Pairing smoking-cessation services with lung cancer screening: A clinical guideline from the Association for the Treatment of Tobacco Use and Dependence and the Society for Research on Nicotine and Tobacco.

Smoking cessation is crucial for reducing cancer risk and premature mortality. The US Preventive Services Task Force (USPSTF) has recommended annual lung cancer screening with low-dose computed tomography (LDCT), and the Center for Medicare and Medicaid Services recently approved lung screening as a benefit for patients ages 55 to 77 years who have a 30 pack-year history. The Society for Research on Nicotine and Tobacco (SRNT) and the Association for the Treatment of Tobacco Use and Dependence (ATTUD) developed the guideline described in this commentary based on an illustrative literature review to present the evidence for smoking-cessation health benefits in this high-risk group and to provide clinical recommendations for integrating evidence-based smoking-cessation treatment with lung cancer screening. Unfortunately, extant data on lung cancer screening participants were scarce at the time this guideline was written. However, in this review, the authors summarize the sufficient evidence on the benefits of smoking cessation and the efficacy of smoking-cessation interventions for smokers ages 55 to 77 years to provide smoking-cessation interventions for smokers who seek lung cancer screening. It is concluded that smokers who present for lung cancer screening should be encouraged to quit smoking at each visit. Access to evidence-based smoking-cessation interventions should be provided to all smokers regardless of scan results, and motivation to quit should not be a necessary precondition for treatment. Follow-up contacts to support smoking-cessation efforts should be arranged for smokers. Evidence-based behavioral strategies should be used at each visit to motivate smokers who are unwilling to try quitting/reducing smoking or to try evidence-based treatments that may lead to eventual cessation.

Results of patch testing in 10 patients with peristomal dermatitis.

BACKGROUND: Peristomal dermatitis is a common problem in patients with ostomies that is a source of considerable morbidity. Irritant contact dermatitis is most common, but allergic contact dermatitis can also occur. Because of the lack of published reports on patch testing for this indication, we undertook a retrospective study of patch testing results in patients with suspected peristomal allergic contact dermatitis. OBJECTIVE: We sought to describe our patch testing experience with patients referred with peristomal dermatitis. METHODS: This was a retrospective review of medical records of patients with ostomies and peristomal dermatitis who underwent patch testing in the Mayo Clinic Departments of Dermatology in Jacksonville, FL; Rochester, MN; and Scottsdale, AZ, during a 10-year period (2000-2010). RESULTS: Ten patients with peristomal dermatitis were referred for patch testing (6 in Minnesota, 2 in Florida, and 2 in Arizona). Patients were patch tested to the materials used in their stoma devices, to the standard series, and in some cases to supplemental series. All 10 had at least one allergic patch test reaction, most commonly to stoma paste (3 of 10 patients). LIMITATIONS: Retrospective nature of study via chart review is a limitation. CONCLUSION: Patch testing is a useful tool for identification of allergens in patients with peristomal dermatitis.

An integrative review of global nursing workforce issues.

Migration has been a way of life since the beginning of time, with migrants seeking other lands for personal and professional betterment. Today, in an era of globalization, trade agreements and technological advances, an increase in migration is inevitable. All professions have been affected, but the migration of health professionals, particularly nurses, has been the most dramatic. However, the migration of nurses across national and international borders comes with many challenges: systematic tracking of migration flows, harmonization of standards, recognition of professional credentials, fair and equitable distribution of the global health care workforce, and the effect of migration on the health care infrastructure of both source and destination countries. The international migration of nurses to address shortages in developed countries has, in some instances, left source countries with insufficient resources to address their own health care needs. The increasing complexity of health care delivery, aging of the population and the nursing workforce, and the escalating global demand for nurses create on-going challenges for policy makers. Strategically addressing global nursing workforce issues is paramount to sustaining the health of nations.

The case for treating tobacco dependence as a chronic disease.

