Two Years in the Life of a University Hospital Tobacco Cessation Service: Recommendations for Improving the Quality of Referrals.

BACKGROUND: Hospitalization, when patients may be more receptive to quitting, provides an opportunity to provide tobacco cessation services for patients who otherwise might not seek help. Although specialized tobacco cessation services are shown to be effective if evidence-based treatment, including follow-up, is completed, resources are limited and guidelines are needed, and few smokers complete all treatment steps. Experience drawn from an analysis of two-year implementation data from the Oregon Health & Science University (OHSU) Tobacco Cessation Consult Service is presented. METHODS: Data for 5,827 smokers discharged from OHSU University hospital between January 2011 and December 2012 were analyzed to determine patient characteristics and identify predictors of completing each of four treatment steps: consult ordered, consult completed, follow-up arranged, and follow-up completed. RESULTS: Smokers were younger and male (p<0.0001) and significantly different with respect to insurance class, admission type, history of mental disorders, primary discharge diagnoses, and length of stay (p<0.0001) than nonsmokers. Predictors of having a tobacco consult order were admission for elective medical procedures; orders for medications to treat withdrawal; history of mental health/substance use disorders; primary diagnoses of cardiovascular, endocrine, gastrointestinal, or pulmonary disease; and longer hospitalizations. Smokers admitted through the emergency department had the lowest rates of follow-up completion and abstinence. Admission for an elective surgery was the only predictor of completing all treatment steps through followup (p≤0.05). CONCLUSIONS: This study adds important information about how hospitalized smokers respond to each step of tobacco treatment in a real-world setting and offers strategies for improving referrals.

Mental health comorbidity in patients with atopic dermatitis.

BACKGROUND: Recent data, primarily from Europe, suggest that children with atopic dermatitis (AD) might be at increased risk of mental health disorders. OBJECTIVE: We aimed to quantify the mental health burden associated with pediatric AD in the United States. METHODS: A cross-sectional study design was used analyzing data from the 2007 National Survey of Children's Health, a survey reporting on the health status of 92,642 noninstitutionalized children aged 0 to 17 years. The lifetime prevalence of various provider-diagnosed mental health conditions was calculated for those with and without a history of AD. RESULTS: The odds of having attention deficit hyperactivity disorder was significantly increased in children with AD compared with the odds in control subjects without AD (odds ratio, 1.87; 95% CI, 1.54-2.27), even after controlling for known confounders. The adjusted odds ratios for depression, anxiety, conduct disorder, and autism were 1.81 (95% CI, 1.33-2.46), 1.77 (95% CI, 1.36-2.29), 1.87 (95% CI, 1.46-2.39), and 3.04 (95% CI, 2.13-4.34), respectively, and these estimates were all statistically significant. A clear dose-dependent relationship was observed between the prevalence of a mental health disorder and the reported severity of the skin disease. CONCLUSIONS: Our data reveal a striking association between mental health disorders and AD in the US pediatric population. The severity of the skin disease alters the strength of the association. Prospective cohort studies are needed to verify these associations and to explore underlying mechanisms. Strategies to prevent AD or to aggressively treat early skin inflammation might modify the risk of mental health disorders in at-risk children.

Cytomegalovirus-specific T cell immunity is maintained in immunosenescent rhesus macaques.

Although CMV infection is largely benign in immunocompetent people, the specific T cell responses associated with control of this persistent virus are enormous and must be maintained for life. These responses may increase with advanced age and have been linked to an "immune risk profile" that is associated with poor immune responsiveness and increased mortality in aged individuals. Based on this association, it has been suggested that CMV-specific T cell responses might become dysfunctional with age and thereby contribute to the development of immune senescence by homeostatic disruption of other T cell populations, diminished control of CMV replication, and/or excess chronic inflammation. In this study, we use the rhesus macaque (RM) model of aging to ask whether the quantity and quality of CMV-specific T cell responses differ between healthy adult RMs and elderly RMs that manifest hallmarks of immune aging. We demonstrate that the size of the CD4(+) and CD8(+) CMV-specific T cell pools are similar in adult versus old RMs and show essentially identical phenotypic and functional characteristics, including a dominant effector memory phenotype, identical patterns of IFN-γ, TNF-α, and IL-2 production and cytotoxic degranulation, and comparable functional avidities of optimal epitope-specific CD8(+) T cells. Most importantly, the response to and protection against an in vivo CMV challenge were identical in adult and aged RMs. These data indicate that CMV-specific T cell immunity is well maintained in old RMs and argue against a primary role for progressive dysfunction of these responses in the development of immune senescence.

