Rectal Adenocarcinoma Presenting as a Perirectal Abscess.

Classic symptoms of rectal cancer (RC) such as hematochezia, tenesmus, rectal pain, and bowel habit changes are well known but can be nonspecific and misdiagnosed. Rare presentations, in combination with these conventional symptoms, can occur warranting a higher degree of clinical suspicion. Here, we report a case of rectal adenocarcinoma presenting as a perirectal abscess. A 52-year-old male with uncontrolled diabetes mellitus presented with a 2-year and 2-month history of rectal bleeding and changes in bowel habits, respectively, which were attributed to other conditions. He initially presented with left buttock pain and severe sepsis. Subsequent workup for suspected Fournier's gangrene and perirectal abscess led to the discovery of a rectal adenocarcinoma (pT4N0M0, stage IIB/C). A combination of debridement, antibiotic therapy, neoadjuvant chemoradiation, and abdominoperineal resection resulted in improvement of the patient's condition and remission. In conclusion, rare presentations of RC, such as a perirectal abscess, especially if present in conjunction with conventional RC symptomology, may necessitate the workup of RC.

Differential mechanisms of change in motivational interviewing versus health education for smoking cessation induction.

Objective: To determine if Motivational Interviewing (MI) versus health education (HE) elicited different types of client language and whether these differences were associated with outcomes in a randomized clinical trial (RCT) for cessation induction among people who smoke with low motivation to quit. Methods: A secondary data analysis was conducted using data from the MI and HE arms of a trial in which people who smoke (N = 202) with low desire to quit were randomly assigned to four sessions of MI, HE or brief advice. Mediation analyses examined two types of client language: change talk (CT) and a novel form of client speech called "learning talk" (LT). Outcomes were assessed at baseline, 3 and 6 months. Results: With HE as the reference group, MI resulted in greater CT (OR = 3.0, 95% CI: 1.7-5.5) which was associated with better outcomes (average d = .34, SD = .13) and HE resulted in greater LT (OR = .05, 95% CI: .02-.10) which was also associated with better outcomes (average d = .42, SD = .08). Indirect parallel mediation effects on quit attempts were significant for both MI-CT (OR = 1.4, 95% CI: 1.1-1.7) and HE-LT (OR = .4, 95% CI: .2-.7). Conclusions: MI and HE were both efficacious via different pathways to change, confirming the utility of MI in this RCT as well as highlighting the potential of HE based on the "5R's" for smoking cessation. These findings emphasize the value of exploring theorized mechanisms of action of interventions evaluated in RCTs. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Race moderates the effects of Motivational Interviewing on smoking cessation induction.

OBJECTIVE: Health disparities necessitate exploration of how race moderates response to smoking cessation treatment. Data from a randomized clinical trial of Motivational Interviewing (MI) for smoking cessation induction were used to explore differential treatment response between African American (AA) vs Non-Black (NB) smokers. METHODS: Adult tobacco smokers (138 AA vs 66 NB) with low desire to quit were randomly assigned to four sessions of MI or health education (HE). Outcomes (e.g., quit attempts) were assessed 3- and 6-months. RESULTS: There was evidence of a Race by Treatment interaction such that MI was less effective than HE in AA smokers. Mean Cohen's d for the interaction effect was -0.32 (95% CI [-0.44, -0.20]). However, the race interaction could be accounted for by controlling for baseline relationship status and communication preference (wants directive approach). CONCLUSIONS: MI may be less effective for smoking cessation induction in AA vs NB smokers when compared to another active and more directive therapy. The differential response between races may be explained by psychosocial variables. PRACTICE IMPLICATIONS: MI may not be an ideal choice for all African American smokers. Patients' relationship status and preference for a directive counseling approach might explain disparities in response to MI treatment.

Motivational interviewing and the decisional balance procedure for cessation induction in smokers not intending to quit.