Smoking remains the leading cause of preventable death in the United States, yet it is still regarded by many as merely a bad habit. Most smokers want to quit but find it difficult. Behavioral counseling and pharmacotherapies are available, safe, and effective in the treatment of tobacco dependence. Nicotine replacement therapy effectively delivers nicotine in safer doses without exposure to the toxins and chemicals in cigarette smoke. The optimal duration of tobacco dependence treatment is unknown, and some smokers may require extended courses. For smokers using long-term cessation medications, health care providers should encourage treatment and insurance carriers should cover it. Both tobacco dependence and such conditions as diabetes are similar in their potential to exacerbate other diseases, their behavioral components of treatment, and their effectiveness of medications. Despite these similarities, treatments for diabetes are well covered by insurance, whereas tobacco dependence treatments are often limited. Tobacco dependence should share the status of other chronic illnesses, with effective treatments given as long as is necessary to achieve successful clinical outcomes.

Outcome after pulmonary radiotherapy in Wilms' tumor patients with pulmonary metastases at diagnosis: a UK Children's Cancer Study Group, Wilms' Tumour Working Group Study.

PURPOSE: To evaluate the effect of whole lung radiotherapy on event-free and overall survival of children with Stage IV Wilms' tumor with pulmonary metastases at diagnosis and to ascertain factors that may have led to the decision to withhold radiotherapy. METHODS AND MATERIALS: We compared recurrence and mortality risks of patients with pulmonary metastases at diagnosis enrolled in the UKW2 and UKW3 clinical trials (1986-2001) according to treatment with pulmonary radiotherapy. RESULTS: Of 102 eligible patients (43 patients in UKW2 and 59 patients in UKW3), 72 (71%) received pulmonary radiotherapy; 30 (29%) did not. After a median follow-up of 9.3 years (range, 0.6-14.1 years), event-free survival was 79.2% (95% confidence interval [CI], 67.8-86.9%) in patients who received pulmonary radiotherapy compared with 53.3% (95% CI, 34.3-69.1%) in patients who did not receive it (p = 0.006), with a hazard ratio of 2.66 (95% CI, 1.28-5.52; p = 0.009). There was no difference in overall survival (84.7% [95% CI, 74.1-91.2%] vs. 73.2% [95% CI, 53.4-85.6%], respectively; p = 0.157). Pulmonary radiotherapy reduced the chance of lung relapse (8.3% vs. 23.3%; p = 0.039). The omission of radiotherapy did not seem to be consistently associated with any specific clinical or radiologic features. CONCLUSIONS: Outcome may be compromised if pulmonary radiotherapy is omitted in children with Wilms' tumor with pulmonary metastases. There was a significant effect on event-free survival; the risk of an event, particularly lung recurrence, was increased nearly threefold. Strategies for selection of children for avoidance of pulmonary irradiation need to be developed in a controlled fashion.

Delayed patch test reading after 5 days: the Mayo Clinic experience.

BACKGROUND: Some patients may have delayed allergic patch test reactions that are not identified with a typical 5-day reading protocol. OBJECTIVE: To identify allergens with delayed-positive reactions and to determine whether a late reading (day 7-9) can be substituted for the day-5 reading. METHODS: We retrospectively reviewed medical records of patients who underwent patch testing for suspected allergic contact dermatitis from October 1997 through December 2006 and returned for delayed readings between days 7 and 10 or beyond. (This cohort was predominantly patients with suspected allergies to metals and corticosteroids). RESULTS: A total of 36,064 individual reactions (471 allergens, 372 patients) were interpreted on day 5 and at least once during days 7 through 21. We analyzed the 170 allergens that were each tested in at least 50 patients. The 4 allergens with the highest percentage of delayed-positive reactions were gold sodium thiosulfate 0.5% (delayed-positive reactions in 22/353 patients), dodecyl gallate 0.25% (6/105), palladium chloride 2% (8/194), and neomycin sulfate 20% (10/253). We observed a low number of delayed-positive readings for p-phenylenediamine 1% (1/251) and for corticosteroids. Reactions to certain preservative and fragrance allergens dissipated after the day-5 reading. Most reactions that dissipated after day 5 were mild, whereas the reactions that became apparent after day 5 were strong. LIMITATIONS: This was a retrospective study. Most patients had suspected allergies to metals and corticosteroids. CONCLUSION: Late patch test readings (day 7 or beyond) were useful when interpreting reactions to metals and topical antibiotics, but it was not useful in the diagnosis of reactions to other allergens, including topical corticosteroids. Because reactions to certain fragrance and preservative allergens may dissipate after 5 days, patch test reactions therefore are optimally read at days 3 and 5, but an additional reading on day 7 or beyond is useful if patch tests to metals and topical antibiotics are performed.

