A retrospective analysis of the comparative effectiveness of smoking cessation medication among individuals with mental illness in community-based mental health and addictions treatment settings.

WHAT IS KNOWN ON THE SUBJECT?: Persons with different mental illnesses smoke for reasons based on their particular diagnosis. As compared to those without, persons with mental illnesses are less able to quit smoking when using smoking cessation medications. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper shows that there may be differences in the ability to quit smoking between persons with different mental illness diagnoses. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Clinicians should be aware that persons with anxiety disorders may find it more difficult to quit smoking as compared to those with other mental illnesses. Clinicians should be aware that of all medications, varenicline seems to help those with mood disorders to quit the best. Clinicians should be aware that persons with psychotic disorders likely need longer treatment durations for smoking cessation as compared to persons with other mental illnesses. ABSTRACT: Introduction Individuals with mental illnesses (MI) have diagnosis-specific reasons for smoking and achieve low smoking cessation when using cessation medications. Aim To assess differences in smoking cessation outcomes by MI diagnosis and cessation medications in outpatient mental health and addictions treatment settings in Vancouver, Canada. Method This is a retrospective analysis of tobacco treatment outcomes from 539 participants. The programme consists of cessation pharmacotherapy with 8 to 12 weeks of behavioural counselling and 12 weeks of support group. Smoking cessation was verified by expired carbon monoxide levels. Generalized estimating equations models assessed differences in cessation by type of medication in both total and stratified samples. Results There were no significant differences in cessation by pharmacotherapy in the total sample. Individuals with a mood disorder were two times more likely to achieve cessation as compared to those with an anxiety disorder. Among individuals with mood disorders, receiving varenicline alone resulted in three times the likelihood of cessation as compared to receiving single NRT. Discussion The differences in outcomes by MI diagnosis suggest the need for more diagnosis-specific approaches to optimize cessation. Implications for Practice Compared with other diagnoses, persons with anxiety disorders may have a greater challenge quitting and those with a psychotic disorder may require longer treatment durations.

The hexadentate hydroxypyridinonate TREN-(Me-3,2-HOPO) is a more orally active iron chelator than its bidentate analogue.

Bidentate hydroxypyridinone chelators effectively complex and facilitate excretion of trivalent iron. To test the hypothesis that hexadentate chelators are more effective than bidentate chelators at low concentrations, urinary and biliary Fe excretions were determined in Fe-loaded rats before and after administration of a bidentate chelator, Pr-(Me-3,2-HOPO), or its hexadentate analogue, TREN-(Me-3,2-HOPO). The bidentate chelator slightly increased biliary Fe excretion in Fe-loaded rats after IV (90 micromol/kg) and PO (90 or 270 micromol/kg) administration, but chelation efficiency did not exceed 1%. The hexadentate chelator markedly increased biliary Fe excretion, achieving overall chelation efficiencies of 14% after IV administration of 30 micromol/kg and 8 or 3% after PO (30 or 90 micromol/kg) administration. The hexadentate chelator was significantly more effective than the bidentate chelator after IV injection and oral dosing. In chelator-treated Fe-loaded or saline-injected rats, >90% of the excreted Fe was in the bile. Oral TREN-(Me-3,2-HOPO), given to non-Fe-loaded rats, did not appreciably change Fe output, indicating that there was little Fe depletion in the absence of Fe overload. These results support the hypothesis that greater Fe chelation efficiency can be achieved with hexadentate than with bidentate chelators at lower, and presumably safer, concentrations. The results also demonstrate that TREN-(Me-3, 2-HOPO) is a promising, orally effective, Fe chelator.

Public opinion and legislators' views on tobacco policy.

We explored the relationship between public opinion and Kentucky state legislators' views on increasing the cigarette excise tax to curb smoking, local option to pass stricter youth access to tobacco laws, and smoking restrictions in public places. The relationship of gender, education, political party affiliation, tobacco use, and tobacco allotment ownership to public and legislators' opinions was examined using logistic regression. Data from the random, statewide University of Kentucky Public Opinion Poll (n = 628 Kentucky adults) and a Delphi study of Kentucky legislators (n = 116 members of the Kentucky General Assembly) were used in this study. Controlling for the demographic differences in gender, age, ethnicity, education, and tobacco allotment ownership between the public opinion and legislator samples, legislators were far less likely than the public to support workplace or restaurant smoking restrictions. Participants with a college education were twice as likely to favor cigarette tax hikes and four to five times more likely to favor workplace and restaurant smoking restrictions than were those without a college degree. Tobacco allotment owners and tobacco users were less likely to support raising cigarette taxes and local option to curb teen tobacco use compared to nonowners and nonusers. Findings of this study suggest that Kentucky legislators are not keeping up with public opinion about tobacco control, particularly in regard to smoking restrictions in workplaces and restaurants. Health professional organizations can play a role by educating both their membership and lawmakers about public support for tobacco control policy.