INTRODUCTION: The decisional balance (DB) procedure examines the pros and cons of behavior change and was considered a component in early formulations of Motivational Interviewing (MI). However, there is controversy and conflicting findings regarding the use of a DB exercise within the treatment of addictions and a need to clarify the role of DB as a component of MI. METHODS: College tobacco smokers (N=82) with no intentions on quitting were randomly assigned to receive a single counseling session of either Motivational Interviewing using only the decisional balance component (MIDB), or health education around smoking cessation (HE). Assessments were obtained at baseline, immediately post-treatment, 1week, and 4weeks. RESULTS: Compared to HE, the MIDB sessions scored significantly higher on the Motivational Interviewing Treatment Integrity (MITI) scale (all standardized differences d>1, p<0.001). Unexpectedly, self-report Pros of smoking scores increased for MIDB but decreased for HE (MIDB vs HE standardized difference d=0.5; 95%CI 0.1 to 1.0, p=0.021). Both groups showed significant reductions in smoking rates and increases in motivation to quit, quit attempts, and self-reported abstinence, with no significant group differences. Changes in the Pros of smoking were correlated with MITI scores, but not with cessation outcomes. In contrast, increases in the Cons of smoking and therapeutic alliance were predictive of better cessation outcomes. CONCLUSIONS: The decisional balance exercise as formulated by earlier versions of MI may be counter-productive and cautions around its use are warranted. Instead, improved cessation outcomes appear associated with increasing perceived benefits of quitting and positive therapeutic alliance.

A Randomized Trial of Motivational Interviewing: Cessation Induction Among Smokers With Low Desire to Quit.

INTRODUCTION: Despite limitations in evidence, the current Clinical Practice Guideline advocates Motivational Interviewing for smokers not ready to quit. This study evaluated the efficacy of Motivational Interviewing for inducing cessation-related behaviors among smokers with low motivation to quit. DESIGN: Randomized clinical trial. SETTING/PARTICIPANTS: Two-hundred fifty-five daily smokers reporting low desire to quit smoking were recruited from an urban community during 2010-2011 and randomly assigned to Motivational Interviewing, health education, or brief advice using a 2:2:1 allocation. Data were analyzed from 2012 to 2014. INTERVENTION: Four sessions of Motivational Interviewing utilized a patient-centered communication style that explored patients' own reasons for change. Four sessions of health education provided education related to smoking cessation while excluding elements characteristic of Motivational Interviewing. A single session of brief advice consisted of brief, personalized advice to quit. MAIN OUTCOMES MEASURES: Self-reported quit attempts; smoking abstinence (biochemically verified); use of cessation pharmacotherapies; motivation; and confidence to quit were assessed at baseline and 3- and 6-month follow-ups. RESULTS: Unexpectedly, no significant differences emerged between groups in the proportion who made a quit attempt by 6-month follow-up (Motivational Interviewing, 52.0%; health education, 60.8%; brief advice, 45.1%; p=0.157). Health education had significantly higher biochemically verified abstinence rates at 6 months (7.8%) than brief advice (0.0%) (8% risk difference, 95% CI=3%, 13%, p=0.003), with the Motivational Interviewing group falling in between (2.9% abstinent, 3% risk difference, 95% CI=0%, 6%, p=0.079). Both Motivational Interviewing and health education groups showed greater increases in cessation medication use, motivation, and confidence to quit relative to brief advice (all p<0.05), and health education showed greater increases in motivation relative to Motivational Interviewing (Cohen's d=0.36, 95% CI=0.12, 0.60). CONCLUSIONS: Although Motivational Interviewing was generally more efficacious than brief advice in inducing cessation behaviors, health education appeared the most efficacious. These results highlight the need to identify the contexts in which Motivational Interviewing may be most efficacious and question recommendations to use Motivational Interviewing rather than other less complex cessation induction interventions. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01188018.

Assessing race and ethnicity data quality across cancer registries and EMRs in two hospitals.