An evaluation of tumor oxygenation and gene expression in patients with early stage non-small cell lung cancers.

BACKGROUND: To directly assess tumor oxygenation in resectable non-small cell lung cancers (NSCLC) and to correlate tumor pO2 and the selected gene and protein expression to treatment outcomes. METHODS: Twenty patients with resectable NSCLC were enrolled. Intraoperative measurements of normal lung and tumor pO2 were done with the Eppendorf polarographic electrode. All patients had plasma osteopontin measurements by ELISA. Carbonic anhydrase-IX (CA IX) staining of tumor sections was done in the majority of patients (n = 16), as was gene expression profiling (n = 12) using cDNA microarrays. Tumor pO2 was correlated with CA IX staining, osteopontin levels, and treatment outcomes. RESULTS: The median tumor pO2 ranged from 0.7 to 46 mm Hg (median, 16.6) and was lower than normal lung pO2 in all but one patient. Because both variables were affected by the completeness of lung deflation during measurement, we used the ratio of tumor/normal lung (T/L) pO2 as a reflection of tumor oxygenation. The median T/L pO2 was 0.13. T/L pO2 correlated significantly with plasma osteopontin levels (r = 0.53, P = 0.02) and CA IX expression (P = 0.006). Gene expression profiling showed that high CD44 expression was a predictor for relapse, which was confirmed by tissue staining of CD44 variant 6 protein. Other variables associated with the risk of relapse were T stage (P = 0.02), T/L pO2 (P = 0.04), and osteopontin levels (P = 0.001). CONCLUSIONS: Tumor hypoxia exists in resectable NSCLC and is associated with elevated expression of osteopontin and CA IX. Tumor hypoxia and elevated osteopontin levels and CD44 expression correlated with poor prognosis. A larger study is needed to confirm the prognostic significance of these factors.

Macrophage and mast-cell invasion of tumor cell islets confers a marked survival advantage in non-small-cell lung cancer.

PURPOSE: The role played by the innate immune system in determining survival from non-small-cell lung cancer (NSCLC) is unclear. The aim of this study was to investigate the prognostic significance of macrophage and mast-cell infiltration in NSCLC. METHODS: We used immunohistochemistry to identify tryptase+ mast cells and CD68+ macrophages in the tumor stroma and tumor islets in 175 patients with surgically resected NSCLC. RESULTS: 5-year survival was 52.9% in patients with an islet macrophage density greater than the median versus 7.7% when less than the median (P < .0001). In the same groups, respectively, median survival was 2,244 versus 334 days (P < .0001). Patients with a high islet macrophage density but incomplete resection survived markedly longer than patients with a low islet macrophage density but complete resection. CONCLUSION: The tumor islet CD68+ macrophage density is a powerful independent predictor of survival from surgically resected NSCLC. The biologic explanation for this and its implications for the use of adjunctive treatment requires further study.

Galectin-1: a link between tumor hypoxia and tumor immune privilege.

