUSIONS: LM-muscle activation does not appear to be a clinical feature that predicts patients with LBP likely to benefit from STB exercises.

The interactive effects of JUUL flavor and nicotine concentration on addiction potential.

Prior research suggests that flavors can influence the pharmacological effects of nicotine. We used commercially available JUUL pods to examine whether preferred menthol versus tobacco flavor increased the addictive potential of nicotine per se. This study recruited 15 regular JUUL e-cigarette users to complete a 2 × 2 factorial crossover trial using an entirely remote video format. Participants completed a sampling baseline session to identify preferred JUUL flavor (menthol vs. tobacco) followed by four counterbalanced experimental sessions separated by ≥ 48 hr: (a) low-nicotine dose (3% JUUL)/nonpreferred flavor; (b) low dose/preferred flavor; (c) high-nicotine dose (5% JUUL)/nonpreferred flavor; and (d) high dose/preferred flavor. In each experimental session, participants completed a puffing procedure followed by subjective ratings of e-cigarette liking and wanting (ELW), urges, and reinforcement using a JUUL pod purchase task. There was a dose-by-flavor interaction for average ELW (F = 4.58, p = .041) in which ELW was significantly greater for the preferred than the nonpreferred flavor at the low-nicotine dose but not the high-nicotine dose. There were also dose-by-flavor interactions for pre- to post-puffing change in overall urge to vape (F = 5.97, p = .021) and urge strength (F = 4.96, p = .049), with greater reductions in overall urge/strength for the preferred compared to the nonpreferred flavor at the low but not the high dose. We found no significant interaction effects for purchase task outcomes. Using a fully remote experimental puffing procedure, our findings suggest preferred flavors increase the rewarding effects most for lower nicotine e-cigarettes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Individuals with non-specific low back pain in an active episode demonstrate temporally altered torque responses and direction-specific enhanced muscle activity following unexpected balance perturbations.

Individuals with a history of non-specific low back pain (LBP) while in a quiescent pain period demonstrate altered automatic postural responses (APRs) characterized by reduced trunk torque contributions and increased co-activation of trunk musculature. However, it is unknown whether these changes preceded or resulted from pain. To further delineate the relationship between cyclic pain recurrence and APRs, we quantified postural responses following multi-directional support surface translations, in individuals with non-specific LBP, following an active pain episode. Sixteen subjects with and 16 without LBP stood on two force plates that were translated unexpectedly in 12 directions. Net joint torques of the ankles, knees (sagittal only), hips, and trunk, in the frontal and sagittal planes, were quantified and the activation of 12 muscles of the lower limb unilaterally and the dorsal and ventral trunk, bilaterally, were recorded using surface electromyography (EMG). Peaks and latencies to peak joint torques, rates of torque development (slopes), and integrated EMGs characterizing baseline and active muscle contributions were analyzed for group by perturbation direction (torques) and group by perturbation by epoch interaction (EMG) effects. In general, the LBP cohort demonstrated APRs that were of similar torque magnitude and rate but peaked earlier compared to individuals without LBP. Individuals with LBP also demonstrated increased muscle activity following perturbation directions in which the muscle was acting as a prime mover and reduced muscle activity in opposing directions, proximally and distally, with some proximal asymmetries. These altered postural responses may reflect increased muscle spindle sensitivity. Given that these motor alterations are demonstrated proximally and distally, they likely reflect the influence of central nervous system processing in this cohort.

Delay discounting and narcissism: A meta-analysis with implications for narcissistic personality disorder.