BACKGROUND: Measurement of patient race/ethnicity in electronic health records is mandated and important for tracking health disparities. OBJECTIVE: Characterize the quality of race/ethnicity data collection efforts. METHODS: For all cancer patients diagnosed (2007-2010) at two hospitals, we extracted demographic data from five sources: 1) a university hospital cancer registry, 2) a university electronic medical record (EMR), 3) a community hospital cancer registry, 4) a community EMR, and 5) a joint clinical research registry. The patients whose data we examined (N = 17 834) contributed 41 025 entries (range: 2-5 per patient across sources), and the source comparisons generated 1-10 unique pairs per patient. We used generalized estimating equations, chi-squares tests, and kappas estimates to assess data availability and agreement. RESULTS: Compared to sex and insurance status, race/ethnicity information was significantly less likely to be available (χ(2 )> 8043, P < .001), with variation across sources (χ(2 )> 10 589, P < .001). The university EMR had a high prevalence of "Unknown" values. Aggregate kappa estimates across the sources was 0.45 (95% confidence interval, 0.45-0.45; N = 31 276 unique pairs), but improved in sensitivity analyses that excluded the university EMR source (κ = 0.89). Race/ethnicity data were in complete agreement for only 6988 patients (39.2%). Pairs with a "Black" data value in one of the sources had the highest agreement (95.3%), whereas pairs with an "Other" value exhibited the lowest agreement across sources (11.1%). DISCUSSION: Our findings suggest that high-quality race/ethnicity data are attainable. Many of the "errors" in race/ethnicity data are caused by missing or "Unknown" data values. CONCLUSIONS: To facilitate transparent reporting of healthcare delivery outcomes by race/ethnicity, healthcare systems need to monitor and enforce race/ethnicity data collection standards.

Using basic laboratory research to understand scheduled smoking: a field investigation of the effects of manipulating controllability on subjective responses to smoking.

OBJECTIVE: To examine, in a naturalistic context, the effect of manipulating smokers' control over their smoking behavior on subjective responses to smoking. DESIGN: A within-subjects yoking design was used in which 23 participants (45% female) first engaged in ad-lib or controllable smoking for 3 days during which a hand-held computer was used to record the timing of every cigarette smoked. This was followed by a 3-day scheduled or uncontrollable smoking phase in which participants were prompted to smoke by the hand-held computer on the same schedule that they had previously recorded. MEASURES: Participants used an 11-point visual analog scale presented on the hand-held computer to report reward from smoking and other subjective responses (craving, mood, etc.) immediately after smoking and also at other times (unrelated to smoking) through the day. RESULTS: During the scheduled or uncontrollable phase participants experienced significantly lower rewarding effects from smoking, poorer mood, less reduction in craving, and less improvement in overall feeling immediately after smoking. CONCLUSIONS: The findings suggest the effect of reduced controllability may partly underlie the effect of scheduled reduced smoking interventions. Results also point to the potential benefit of translating basic laboratory research to the field for developing clinical interventions.

Patterns of smoking and methadone dose in drug treatment patients.

Cigarette smoking prevalence is very high, and cessation rates are very low, among people in methadone treatment. This may in part be due to interactions between methadone administration and cigarette smoking. The present study explores relationships between methadone dose timing and smoking rates. Twenty methadone patients, over a period of 19 days, used electronic cigarette packs to record their smoking patterns and called a voice mailbox daily to report their methadone dose and timing. The average proportion of daily cigarettes smoked was calculated for 2-hr blocks preceding and following methadone dose administration. For all participants, peak smoking rates occurred after methadone administration. Participants smoked a greater proportion of cigarettes in their first 2-hr block after methadone dosing (M = 0.368, SD = 0.135) than during their first 2-hr block of smoking of the day (M = 0.245, SD = 0.010; S = 85.5, p < .0001). The proportion of cigarettes smoked increased by 0.02 from more than 2 hr before methadone to the 2-hr time block before methadone, by 0.04 from the 2-hr time block before methadone to the 2-hr time block after methadone, and by 0.015 from the 2-hr time block after methadone to the next 2-hr time block. From this time block (2-4 hr after methadone), smoking decreased by 0.02 in the 4-plus hr postmethadone dose. All of these changes were statistically significant. Future research should use experimental designs to better examine whether a causal relationship exists and examine the impact of other types of opioid maintenance medications on smoking patterns.

Using motivational interviewing with smokers: do therapist behaviors relate to engagement and therapeutic alliance?