Size-appropriate radiation doses in pediatric body CT: a study of regional community adoption in the United States.

BACKGROUND: During the last decade, there has been a movement in the United States toward utilizing size-appropriate radiation doses for pediatric body CT, with smaller doses given to smaller patients. OBJECTIVE: This study assesses community adoption of size-appropriate pediatric CT techniques. Size-specific dose estimates (SSDE) in pediatric body scans are compared between community facilities and a university children's hospital that tailors CT protocols to patient size as advocated by Image Gently. MATERIALS AND METHODS: We compared 164 pediatric body scans done at community facilities (group X) with 466 children's hospital scans. Children's hospital scans were divided into two groups: A, 250 performed with established pediatric weight-based protocols and filtered back projection; B, 216 performed with addition of iterative reconstruction technique and a 60% reduction in volume CT dose index (CTDIvol). SSDE was calculated and differences among groups were compared by regression analysis. RESULTS: Mean SSDE was 1.6 and 3.9 times higher in group X than in groups A and B and 2.5 times higher for group A than group B. A model adjusting for confounders confirmed significant differences between group pairs. CONCLUSIONS: Regional community hospitals and imaging centers have not universally adopted child-sized pediatric CT practices. More education and accountability may be necessary to achieve widespread implementation. Since even lower radiation doses are possible with iterative reconstruction technique than with filtered back projection alone, further exploration of the former is encouraged.

Loss of naive T cells and repertoire constriction predict poor response to vaccination in old primates.

Aging is usually accompanied by diminished immune protection upon infection or vaccination. Although aging results in well-characterized changes in the T cell compartment of long-lived, outbred, and pathogen-exposed organisms, their relevance for primary Ag responses remain unclear. Therefore, it remains unclear whether and to what extent the loss of naive T cells, their partial replacement by oligoclonal memory populations, and the consequent constriction of TCR repertoire limit the Ag responses in aging primates. We show in this study that aging rhesus monkeys (Macaca mulatta) exhibit poor CD8 T cell and B cell responses in the blood and poor CD8 responses in the lungs upon vaccination with the modified vaccinia strain Ankara. The function of APCs appeared to be maintained in aging monkeys, suggesting that the poor response was likely intrinsic to lymphocytes. We found that the loss of naive CD4 and CD8 T cells, and the appearance of persisting T cell clonal expansions predicted poor CD8 responses in individual monkeys. There was strong correlation between early CD8 responses in the transitory CD28+ CD62L- CD8+ T cell compartment and the peak Ab titers upon boost in individual animals, as well as a correlation of both parameters of immune response to the frequency of naive CD8+ T cells in old but not in adult monkeys. Therefore, our results argue that T cell repertoire constriction and naive cell loss have prognostic value for global immune function in aging primates.

Antiviral immunity following smallpox virus infection: a case-control study.

Outbreaks of smallpox (i.e., caused by variola virus) resulted in up to 30% mortality, but those who survived smallpox infection were regarded as immune for life. Early studies described the levels of neutralizing antibodies induced after infection, but smallpox was eradicated before contemporary methods for quantifying T-cell memory were developed. To better understand the levels and duration of immunity after smallpox infection, we performed a case-control study comparing antiviral CD4(+) and CD8(+) T-cell responses and neutralizing antibody levels of 24 smallpox survivors with the antiviral immunity observed in 60 smallpox-vaccinated (i.e., vaccinia virus-immune) control subjects. We found that the duration of immunity following smallpox infection was remarkably similar to that observed after smallpox vaccination, with antiviral T-cell responses that declined slowly over time and antiviral antibody responses that remained stable for decades after recovery from infection. These results indicate that severe, potentially life-threatening disease is not required for the development of sustainable long-term immunity. This study shows that the levels of immunity induced following smallpox vaccination are comparable in magnitude to that achieved through natural variola virus infection, and this may explain the notable success of vaccination in eradicating smallpox, one of the world's most lethal diseases.