Kindergarten children's knowledge and perceptions of alcohol, tobacco, and other drugs.

Kindergarten children's knowledge and perceptions of alcohol, tobacco, and other drugs (ATODs) were assessed and the congruence between parent ATOD use and children's knowledge of ATODs was examined. Data were collected during the pre-intervention phase of an ATOD prevention trial with 5- and 6-year-old children and their parents. Three elementary schools were randomly selected from a population of 15 high-risk elementary schools in Lexington, Ky., (n = 126 parent-child dyads). Children were interviewed about their knowledge, feelings, and attitudes toward ATODs using the Child Drug Awareness Inventory. Parents self-reported ATOD use. Almost all (95%) kindergarten children recognized cigarettes; 56% correctly identified alcoholic beverages; and 17% recognized at least one illicit drug. Minority children were almost four times more likely to recognize illicit drugs than were non-minority children. Children's knowledge of ATODs was not correlated with the parents' reported drug use. ATOD prevention programs for young children merit greater emphasis.

Consensus for tobacco policy among former state legislators using the policy Delphi method.

OBJECTIVE: To test a novel approach for building consensus about tobacco control policies among legislators. DESIGN: A pilot study was conducted using a two-round, face-to-face policy Delphi method. PARTICIPANTS: Randomly selected sample of 30 former Kentucky legislators (60% participation rate). MAIN OUTCOME MEASURE: Consensus on tobacco control and tobacco farming policies. RESULTS: Former state legislators were more supportive of tobacco control policies than expected, and highly supportive of lessening the state's dependence on tobacco. Former state legislators were in agreement with 43% of the second-round items for which there was no agreement at the first round, demonstrating a striking increase in consensus. With new information from their colleagues, former lawmakers became more supportive of workplace smoking restrictions, limitations on tobacco promotional items, and modest excise tax increases. CONCLUSIONS: The policy Delphi method has the potential for building consensus for tobacco control and tobacco farming policies among state legislators. Tobacco control advocates in other states might consider using the policy Delphi method with policymakers in public and private sectors.

Kentucky legislators' views on tobacco policy.

CONTEXT: Kentucky leads the nation in adult and teen smoking prevalence. Even though Kentucky is one of the most tobacco-dependent states, tobacco policy is subject to change in light of possible national tobacco legislation. OBJECTIVE: To describe the degree of agreement among Kentucky legislators regarding tobacco control and tobacco farming policy, and to discover whether use of the policy Delphi method produces a shift toward consensus on tobacco policy. DESIGN: A two-round policy Delphi study was conducted using in-person interviews. SETTING: Legislators' offices in Frankfort, Kentucky. PARTICIPANTS: Volunteer sample of 116 Kentucky legislators (84% response rate). MAIN OUTCOME MEASURES: Degree of agreement on tobacco control and tobacco farming policies. RESULTS: Lawmakers were highly supportive of policies to lessen the state's dependence on tobacco, and were favorable toward stronger tobacco control policies. There were discrepancies, however, between what policies legislators thought were desirable and what policies were realistic. Tobacco interests were identified as possible explanations for this disparity. Tobacco allotment ownership was associated with less support for tobacco control and tobacco farming policies. A shift toward consensus on tobacco policy was achieved in the second round for 45% of the interview items common to both rounds. CONCLUSIONS: Kentucky legislators were highly supportive of reducing the state's dependence on tobacco and more supportive of tobacco control policies than expected. The policy Delphi method has the potential for shifting opinions about tobacco policies among state legislators. The findings of this study identify opportunities for public health policy change in one of the most tobacco-dependent states in the United States.

Psychometrics for two short forms of the Center for Epidemiologic Studies-Depression Scale.