PURPOSE: To identify a 15-KDa novel hypoxia-induced secreted protein in head and neck squamous cell carcinomas (HNSCC) and to determine its role in malignant progression. METHODS: We used surface-enhanced laser desorption ionization time-of-flight mass spectrometry (SELDI-TOF-MS) and tandem MS to identify a novel hypoxia-induced secreted protein in FaDu cells. We used immunoblots, real-time polymerase chain reaction (PCR), and enzyme-linked immunoabsorbent assay to confirm the hypoxic induction of this secreted protein as galectin-1 in cell lines and xenografts. We stained tumor tissues from 101 HNSCC patients for galectin-1, CA IX (carbonic anhydrase IX, a hypoxia marker) and CD3 (a T-cell marker). Expression of these markers was correlated to each other and to treatment outcomes. RESULTS: SELDI-TOF studies yielded a hypoxia-induced peak at 15 kDa that proved to be galectin-1 by MS analysis. Immunoblots and PCR studies confirmed increased galectin-1 expression by hypoxia in several cancer cell lines. Plasma levels of galectin-1 were higher in tumor-bearing severe combined immunodeficiency (SCID) mice breathing 10% O2 compared with mice breathing room air. In HNSCC patients, there was a significant correlation between galectin-1 and CA IX staining (P = .01) and a strong inverse correlation between galectin-1 and CD3 staining (P = .01). Expression of galectin-1 and CD3 were significant predictors for overall survival on multivariate analysis. CONCLUSION: Galectin-1 is a novel hypoxia-regulated protein and a prognostic marker in HNSCC. This study presents a new mechanism on how hypoxia can affect the malignant progression and therapeutic response of solid tumors by regulating the secretion of proteins that modulate immune privilege.

Phospho-akt expression is associated with a favorable outcome in non-small cell lung cancer.

Akt, a Serine/Threonine protein kinase, mediates growth factor-associated cell survival. Constitutive activation of Akt (phosphorylated Akt, P-Akt) has been observed in several human cancers, including lung cancer and may be associated with poor prognosis and chemotherapy and radiotherapy resistance. The clinical relevance of P-Akt in non-small cell lung cancer (NSCLC) is not well described. In the present study, we examined 82 surgically resected snap-frozen and paraffin-embedded stage I to IIIA NSCLC samples for P-Akt and Akt by Western blotting and for P-Akt by immunohistochemistry. P-Akt protein levels above the median, measured using reproducible semiquantitative band densitometry, correlated with a favorable outcome (P = 0.007). Multivariate analysis identified P-Akt as a significant independent favorable prognostic factor (P = 0.004). Although associated with a favorable prognosis, high P-Akt levels correlated with high tumor grade (P = 0.02). Adenocarcinomas were associated with low P-Akt levels (P = 0.039). Akt was not associated with either outcome or clinicopathologic variables. Cytoplasmic (CP-Akt) and nuclear (NP-Akt) P-Akt tumor cell staining was detected in 96% and 42% of cases, respectively. Both CP-Akt and NP-Akt correlated with well-differentiated tumors (P = 0.008 and 0.017, respectively). NP-Akt also correlated with nodal metastases (P = 0.022) and squamous histology (P = 0.037).These results suggest P-Akt expression is a favorable prognostic factor in NSCLC. Immunolocalization of P-Akt, however, may be relevant as NP-Akt was associated with nodal metastases, a known poor prognostic feature in this disease. P-Akt may be a potential novel therapeutic target for the management of NSCLC.

Factors associated with quitting smoking at a tobacco dependence treatment clinic.

OBJECTIVE: To identify factors associated with successful quitting at a free tobacco treatment clinic. METHODS: A cohort study of the first 1021 patients who made a quit attempt. Baseline and treatment variables were recorded, and logistic regression was used to identify factors associated with abstinence at 4-week and 6-month follow-up. RESULTS: Three hundred twenty (31.3%) patients reported tobacco abstinence at 6 months. Several markers of low socioeconomic status and high nicotine dependence were predictive of poorer smoking cessation outcomes. Compliance with evidence-based treatment was associated with improved treatment outcome, as was older age and having more than 2 children. CONCLUSIONS: Efforts should be made to enhance treatment compliance among smokers with indicators of high nicotine dependence and low socioeconomic status.