Several psychiatric conditions (e.g., substance use, mood, and personality disorders) are characterized, in part, by greater delay discounting (DD)-a decision-making bias in the direction of preferring smaller, more immediate over larger, delayed rewards. Narcissistic personality disorder (NPD) is highly comorbid with substance use, mood, and other personality disorders, suggesting that DD may be a process underpinning risk for NPD as well. This meta-analysis examined associations between DD and theoretically distinct, clinically relevant dimensions of narcissism (i.e., grandiosity, entitlement, and vulnerability). Literature searches were conducted and articles were included if they were written in English, published in a peer-reviewed journal, contained measures of DD and narcissism and reported their association, and used an adult sample. Narcissism measures had to be systematically categorized according to clinically relevant dimensions (Grijalva et al., 2015; Wright & Edershile, 2018). Seven studies met inclusion criteria (N = 2,705). DD was positively associated with narcissism (r = .21; 95% confidence interval [.10, .32]), with this association being largely attributable to measures of trait grandiosity that were used in each study (r = .24; 95% confidence interval [.11, .37]). No studies included diagnostic NPD assessments. These findings provide empirical evidence that DD is related to trait narcissism and perhaps risk for NPD (e.g., grandiosity listed in Criterion B of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, alternative model of personality disorders). Considering the positive evidence from this review, and the dearth of research examining DD in individuals with NPD, investigators studying NPD may consider incorporating DD measures in future studies to potentially inform clinical theory and novel adjunctive treatment options. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Predictive validity of the Seasonal Beliefs Questionnaire for discriminating between seasonal and nonseasonal major depressive disorder.

The Seasonal Beliefs Questionnaire (SBQ) is a 26-item self-report measure of a winter seasonal affective disorder (SAD)-specific cognitive vulnerability consisting of maladaptive thoughts about the seasons, light availability, and weather conditions. In a known groups comparison, currently depressed adults with SAD had significantly higher SBQ scores than currently depressed adults with nonseasonal major depressive disorder (MDD) and healthy controls, and the MDD group had significantly higher SBQ scores than controls. Using that database, this study explored the predictive validity of using an SBQ cutoff score to differentiate SAD from MDD. Receiver operator characteristic curve analyses used SBQ total score to predict SAD versus MDD, SAD versus control, and MDD versus control status. The SBQ subscale combined score, derived from multivariable logistic regression with SBQ subscales, was examined as an alternative predictor. SBQ total score with a cutpoint of 132 had good predictive ability for distinguishing SAD from MDD (C-statistic = .792, sensitivity = .798, specificity = .794). The SBQ subscale combination score slightly improved predictive ability for the SAD/MDD distinction (C-statistic = .813), with better sensitivity (.930) but worse specificity (.571). In contrast, the score on a generic measure of depressogenic cognitive vulnerability, the Dysfunctional Attitudes Scale, was poor for differentiating SAD from MDD. SBQ total score was excellent in discriminating SAD cases from controls with a cutpoint of 121 (C-statistic = .962, sensitivity = .939, specificity .873), but had poor sensitivity for discriminating MDD cases from controls. Results support using the SBQ to screen for probable SAD in practice settings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Acute Kidney Injury and Renin-Angiotensin System Inhibition Following Transcatheter Aortic Valve Replacement.

OBJECTIVE: To identify renin-angiotensin system (RAS) inhibition utilization and discontinuation after transcatheter aortic valve replacement (TAVR) and identify predictors of use and discontinuation. BACKGROUND: RAS inhibition after TAVR has been associated with lower cardiac mortality and heart failure readmissions. METHODS: We analyzed 735 consecutive TAVR patients (2014-2019) who survived to hospital discharge at a high-volume TAVR center to determine the utilization and discontinuation of RAS inhibition after TAVR and identify predictors of use and discontinuation. Clinical characteristics, procedural variables, and hospital outcomes were compared between patients receiving vs not receiving discharge RAS inhibitors. Data were compared using t-test and Chi-square test. Multivariable analysis was used to determine independent clinical predictors. RESULTS: Of the 735 patients, 41.9% were discharged with at least 1 RAS inhibitor. In TAVR patients with heart failure with reduced ejection fraction (HFrEF), defined as EF ≤40%, the utilization of RAS inhibitors at discharge was 51.1%. Patients receiving discharge RAS inhibitors had lower incidences of acute kidney injury (AKI) post procedure (8.1% vs 17.8%; P<.01). Discontinuation of RAS inhibition was observed in approximately 1 in 3 patients and was associated with AKI and pacemaker requirement. Three predictors of RAS inhibitor utilization were higher systolic blood pressure, RAS inhibitor use prior to TAVR, and HFrEF. Conversely, new pacemaker and AKI were associated with less utilization of RAS inhibitors; patients developing AKI were 74% less likely to receive RAS inhibitors than those without AKI. CONCLUSION: Decreased RAS inhibition provides a potential mechanism for worse outcomes in TAVR patients who develop AKI.