The Center for Epidemiologic Studies-Depression Scale (CES-D; L. S. Radloff, 1977) assesses the presence and severity of depressive symptoms occurring over the past week. Although it contains only 20 items, its length may preclude its use in a variety of clinical populations. This study evaluated psychometric properties of 2 shorter forms of the CES-D developed by F. J. Kohout, L. F. Berkman, D. A. Evans, and J. Cornoni-Huntley (1993): the Iowa form and the Boston form. Data were pooled from 832 women representing 6 populations. Internal consistency estimates, correlations with the original version of the CES-D, and omitted-included item correlations supported use of the Iowa form over the Boston form when a shortened version of the scale is desired. Regression statistics are provided for use in estimating scores on the original CES-D when either shortened form is used. Factor analytic results from two populations support a single-factor structure for the original CES-D as well as the short forms.

Assessment of fine-needle aspiration sampling technique in thyroid nodules.

BACKGROUND: A prospective two-yr study was undertaken to assess the heterogeneity of thyroid nodules using the fine-needle aspiration (FNA) technique of systematic regional sampling. In addition, we determined the number of regions to be sampled to minimize non-diagnostic results, and to optimally characterize thyroid nodules. DESIGN: FNA was performed on 74 nodules > or = 1.5 cm. in diameter in five distinct regions in sequence (center, then four quadrants starting at 12:00, clockwise). Slides from each region were coded, randomized, subjected to blind review, and categorized as non-diagnostic (ND), benign (B), indeterminate (ID), suspicious/neoplastic (S/N), or malignant (M). Final cytologic diagnosis (CD) was made from all slides of each nodule. RESULTS: The ND rate for center FNAs alone was 16%, but addition of the 12:00 region decreased it to 5.3%. With 3, 4, or 5 sequential sites the nondiagnostic rates were 4, 2.6, and 2.6%. The center region diagnosis was identical to the final CD in 71% of the cases. Addition of the 12:00 region increased the concordance to 88%. Three sequential regions equaled the CD in 93% of cases, and 4 regions equaled the CD in 99% of cases. All nodules characterized as M or S/N were resected as were 76% of the ID nodules. Of the 43 nodules characterized as B, 3 were resected, 24 involuted, 6 were unchanged, and 10 were lost to follow-up. All 3 M nodules proved malignant by histology, as did 7/10 S/N, 0/17 ID, and 0/43 B nodules; 3/10 S/N, 1/17 ID and 1/43 B were adenomas. Likelihood ratios for diagnosing neoplasia were ND:0, B:0.10, ID:0.21, S/N:infinity, M:infinity. CONCLUSIONS: Sampling of at least four distinct regions accurately assesses thyroid nodules while minimizing ND results. Regional sampling also addresses intranodular heterogeneity.

Treatment of leukemia with partially matched related bone marrow transplantation.

The results of partially matched related donor (PMRD) marrow transplantation for 82 patients with leukemia are reported, including 45 who received two antigen disparate grafts. Following intensive radiochemotherapy, patients received grafts which were partially depleted of T cells by the monoclonal antibody T10B9 and complement. Actuarial probability of engraftment was 86% (95% CI = 78-93%). The median day to engraftment was similar among recipients of grafts disparate at one, two or three antigen loci. The incidence of severe (grades III and IV) acute graft-versus-host disease and extensive chronic graft-versus-host disease was 13% and 6%, respectively. The probability of disease-free survival for the entire cohort of patients is 31% at 3 years. Age < or = 30 years, early or intermediate stage disease and a graft disparate at one or two loci predicted longer disease-free survival in multivariant analysis. Moreover, 47% of patients receiving PMRD grafts disparate at two loci who had both these favorable pretransplant characteristics were alive and free of disease 3 years after transplantation. We believe that the utilization of PMRDs, especially those with two antigen disparate grafts, can extend allogeneic transplantation to additional leukemic patients lacking a histocompatible donor, with acceptable results.

Impact of obesity on allogeneic stem cell transplant patients: a matched case-controlled study.

PURPOSE: To determine the impact of obesity on survival after high-dose therapy followed by allogeneic stem cell transplant in adults and children with various malignancies as well as metabolic disorders. PATIENTS AND METHODS: A matched case-controlled evaluation of 322 allogeneic patients from a single institution with a median follow-up of 296 and 120 days among nonobese and obese patients, respectively, was conducted between April 1983 and June 1995 at the University of Kentucky. The overall survival distributions among subsets defined as either obese or nonobese were measured. RESULTS: The overall survival among the nonobese and obese was 35% and 20%, respectively (P = 0.0045). When patients were separated by age, the adult patients maintained this difference, while the children did not. When patients were stratified according to donor status, both the histocompatible and the nonhistocompatible adults had an inferior outcome among obese patients. The difference, however, was significant only among the histocompatible group (P = 0.0007). Causes of deaths were insignificantly distributed among both relapse as well as nonrelapse mechanisms. CONCLUSION: Adult obese patients undergoing high-dose chemotherapy with stem cell rescue have a more adverse outcome. Both relapse and nonrelapse causes are responsible for the different outcome between obese and nonobese groups.