Carbonic anhydrase IX expression, a novel surrogate marker of tumor hypoxia, is associated with a poor prognosis in non-small-cell lung cancer.

PURPOSE: To evaluate carbonic anhydrase (CA) IX as a surrogate marker of hypoxia and investigate the prognostic significance of different patterns of expression in non-small-cell lung cancer (NSCLC). METHODS: Standard immunohistochemical techniques were used to study CA IX expression in 175 resected NSCLC tumors. CA IX expression was determined by Western blotting in A549 cell lines grown under normoxic and hypoxic conditions. Measurements from microvessels to CA IX positivity were obtained. RESULTS: CA IX immunostaining was detected in 81.8% of patients. Membranous (m) (P =.005), cytoplasmic (c) (P =.018), and stromal (P <.001) CA IX expression correlated with the extent of tumor necrosis (TN). The mean distance from vascular endothelium to the start of tumor cell positivity was 90 micro m, which equates to an oxygen pressure of 5.77 mmHg. The distance to blood vessels from individual tumor cells or tumor cell clusters was greater if they expressed mCA IX than if they did not (P <.001). Hypoxic exposure of A549 cells for 16 hours enhanced CA IX expression in the nuclear and cytosolic extracts. Perinuclear (p) CA IX (P =.035) was associated with a poor prognosis. In multivariate analysis, pCA IX (P =.004), stage (P =.001), platelet count (P =.011), sex (P =.027), and TN (P =.035) were independent poor prognostic factors. CONCLUSION: These results add weight to the contention that mCA IX is a marker of tumor cell hypoxia. The absence of CA IX staining close to microvessels suggests that these vessels are functionally active. pCA IX expression is representative of an aggressive phenotype.

Patch test results from the Mayo Clinic Contact Dermatitis Group, 1998-2000.

BACKGROUND: Patch testing is a diagnostic tool for the evaluation of patients with suspected allergic contact dermatitis. A standard series of allergens similar to that used by the North American Contact Dermatitis Group (NACDG) is used at Mayo Clinic. OBJECTIVE: Our aim was to report the results of patch testing with a standard series at Mayo Clinic from July 1, 1998, to Dec 31, 2000 and to compare our findings with those of the NACDG during the same period. METHODS: The results of patch testing with the standard series at Mayo Clinic were examined. Positive reaction rates were compared between Mayo Clinic and the NACDG. RESULTS: During the 30-month period, 1324 Mayo Clinic patients were patch tested with a standard series of allergens (mean, 60 allergens), whereas the NACDG standard series during this period included 50 allergens. Overall, 917 patients (69.3%) had at least one positive reaction and 606 patients (45.8%) had two or more positive reactions. The 10 allergens used both by Mayo Clinic and by the NACDG that most frequently caused positive reactions were nickel sulfate hexahydrate, balsam of Peru (Myroxylon pereirae), neomycin sulfate, cobalt chloride, fragrance mix, potassium dichromate (0.25%), thimerosal, bacitracin, formaldehyde, and glutaraldehyde. Statistically significant differences in positive reaction rates (P < .05) were observed for 12 of the 43 allergens common to both Mayo Clinic and the NACDG. CONCLUSION: With large standard patch test series, one can identify commonly encountered and potentially relevant contact allergens.

Low yield for extended reading of patch tests with topical corticosteroids.

