Concordance between Cigarette Smoking and the Modified Fagerström Tolerance Questionnaire in Controlled Studies of ADHD

Our objective was to compare scores on a smoking questionnaire to a diagnosis of cigarette smoking. As part of follow‐ups in studies of ADHD, we assessed for cigarette smoking using structured interviews and the modified Fagerström Tolerance Questionnaire (mFTQ). Data were obtained from 162 subjects (mean = 19.2 yrs). ROC analysis and kappa coefficients revealed that a cutoff score of 3 on the mFTQ showed the strongest agreement with a full diagnosis of cigarette smoking (kappa = 0.68). Clinicians and researchers using the mFTQ in adolescents and young adults should consider a cutoff score of 3 to be indicative of cigarette smoking.     

Evaluating the validities of different DSM-IV-based conceptual constructs of tobacco dependence

Aim To compare the concurrent and predictive validities of two subsets of DSM‐IV criteria for nicotine dependence (tolerance and withdrawal; withdrawal; difficulty controlling use; and use despite harm) to the concurrent and predictive validity of the full DSM‐IV criteria. Design Analysis of baseline and outcome data from three randomized clinical trials of cigarette smoking treatment. Setting San Francisco, California. Participants Two samples of cigarette smokers (n = 810 and 322), differing with regard to baseline characteristics and treatment received, derived from three randomized clinical trials. Measurements DSM‐IV nicotine dependence criteria were measured at baseline with a computerized version of the Diagnostic Interview Schedule for DSM‐IV (DIS‐IV). Additional baseline measures included the Fagerström Test of Nicotine Dependence (FTND), number of cigarettes smoked per day, breath carbon monoxide (CO) level, the Minnesota Nicotine Withdrawal Scale (MNWS), the Michigan Nicotine Reinforcement Questionnaire (M‐NRQ) and the Profile of Mood States (POMS). Seven‐day point‐prevalence abstinence was assessed at week 12. Findings Full DSM‐IV criteria displayed greater concurrent validity than either of the two subsets of criteria. However, DSM‐IV symptoms accounted for only a nominal amount of the variance in baseline smoking‐related characteristics and were unrelated to smoking abstinence at week 12. Cigarettes smoked per day was the only significant predictor of abstinence at week 12. Conclusions Although the findings do not provide a compelling alternative to the full set of DSM‐IV nicotine dependence criteria, its poor psychometric properties and low predictive power limit its clinical and research utility.     

Strength of urges to smoke as a measure of severity of cigarette dependence: comparison with the Fagerström Test for Nicotine Dependence and its components

Aims Measuring the strength of urges to smoke during a normal smoking day among smokers in a culture where smoking is restricted could provide a good measure of the severity of cigarette dependence. An important criterion for a measure of cigarette dependence is how well it predicts failure of attempts to stop smoking. This study compared ratings of Strength of Urges to Smoke (SUTS) with the Fagerström Test of Nicotine Dependence (FTND) and its components, including the Heaviness of Smoking Index (HSI). Design A longitudinal study involving a household survey of a representative sample of adult smokers at baseline and 6‐month follow‐up by postal questionnaire. Setting England. Participants A total of 15 740 smokers aged 16 and over underwent the baseline interview; 2593 were followed‐up 6 months later, of whom 513 reported having made a quit attempt following the baseline survey but at least 1 month prior to the follow‐up. Measurements SUTS, FTND, HSI, cigarettes per day, time to first cigarette, age, social grade and gender were measured at baseline. Quit attempts since the baseline assessment and self‐reported abstinence were measured at 6‐month follow‐up. Findings In logistic regressions, all dependence measures predicted success of subsequent quit attempts, but SUTS had the strongest association (beta for SUTS, FTND and HSI: 0.41: P < 0.001, 0.13: P = 0.005, and 0.19: P = 0.003, respectively). In multiple logistic regressions when SUTS was entered as a predictor of abstinence, together with other dependence measures, it remained as the only predictive dependence measure. Conclusions A simple rating of strength of urges on a normal smoking day appears to be a good predictor of at least short‐term quit success in English smokers and as such may be a useful measure of cigarette addiction.     