Single focus of adenocarcinoma in the prostate biopsy specimen is not predictive of the pathologic stage of disease.

OBJECTIVES: To determine whether a very small focus of prostate cancer in a needle biopsy specimen correlates with organ-confined disease or with favorable disease parameters. METHODS: Of 598 needle biopsies of the prostate performed from January 1990 through June 1994, 49 specimens (8.2%) contained a microscopic focus (less than 2 mm in length of the entire biopsy core specimen) of adenocarcinoma. For these 49 patients, the clinical and pathologic features were correlated. RESULTS: Of these 49 patients, 27 (55.1%) underwent either radical prostatectomy, with or without pelvic lymph node dissection (26), or pelvic lymph node dissection alone (1). Seven of these 27 patients (25.9%) had extraprostatic disease: lymph node involvement (1), positive surgical margins (5), or seminal vesicle invasion (1). Ten of the 49 patients (20.4%) underwent radiotherapy, and 12 (24.5%) chose hormonal therapy. The pathologic stage for these 22 patients could not be ascertained. However, despite the limited amount of disease in the biopsy specimen, 2 patients treated with radiotherapy suffered a relapse (mean interval to recurrence, 11.5 months), and 3 patients treated with hormonal therapy (early or delayed) had bony metastasis at the time of diagnosis. Overall, 12 of the 49 patients (24.5%) had unfavorable disease (as defined by extraprostatic disease on pathologic specimen, relapse after radiotherapy, or bony metastasis at the time of diagnosis). CONCLUSIONS: These findings suggest that a microscopic focus of prostatic adenocarcinoma in a needle biopsy specimen, per se, does not predict the pathologic stage or the biologic behavior of a tumor.

Allogeneic bone marrow transplantation with T cell-depleted partially matched related donors for advanced acute lymphoblastic leukemia in children and adults: a comparative matched cohort study.

Allogeneic BMT provides the best treatment currently available for long-term disease-free survival in patients with recurrent ALL. Historically, partially matched related donors provided the opportunity for treatment to a greater number of patients than matched related donors at the expense of decreased overall survival. In this study we compare the results in recurrent ALL patients transplanted with either HLA identical sibling bone marrow or partially matched related bone marrow. Thirty-two patients with relapsed ALL received partially matched bone marrows from a relative with one to three HLA, A, B and Dr antigen mismatches. Bone marrow was partially T cell-depleted with murine T10B9.1A-31 moAb. Sixteen patients with relapsed ALL received HLA-matched sibling bone marrows. All partially matched patients received additional GVHD prophylaxis with methylprednisolone in addition to anti-CD5 immunotoxin and/or CYA. All matched patients in addition to methylprednisolone received MTX and/or CYA. We observed no difference in disease-free survival between patients transplanted with partially matched bone marrow (median follow-up 1252 days, range 778-2035 days) vs those transplanted with HLA-matched bone marrow (median follow-up 1472 days, range 1165-2800 days; P = 0.48). Median survival for all patients is 38% (95% CI 24-52%) at 6 years. Patients transplanted in remission had a significant increase in disease-free survival when compared to those in relapse (P = 0.007). Our data suggest that partially matched BMTs from related donors are a comparable alternative to fully matched transplants in patients with ALL.

Participation in transvaginal ovarian cancer screening: compliance, correlation factors, and costs.

The objective was to identify factors influencing participation in screening for ovarian cancer using transvaginal sonography in the free experimental program at the University of Kentucky over its 6+ year history. Database records for screenings, performed from 1987 to June 1994, were utilized. Computer sorts, 1990 census information as predictors, and stepwise multiple regression analysis were employed. Participation in the model ovarian screening program took 3-4 years to approach > 300 screens/month, with repeat screenings exceeding new subject participation in this time period. A number of participants traveled > 200 miles for screening on both initial and repeat encounters. Analysis of distance to the screening site, median family income, county physician population, and education levels indicated that distance and then education correlated best with participation. Unit screening cost shrank from $45 to under $25 when maximal participation was achieved. Distance and education correlated with participation. Expenses compare favorably with diagnostic procedures for other diseases.