This study examined whether therapist behaviors consistent with motivational interviewing (MI) were associated with within-session working alliance and client engagement. Forty-six audiotaped counseling sessions were drawn from a group-randomized comparison-controlled smoking cessation trial for public housing residents. Separate raters coded therapist behaviors and client behaviors. Therapist behaviors were coded using the Motivational Interviewing Skill Code. Results indicated that an MI-consistent style (average of the global ratings of collaboration, egalitarianism, and empathy) was positively associated with alliance and engagement, whereas confrontation was negatively related to alliance. Small to moderate effect sizes were found for affirming, asking open-ended questions, confronting, reflecting, and summarizing. Significant covariates include treatment condition, session sequence, and session date. Findings empirically support Miller and Rollnick's [Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press] emphasis on the importance of MI spirit for enhancing alliance and engagement and their findings that any tears/ruptures in the alliance through the use of confrontation could significantly relate to poor outcomes.

Healthcare providers' treatment of college smokers.

About 28% of college students smoke tobacco, and many will continue smoking into adulthood. Although little is known about how to help college students quit smoking, 1 promising strategy is healthcare providers' advice. To estimate their life-time receipt of brief advice and to identify characteristics that predict who may receive that advice, 348 college students completed a survey about their smoking and related practices. Seventy-seven percent of the smokers (73% of the students) were asked about smoking. Of those smokers, 57% were advised to quit, 22% were given advice about quitting, 5% were helped with setting a quit date, and 4% were offered follow-up. Occasional smokers were less likely than daily smokers to be advised to quit. Although 36.2% of the smokers did not report their smoking accurately, smokers who were accurate were more likely to be advised to quit and to be given advice about quitting.

Use of a brief Smoking Consequences Questionnaire for Adults (SCQ-A) in African American smokers.

Purposes of the present study were to (a) examine psychometric properties of a brief Smoking Consequences Questionnaire-Adult (SCQ-A) among an African American sample and (b) explore differences in smoking expectancies across levels of smoking-nicotine dependence. Four hundred eighty-four smokers attending an urban health clinic completed the brief SCQ-A. Maximum likelihood factor extraction with a varimax rotation specifying 9 factors replicated 9 factors of the original SCQ-A. Evidence for the brief SCQ-A's reliability and validity was found. Heavier and/or more dependent smokers had significantly higher scores than lighter and/or less dependent smokers on positive expectancies SCQ-A subscales. Results suggest the brief SCQ-A may be a useful alternative to the full scale SCQ-A. Results also provide evidence for the SCQ-A's validity with African American smokers.

Acute nicotine reinforcement, but not chronic tolerance, predicts withdrawal and relapse after quitting smoking.

Little research has examined the association of tobacco dependence with nicotine tolerance or reinforcement in a clinical sample. Smokers preparing to quit smoking participated in laboratory sessions to assess nicotine tolerance on subjective, cardiovascular, and performance measures and to assess nicotine reinforcement using a choice procedure. Participants were then provided with individual counseling (but no medication), made a quit attempt, and were followed for 1 year to determine clinical outcome, as determined by postquit withdrawal and days to relapse. Nicotine tolerance was unrelated to either withdrawal or relapse. However, acute nicotine reinforcement was significantly related to both greater withdrawal and faster relapse. Results challenge the common assumption that nicotine tolerance is closely related to dependence but suggest that nicotine reinforcement may have theoretical and clinical significance for dependence.

The effect of smoking on sensory and attentional masking.

This study examined the influence of smoking on low-level sensory and higher level visual cognitive abilities. Three groups (nonsmokers, deprived smokers, and nondeprived smokers) of 22 observers were tested using a visual target discrimination task. To assess sensory and visual cognitive differences, a masking task developed by Enns and Di Lollo (1997) was used. In the task, the target was masked by either a contour mask (contour masking) or an object mask (attentional masking by object substitution). The strongest masking effects were found in the group of nondeprived smokers, for both sensory and attentional masking. This pattern of results as well as results in the deprived smokers indicated changes in transient visual processing channels due to the acute actions of nicotine, not mediated by withdrawal relief.