Detecting Critical Decision Points during Cognitive-Behavioral Therapy and Light Therapy for Winter Depression Nonremission and Recurrence.

Using data from a clinical trial comparing cognitive-behavioral therapy (CBT-SAD) and light therapy (LT) for winter seasonal affective disorder (SAD; N = 177), we explored critical decision points, or treatment weeks, that predict likelihood of nonremission at post-treatment and depression recurrence following treatment. In receiver operator characteristic (ROC) curve analyses, we used weekly Structured Clinical Interview for the Hamilton Rating Scale for Depression-SAD Version (SIGH-SAD) scores during treatment to predict nonremission at post-treatment (Week 6) and recurrence one winter later (Winter 1), two winters later (Winter 2), and any recurrence. Although several C-statistics of ≥ .70 were found, only Week 4 SIGH-SAD scores in CBT-SAD for nonremission had enough predictive ability to inform clinical decision-making (C-statistic = .80; sensitivity = .91; specificity = .68). Week 4 of CBT-SAD may be a critical time point to identify likely nonremitters who need tailoring of intervention, based on SIGH-SAD cutpoint score ≥ 13. This study illustrates how clinical trial data can inform detecting optimal decision points in treatment for identifying patients unlikely to remit, a critical first step to developing adaptive treatment strategies using decision rules to operationalize when and for whom treatment should change to maximize clinical benefit.

Using the Cigarette Purchase Task to examine the relative reinforcing value of cigarettes among mothers with versus without opioid dependence.

The Cigarette Purchase Task (CPT), in which participants estimate the number of cigarettes they would smoke across increasing cigarette prices, measures the relative reinforcing value of cigarettes. Although opioid-dependent individuals are particularly vulnerable to tobacco addiction, more research is needed to elucidate whether and to what extent their motivation to smoke differs from not-opioid-dependent smokers controlling for potential sociodemographic differences. Participants were 173 women (65 opioid-dependent) in an ongoing clinical trial for smoking cessation. Baseline CPT responses were compared between opioid-dependent and not-opioid-dependent women using five demand indices: Demand Intensity; Omax; Pmax; Breakpoint (BP); and α, and two latent factors: Amplitude and Persistence. Final regression models adjusted for sociodemographic characteristics differing between the two groups. Opioid-dependent women had greater demand Intensity (i.e., number of cigarettes they would smoke if they were free) than not-opioid dependent women in the adjusted model, F(1, 156) = 6.93, p = .016. No other demand indices differed significantly. Regarding latent factors, demand Amplitude (i.e., volumetric consumption), but not Persistence (i.e., price insensitivity), was greater for opioid-dependent women in the adjusted model, F(1, 146) = 4.04, p = .046. These results further demonstrate that the CPT is a highly sensitive task that can illuminate potentially important individual and population differences in the relative reinforcing value of smoking. Greater demand Intensity and Amplitude differentiated smokers with comorbid opioid dependence; thus, decreasing smoking prevalence among opioid-dependent populations may require policies and interventions that can decrease cigarette demand Intensity and Amplitude. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A measure of cognitions specific to seasonal depression: Development and validation of the Seasonal Beliefs Questionnaire.