A randomized, double-blind, placebo-controlled clinical evaluation of a nicotine sublingual tablet in smoking cessation

Aims. Evaluation of the clinical efficacy and safety of a nicotine 2-mg sublingual tablet in smoking cessation. Design. A randomized, double-blind, placebo-controlled study of smokers using the 2-mg tablet for 3-6 months with follow-up to 12 months. Dosing was established according to baseline nicotine dependence, scored on the Fagerström Tolerance Questionnaire (FTQ): FTQ ≥ 7, two tablets/hour (maximum 40/day); FTQ < 7, one tablet/hour (maximum 20/day). Setting. Smoking cessation programme in a department of oral and maxillofacial surgery. Participants. A total of 247 adult smokers, smoking ≥ 10 cigarettes/day for ≥ 3 years, of whom 123 received active and 124 placebo treatment. The study was powered to detect difference at 6 months. Measurements. Efficacy and safety were evaluated at 6 weeks and 3, 6 and 12 months. Self-reported abstinence was verified by exhaled CO < 10 p.p.m. Findings. Success rates for complete abstinence (no slips after 2 weeks) for active vs. placebo were 50% vs. 29% at 6 weeks, 42% vs. 23% at 3 months, 33% vs. 18% at 6 months and 23% vs. 15% at 12 months ( p < 0.001, 0.001, 0.005 and p = 0.14), respectively. Craving during the first 8 days was significantly reduced among highly dependent smokers on active treatment compared to placebo. Baseline mucosal lesions among abstinent subjects were reduced during the treatment period and at the non-treatment follow-up. Adverse events were mild and tolerable, the most common being irritation and soreness in the mouth and throat. Conclusion. The nicotine sublingual tablet increased the smoking cessation rate compared to placebo, reduced craving in highly dependent smokers and was well tolerated.     

Greater prevalence of proposed DSM-5 nicotine use disorder compared to DSM-IV nicotine dependence in treated adolescents and young adults

Aims Compared to DSM‐IV nicotine dependence, proposed DSM‐5 nicotine use disorder (NUD) would lower the threshold from three to two symptoms, and increase the number of criteria used for diagnosis from seven to 11. The impact of the proposed changes on nicotine disorder prevalence and the concurrent validity of diagnostic criteria were examined. Design Cross‐sectional survey to compare DSM‐IV and proposed DSM‐5 algorithms. Setting and participants Adolescent (n = 179) and young adult (n = 292) past‐year cigarette users recruited from addictions treatment. Measurements Semi‐structured clinical interview to evaluate DSM‐IV nicotine dependence, and 10 of the 11 proposed DSM‐5 NUD criteria; 30‐day time‐line follow‐back; and the Fagerström Test for Nicotine Dependence (FTND). Findings Prevalence of proposed DSM‐5 NUD (two‐symptom threshold) was much higher (adolescents: 68.7%, young adults: 86.0%) than DSM‐IV nicotine dependence (33.0% and 59.6%, respectively), although prevalence of DSM‐5 severe NUD (four‐symptom threshold) was similar to DSM‐IV nicotine dependence. Concurrent validity analyses in both samples indicated consistent support for DSM‐5 severe NUD diagnosis (four symptoms) but not for the moderate NUD (two symptoms) diagnosis, which had modest relations with only FTND score. IRT analyses indicated strong support for the new craving item, but not for the proposed interpersonal problems and hazardous use items. Conclusions The proposed DSM‐5 nicotine use disorder criteria have substantial limitations when applied to adolescents and young adults, and appear to have low concurrent validity.     

Light smoking and dependence symptoms in high-school students

In high-school students, prevalence of smoking is high but few studies analyzed smoking in the student population according to nicotine content of smoked cigarettes and gender. We analyzed the responses to a questionnaire, including the modified Fagerstr?m Tolerance Questionnaire (FTQ), administered to 555 students (382 males, 173 females) of a professional high school in Palermo, Italy, to assess the prevalence in both genders of: (1) smoking "light" and high nicotine (HN) cigarettes; (2) signs of nicotine dependence and (3) respiratory symptoms. Nicotine content of habitually smoked cigarettes was considered as "light" if 0.8 mg; as high if >0.8 mg. Forty-four percent of students smoked, without differences between genders. Two-thirds of the total sample reported "light" cigarette smoking (76.7% of females vs. 62.0% of males, P<0.05). On average, "light" cigarette smoking was associated with lower pack/year and FTQ global score compared to HN smoking. However, when FTQ global score was analyzed by taking into account pack/year, no major difference was found between "light" and HN cigarette smokers. Cough with phlegm and breathlessness were more frequently reported by smoking than non-smoking students, without differences between "light" and HN cigarette smokers. About 50% of smoking students reported having tried to quit, while only 3.4% of students were ex-smokers. "Light" smoking was common in high school students, especially among females. Dependence appeared more influenced by the smoking history than by nicotine content. Respiratory symptoms were similar in "light" and HN cigarette smokers.     