Improving Smoking Cessation Outcomes Through Tailored-Risk Patient Messages at a University Hospital Tobacco Cessation Service.

BACKGROUND: Postdischarge follow-up is a critical step for increasing effectiveness of hospital smoking cessation treatment. A quality improvement project was undertaken at an academic medical center tobacco cessation consult service to evaluate whether a tailored message (TM) linking immediate risks of continued smoking-particularly carbon monoxide exposure-to hospital recovery would stimulate more patient interest in the hospital's cessation treatment, including agreement to postdischarge follow-up, compared to patients receiving the usual treatment protocol with a standard message (SM) regarding more general health benefits of abstinence. METHODS: Data from 697 smokers ordered/referred for smoking cessation treatment in 2013 who received either the SM (January-April; n = 323) or the TM (April-November; n =374) were analyzed. RESULTS: Multivariate regression analysis showed that the TM was associated with significantly greater agreement for follow-up (odds ratio [OR] = 10.83, 95% confidence interval [CI] = 3.66-32.04, p < 0.0001) than the SM. Those patients who received the TM were more willing to try to remain abstinent postdischarge (willingness score = 10, p = 0.0052) and engaged in longer consults (consult time > 10 minutes, p = 0.0075) than SM patients. TM patients also self-reported a higher continuous abstinence rate (OR = 2.07, 95% CI = 1.17-3.66, p = 0.0130] at follow-up than SM. CONCLUSION: Linking risks of continued smoking, particularly carbon monoxide exposure, to hospital patients' immediate recovery following discharge in a treatment protocol resulted in longer consult times and increased agreement to follow-up compared to the usual protocol message. The TM was integrated into the hospital tobacco cessation intervention as standard of care.

Effect of low concentrations of apomorphine on parkinsonism in a randomized, placebo-controlled, crossover study.

OBJECTIVE: To determine whether low concentrations of a dopamine agonist worsen parkinsonism, which would suggest that activation of presynaptic dopamine autoreceptors causes a super-off state. DESIGN: Randomized, double-blind, placebo-controlled, crossover clinical trial. SETTING: Academic movement disorders center. PATIENTS: Patients with Parkinson disease and motor fluctuations. INTERVENTION: Fourteen patients with Parkinson disease and motor fluctuations were randomized to receive 1 of 6 possible sequences of placebo, low-dose (subthreshold) apomorphine hydrochloride, and high-dose (threshold to suprathreshold) apomorphine hydrochloride infusions. Subthreshold doses of apomorphine hydrochloride (12.5 microg/kg/h every 2 hours and 25 microg/kg/h every 2 hours), threshold to suprathreshold doses of apomorphine hydrochloride (50 microg/kg/h every 2 hours and 100 microg/kg/h every 2 hours), and placebo were infused for 4 hours daily for 3 consecutive days. MAIN OUTCOME MEASURES: Finger and foot tapping rates. RESULTS: There was no decline in finger or foot tapping rates during the low-dose apomorphine hydrochloride infusions relative to placebo. The high-dose infusions increased foot tapping (P < .001) and trended toward increasing finger tapping compared with placebo infusions. CONCLUSIONS: Subthreshold concentrations of apomorphine did not worsen parkinsonism, suggesting that presynaptic dopamine autoreceptors are not important to the motor response in moderate to advanced Parkinson disease. Trial Registration clinicaltrials.gov Identifier: NCT00472355.

Desired qualities and hypothetical contextual use of vaginal microbicides in a diverse sample of US women.