We introduce the Seasonal Beliefs Questionnaire (SBQ), a self-report inventory of maladaptive thoughts about the seasons, light availability, and weather conditions, proposed to constitute a unique cognitive vulnerability to winter seasonal affective disorder (SAD; Rohan, Roecklein, & Haaga, 2009). Potential items were derived from a qualitative analysis of self-reported thoughts during SAD-tailored cognitive-behavioral therapy (CBT-SAD) and subsequently refined based on qualitative feedback from 48 SAD patients. In the psychometric study (N = 536 college students), exploratory and confirmatory factor analyses pruned the items to a 26-item scale with a 5-factor solution, demonstrating good internal consistency, convergent and divergent validity, and 2-week test-retest reliability. In a known groups comparison, the SBQ discriminated SAD patients (n = 86) from both nonseasonal major depressive disorder (MDD) patients (n = 30) and healthy controls (n = 110), whereas a generic measure of depressogenic cognitive vulnerability (the Dysfunctional Attitudes Scale [DAS]) discriminated MDD patients from the other groups. In a randomized clinical trial comparing CBT-SAD with light therapy (N = 177), SBQ scores improved at twice the rate in CBT-SAD than in light therapy. Greater change in SBQ scores during CBT-SAD, but not during light therapy, was associated with a lower risk of depression recurrence 2 winters later. In contrast, DAS scores improved comparably during CBT-SAD and light therapy, and DAS change was unrelated to recurrence following either treatment. These results support using the SBQ as a brief assessment tool for a SAD-specific cognitive vulnerability and as a treatment target in CBT-SAD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Lift-off Test Results After Lesser Tuberosity Osteotomy Versus Subscapularis Peel in Primary Total Shoulder Arthroplasty.

BACKGROUND: The ideal method for management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial. METHODS: In a retrospective cohort study, primary anatomic TSA procedures performed with either a subscapularis peel or a lesser tuberosity osteotomy from 2002 to 2010 were reviewed at a minimum 1-year follow-up. The primary outcome measure was the performance of a normal lift-off test postoperatively. Multivariate logistic regression analysis was performed to determine if other covariates besides surgical technique correlated with an abnormal lift-off test result. RESULTS: Ninety TSA procedures were evaluated. Forty-six procedures were performed with subscapularis peel, and 44 were performed with lesser tuberosity osteotomy. Mean follow-up was 4 years. In the subscapularis peel group, 32 of 46 shoulders (69.6%) had a normal lift-off test, compared with 40 of 44 shoulders (90.9%) in the lesser tuberosity osteotomy group (P = 0.01). The results of multivariate logistic regression suggested that lesser tuberosity osteotomy was associated with a normal postoperative lift-off test 4.5 times more often than was subscapularis peel. CONCLUSIONS: Our study suggests that the use of lesser tuberosity osteotomy as the surgical approach for anatomic TSA is a reliable option that provides the patient with a better chance of maintaining subscapularis function postoperatively than the subscapularis peel does. LEVEL OF EVIDENCE: Level III retrospective cohort study.

Relationship between geometry of the extensor mechanism of the knee and risk of anterior cruciate ligament injury.

The complex inter-segmental forces that are developed across an extended knee by body weight and contraction of the quadriceps muscle group transmits an anteriorly directed force on the tibia that strain the anterior cruciate ligament (ACL). We hypothesized that a relationship exists between geometry of the knees extensor mechanism and the risk of sustaining a non-contact ACL injury. Geometry of the extensor mechanism was characterized using MRI scans of the knees of 88 subjects that suffered their first non-contact ACL injury and 88 matched control subjects with normal knees that were on the same team. The orientation of the patellar tendon axis was measured relative to the femoral flexion-extension axis to determine the extensor moment arm (EMA), and relative to tibial long axis to measure coronal patellar tendon angle (CPTA) and sagittal patellar tendon angle (SPTA). Associations between these parameters and ACL injury risk were tested with and without adjustment for flexion and internal rotation position of the tibia relative to the femur during MRI data acquisition. After adjustment for internal rotation position of the tibia relative to the femur there were no associations between EMA, CPTA, and SPTA and risk of suffering an ACL injury. However, increased internal rotation position of the tibia relative to the femur was significantly associated with increased risk of ACL injury in female athletes both in univariate analysis (Odds Ratio = 1.16 per degree of internal rotation of the tibia, p = 0.002), as well as after adjustment for EMA, CPTA, and SPTA.: © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:965-973, 2017.