BACKGROUND: On the basis of reports that up to 30% of patch test reactions are missed if an extended reading is not performed, we required that patients who were being patch tested with the corticosteroid series return for a reading at least 1 week after placement of the allergens. OBJECTIVE: To report our institutional experience with extended readings (day 7 or beyond) of patch test reactions to the corticosteroid series. METHODS: We retrospectively reviewed patch test reactions to corticosteroids since extended readings were implemented (April 2001 to June 2004). RESULTS: A total of 135 patients were patch tested with 1,656 corticosteroid allergens. On day 5, five patients had five positive patch test reactions; by the time of the extended reading, no new reactions had developed in these patients. Of the patients with no reactions on day 5, two had a positive result at the extended reading: each had a relevant reaction to budesonide 0.1%, one on day 7 and the other on day 9. CONCLUSIONS: Only 2 reactions (to 1,656 corticosteroids) became apparent at the extended reading. Extended readings were of limited value in our experience.

Laparoscopic Nissen fundoplication in a community hospital: analysis of 202 patients.

We analyzed 202 patients undergoing Laparoscopic Nissen fundoplication. One hundred and three patients (90.6%) had typical reflux symptoms. Hiatal hernias were present in 84.6%. Most patients had erosive esophagitis; sixty-four patients (31.6%) had strictures. Complications occurred in 38 patients (18.8%), with major complications in 15 patients (7.4%). Major complications included bleeding in six, two requiring transfusion, slipped Nissen in three, pneumothorax in two, and esophageal leak in two patients. Eleven patients had postoperative dysphagia that responded to dilation therapy within three months. There was no mortality.

Tumour necrosis is an independent prognostic marker in non-small cell lung cancer: correlation with biological variables.

BACKGROUND: Tumour necrosis (TN) is recognized to be a consequence of chronic cellular hypoxia. TN and hypoxia correlate with poor prognosis in solid tumours. METHODS: In a retrospective study the prognostic implications of the extent of TN was evaluated in non-small cell lung cancer (NSCLC) and correlated with clinicopathological variables and expression of epidermal growth factor receptor, Bcl-2, p53 and matrix metalloproteinase-9 (MMP-9). Tissue specimens from 178 surgically resected cases of stage I-IIIA NSCLC with curative intent were studied. The specimens were routinely processed, formalin-fixed and paraffin-embedded. TN was graded as extensive or either limited or absent by two independent observers; disagreements were resolved using a double-headed microscope. The degree of reproducibility was estimated by re-interpreting 40 randomly selected cases after a 4 month interval. RESULTS: Reproducibility was attained in 36/40 cases, Kappa score = 0.8 P < 0.001. TN correlated with T-stage (P = 0.001), platelet count (P = 0.004) and p53 expression (P = 0.031). Near significant associations of TN with N-stage (P = 0.063) and MMP-9 expression (P = 0.058) were seen. No association was found with angiogenesis (P = 0.98). On univariate (P = 0.0016) and multivariate analysis (P = 0.023) TN was prognostic. CONCLUSION: These results indicate that extensive TN reflects an aggressive tumour phenotype in NSCLC and may improve the predictive power of the TMN staging system. The lack of association between TN and angiogenesis may be important although these variables were not evaluated on serial sections.

The future of nursing: domestic agenda, global implications.

The 2010 Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, challenges the nursing profession to take a key role in redesigning the health care system. Intended to shape the future of nursing in the United States, the IOM report has implications for nursing worldwide. While individual states and nursing organizations are developing initiatives to implement the IOM recommendations in the United States, there must be a concomitant effort to examine the ripple effect on global health and the nursing community. This article addresses four IOM recommendations that are directly relevant to internationally educated nurses who practice across borders: nurse residency programs, lifelong learning, leading change to advance health, and interprofessional health care workforce data. The article discusses the IOM recommendations through a global perspective and offers policy implications for legislators, health care organizations and nurse educators, regulators and administrators.

Patch testing with textile allergens: the mayo clinic experience.