BACKGROUND: Vaginal microbicides represent an important emerging class of antiinfectives. To guide research and development, we conducted a survey to determine interest in desired qualities of and intended use of microbicides within the current milieu of contraceptive options. STUDY DESIGN: Women completed an anonymous survey while waiting for health care clinic appointments in Portland, OR, and Atlanta, GA, and in one public area (Atlanta). RESULTS: Four hundred one women completed the survey. Subjects had a mean age of 25.6 (SD=7.4), parity of 1.5 (SD=1.6) and 47.7% were non-Caucasian. Respondents showed moderate interest in noncontraceptive anti-HIV gel-based microbicides (mean, 53.8; SD, 39.6; n=362) and significantly stronger interest in contraceptive anti-HIV microbicides (mean, 89.4 mm; SD, 20.7; n=363; p<.001). The qualities of HIV, pregnancy and sexually transmitted infection (STI) prevention were the highest priorities of the largest percentage (40%) of respondents. Half (49.6%) of respondents reported they would use another form of protection in conjunction with a contraceptive anti-HIV microbicide. CONCLUSIONS: A diverse sample of women reported substantial interest in vaginal microbicides capable of preventing HIV and pregnancy, and a smaller high-risk subgroup was interested in noncontraceptive anti-HIV microbicides. Most women would prefer a product capable of preventing HIV, pregnancy and STIs. Almost half of respondents would use vaginal microbicides as part of a dual method.

Eczema prevalence in the United States: data from the 2003 National Survey of Children's Health.

Using the 2003 National Survey of Children's Health sponsored by the federal Maternal and Child Health Bureau, we calculated prevalence estimates of eczema nationally and for each state among a nationally representative sample of 102,353 children 17 years of age and under. Our objective was to determine the national prevalence of eczema/atopic dermatitis in the US pediatric population and to further examine geographic and demographic associations previously reported in other countries. Overall, 10.7% of children were reported to have a diagnosis of eczema in the past 12 months. Prevalence ranged from 8.7 to 18.1% between states and districts, with the highest prevalence reported in many of the East Coast states, as well as in Nevada, Utah, and Idaho. After adjusting for confounders, metropolitan living was found to be a significant factor in predicting a higher disease prevalence with an odds ratio of 1.67 (95% confidence interval of 1.19-2.35, P=0.008). Black race (odds ratio 1.70, P=0.005) and education level in the household greater than high school (odds ratio 1.61, P=0.004) were also significantly associated with a higher prevalence of eczema. The wide range of prevalence suggests that social or environmental factors may influence disease expression.

Impact of combination medical therapy on mortality in vascular surgery patients.

BACKGROUND: Th use of beta-blockers or statins has been associated with decreased mortality after noncardiac surgery. There are no prior perioperative studies of concurrent use of other cardioprotective drugs. OBJECTIVE: To ascertain whether combinations of aspirin, beta-blockers, statins, and/or angiotensin-converting enzyme (ACE) inhibitors were associated with decreased mortality 6 months after vascular surgery. PATIENTS AND DESIGN: We performed a retrospective cohort study on the 3020 patients who underwent vascular surgery between January 1998 and March 2005 at 5 regional Veterans Affairs (VA) medical centers. The Cochran-Mantel-Haenszel test was used to assess associations with 6-month all-cause mortality for the combination drug exposures compared to no exposure while adjusting for propensity score. RESULTS: Exposure to all 4 of the study drugs compared to none had a propensity-adjusted relative risk (aRR) of 0.52 (95% confidence interval [CI], 0.26-1.01; P = 0.052), number needed to treat (NNT) 19; 3 drugs vs. none, aRR 0.60 (95% CI, 0.38-0.95; P = 0.030), NNT 38; 2 drugs vs. none, aRR 0.68 (95% CI, 0.46-0.99; P = 0.043), NNT 170; and 1 drug vs. none, aRR 0.88 (95% CI, 0.63-1.22; P = 0.445). ACE inhibitor exposure was common in all combinations. CONCLUSIONS: Combination use of 2 to 3 study drugs, some of which included ACE inhibitors, was associated with decreased mortality after vascular surgery. Combination use of all 4 study drugs was not statistically significant due to the small number of events in this group. Further prospective studies of combination perioperative aspirin, beta-blockers, statins, and ACE inhibitors are warranted.

Foot-tapping rate as an objective outcome measure for Parkinson disease clinical trials.

OBJECTIVES: To explore foot-tapping rate as a reliable and a valid measure of motor function in Parkinson disease (PD). METHODS: We present data from a randomized, single-blind, outpatient study and a randomized, double-blind, placebo-controlled, crossover, inpatient study. Fifty PD subjects completed the outpatient study. A Unified Parkinson Disease Rating Scale motor score was determined for each subject. Subsequently, finger tapping, alternate (between 2 pedals) and repetitive (on 1 pedal) foot-tapping rates, and gait were measured. Thirteen PD subjects completed the inpatient study. Each subject received a daily infusion of high-dose apomorphine (APO), low-dose APO, and placebo in random order over 3 days. In this subanalysis, we compared variance and reliability of the finger- and the foot-tapping techniques during the placebo day and compared the validity of these outcome measures to detect improvement in parkinsonism during high-dose APO infusion. RESULTS: Alternate foot tapping was reliable (interclass correlation on the placebo inpatient day, 84%). Only foot tapping detected improvement in parkinsonism with high-dose APO treatment (a measure of validity). In the outpatient study, there was a significant correlation between alternate and repetitive tapping with finger tapping (R2 = 0.28 and 0.23, respectively) and Unified Parkinson Disease Rating Scale motor score (R2 = 0.09 and 0.08), but only alternate tapping correlated with gait (R2 = 0.16). CONCLUSIONS: Alternate foot tapping was equally reliable but more valid than finger tapping. Alternate foot tapping correlated better did existing PD outcome measures than did repetitive foot tapping. Foot tapping may be a useful outcome measure for determination of dopaminergic medication effect in PD clinical trials.

N-acetylcysteine for patients with prolonged hypotension as prophylaxis for acute renal failure (NEPHRON).

BACKGROUND: Acute renal failure is a common complication in critically ill patients and carries an increased morbidity and mortality. N-acetylcysteine is an antioxidant and anti-inflammatory agent that may counteract some of the pathophysiologic derangements in shock states. OBJECTIVE: To test whether the administration of N-acetylcysteine, compared with placebo, reduces the incidence of acute renal failure in hypotensive patients. DESIGN: Prospective, randomized, double-blinded, placebo-controlled study. SETTING: Intensive care units of a university tertiary care hospital. PATIENTS: One hundred forty-two patients with new onset (within 12 hrs) of at least>or=30 consecutive minutes of hypotension and/or vasopressor requirement. INTERVENTIONS: Patients were randomized to receive either N-acetylcysteine or placebo for 7 days, in addition to standard supportive therapy. MEASUREMENTS AND MAIN RESULTS: Patients who received N-acetylcysteine had an incidence of acute renal failure (>or=0.5 mg/dL increase in creatinine) of 15.5%, compared with 16.9% in those receiving placebo (p=.82, not significant). There were no significant differences between treatment arms in any of the secondary outcomes examined, including incidence of a 50% increase in creatinine, maximal rise in creatinine, recovery of renal function, length of intensive care unit and hospital stay, requirement for renal replacement therapy, and mortality. Among patients receiving N-acetylcysteine, there were trends toward reduced incidence of acute renal failure in patients with baseline Sequential Organ Failure Assessment (SOFA) score>8 (p=.12), lower SOFA scores during the first 4 days of treatment (p=.28), and reduced mortality in patients<65 yrs of age (p=.20). CONCLUSIONS: There were no significant differences in any of our primary or secondary end points between patients treated with N-acetylcysteine or placebo. Trends toward reduced incidence of acute renal failure in patients with baseline SOFA score >8, reduced SOFA scores during the first 4 days, and reduced mortality in patients<65 yrs of age are provocative but require further study to determine their clinical significance.

Initial pharmacotherapy in a population of veterans with Parkinson disease.

The authors analyzed patient and prescribing provider characteristics for 530 veterans identified from VA pharmacy records with Parkinson disease (PD) and initial pharmacotherapy. Neurologists prescribed 29% of initial therapy. While a patient being younger and seeing a movement disorder specialist predicted receiving dopamine agonists, only 20% of patients younger than age 65 years received dopamine agonists. Initial pharmacotherapy is strongly influenced by the provider's specialty but mostly initiated by providers without PD expertise.