BACKGROUND: Recognition of allergic contact dermatitis attributed to textile dyes and resins is steadily increasing. OBJECTIVE: This study aims to review the results of patch testing with a textile series at our institution and to compare with previously published reports. METHODS: We performed a retrospective review of results in patients who underwent patch testing using a series of textile dyes and resins from January 1, 2000, through September 30, 2011. RESULTS: A total of 671 patients (mean age, 56.5 years; female, 65.9%) were patch tested with the textile series (42 dyes and resins). These patients were also generally tested with the standard patch test series (n = 620). Of the patients, 219 (32.6%) demonstrated allergic reaction to 1 or more textile dyes and resins, and 71 (10.6%) manifested irritant reactions. The most frequent allergens were disperse blue 106 1% (8.3%), disperse blue 124 1% (8.0%), and melamine formaldehyde 7% (8.0%). Of patients tested with the standard series, 36 (5.8%) showed a positive reaction to the traditional textile screening allergen p-phenylenediamine 1%. CONCLUSIONS: Supplementing the standard series with the textile series increased detection of textile allergies. In patients suspected of textile allergy, addition of the textile series is necessary for appropriate diagnosis.

Patch-testing with hairdressing chemicals.

BACKGROUND: Hairdressing chemicals may be associated with allergic contact dermatitis. OBJECTIVE: To review our experience of patch-testing with hairdressing chemicals. METHODS: We reviewed results from patients who underwent patch testing with our standard allergen series (including 15 hairdressing chemicals) and a supplementary "hairdresser series" (18 additional hairdressing chemicals) at Mayo Clinic (Rochester, MN; Scottsdale, AZ; and Jacksonville, FL) from January 1, 2000, through December 31, 2008. RESULTS: Two hundred ten patients (mean age, 53.8 years [SD, 16.9 yr]; female, 94.8%) were patch-tested. The most common sites of dermatitis were the scalp, face, and hands. Patients had widely varying occupations. The most common occupations were cosmetologist (10.5%), housewife (9.5%), and beautician (5.2%); 14.3% were retired. The hairdresser series detected 13 additional patients with allergies (6.4%; 204 patients tested with both series) who would not have been detected with the standard allergen series alone. The highest allergic patch-test rates in the supplemental hairdresser series were with ammonium persulfate (14.4%), 4-aminoazobenzene (13.4%), and pyrogallol (9.1%). CONCLUSIONS: Patch-testing with hairdressing-specific chemicals (standard series plus supplemental hairdresser series) was appropriate for numerous clinical situations and was not limited to patients in hair care occupations. The supplemental hairdresser series helped identify more patients than would have been identified with the standard series alone.

Abstinence and psychological distress in co-morbid smokers using various pharmacotherapies.

BACKGROUND: Existing trials of varenicline have typically excluded smokers with concurrent medical and psychiatric illnesses and no data exist comparing effectiveness of varenicline with combination pharmacotherapy. This study evaluated abstinence and psychiatric outcomes of various tobacco dependence medications, including varenicline. METHODS: Retrospective cohort of 723 smokers, most with significant medical and psychiatric comorbidity, was evaluated at the UMDNJ-Tobacco Dependence Clinic from 2006 to 2008. Demographics, measures of tobacco dependence and co-morbidities, and a validated instrument measuring psychological distress (Kessler-6) were obtained. Primary outcome was 7-day point abstinence at 6 months after target quit date. RESULTS: Cessation medications used included combination pharmacotherapy (39%), single nicotine replacement therapy (NRT) or bupropion (29%), and varenicline (23%), with 9% using no medications. Overall, 23% of patients were abstinent at 6 months. In an adjusted regression model, smokers using varenicline or combination medications were more likely abstinent at 6 months than those using no medications (adjusted odds ratio=2.99; 95% confidence interval=1.20-7.47 and 2.80; 1.15-6.82, respectively), but not statistically higher than those using single medications (AOR=1.70). Age, gender, education, marital status, cigarettes per day, time to first cigarette, night smoking, and menthol smoking were not significantly related to abstinence. Varenicline or combination medications did not significantly increase serious psychological distress over the treatment period compared to other medication options. CONCLUSIONS: Both varenicline and combination pharmacotherapy were effective and did not increase psychological distress for up to 6 months in smokers with co-morbidities treated at a specialty clinic.