The Modified Reasons for Smoking Scale: factorial structure, gender effects and relationship with nicotine dependence and smoking cessation in French smokers

Aims To assess the validity of the French version of the Modified Reasons for Smoking Scale (MRSS), and to identify which smoking patterns differentiate male and female smokers, which are related to tobacco dependence (as assessed by the Fagerström Test for Nicotine Dependence, FTND), to mood (Beck Depression Inventory II), to affect (Positive and Negative Affect Schedule) and which are predictors of successful quitting. Participants Three hundred and thirty smokers [(mean ± SD) aged 40 ± 9 years, 145 (44%) women, mean FTND score: 6.2 ± 2], candidates for a smoking cessation programme and smoking at least 15 cigarettes/day. Findings Factor analysis of the 21‐item scale gave the optimal fit for a seven‐factor model, which accounted for 62.3% of the total variance. The following factors were identified: ‘addictive smoking’, ‘pleasure from smoking’, ‘tension reduction/relaxation’, ‘social smoking’, ‘stimulation’, ‘habit/automatism’ and ‘handling’. The ‘addictive smoking’ score increased in a dose‐dependent manner with number of cigarettes smoked per day; the ‘habit/automatism’ score was significantly higher, with more than 20 cigarettes per day than with ≤ 20 cigarettes per day. The reasons for smoking were different for males and females: females scored higher on ‘tension reduction/relaxation’, ‘stimulation’ and ‘social smoking’. A high level of dependence (FTND ≥ 6) was associated with significantly higher scores only on ‘addictive smoking’, the association being stronger in females. Time to first cigarette after awakening was associated with higher ‘addictive smoking’ and ‘habit/automatism’ (P < 0.001). In a multivariate logistic regression, failed quitting was predicted by higher habit/automatism score (odds ratio = 1.44, 95% CI = 1.06–1.95, P = 0.02) and greater number of cigarettes smoked per day (odds ratio = 1.03, 95% CI = 1.01–1.06, p = 0.03). Conclusions The questionnaire yielded a coherent factor structure; women smoked more for tension reduction/relaxation, stimulation and for social reasons than men; addictive smoking and automatic smoking behaviour were similar in both sexes and were associated strongly with a high level of nicotine dependence; the ‘habit/automatism’ score predicted failure to quit over and above cigarettes per day.     

A pilot study to investigate the scope for an inpatient smoking cessation programme

Background: Many Australian hospitals have recently introduced smoke‐free policies. Aim: The aim of this study was to determine the smoking habits of hospital inpatients and to investigate the scope for an inpatient smoking cessation programme. Methods: A cross‐sectional survey of adult inpatients of a tertiary‐referral hospital who were smoking just before admission. The questionnaire contained items on general demographics, views on quitting, past quit attempts and validated scales – Fagerström test of nicotine dependence, Biener's contemplation ladder and Velicer's smoking decisional balance. Results: Participants' (n= 125) median age was 53 years and had smoked for 35.0 ± 17.2 years. The majority were male (n= 84; 67.2%) and 45 (36.3%) lived with someone who smoked. Participants self‐reported 4.5 ± 7.3 past attempts to quit. Only 61 (49.6%) said that their health professionals ever discussed options to assist quitting. Forty‐nine (39.2%) reported accessing smoking areas during their hospital stay. Participants scored 4.5 ± 2.5 on the Fagerström test. Forty‐two (33.8%) ranked themselves very high (9 or 10) on the contemplation ladder. The mean difference between the Velicer's subscales –‘cons’ (α= 0.81) and ‘pros’ (α= 0.80) was 3.2 ± 10.6 in favour of quitting. Fifty‐four (43.9%) participants were interested in starting smoking cessation therapy during their hospital stay. Nicotine patches (31; 25.4%) were the preferred dosage forms to assist quitting followed by oral tablets (23; 18.9%) and chewing gum (20; 16.4%). Conclusions: Our findings could guide the design of inpatient smoking cessation interventions. Greater efforts from health professionals are essential for informing people about smoking cessation options, promoting their uptake, potentially resulting in higher quit rates.     

Life-time prevalence and risk factors of tobacco/nicotine dependence in male ever-smokers in Japan

Aims. To estimate the life-time prevalence rate of tobacco/nicotine dependence and demographic variables and smoking habits associated with the disorder in male ever-smokers in Japan. Design. A cross-sectional community-based interview study. Setting. Takayama city, Gifu Prefecture, Japan. Participants. A total of 170 male ever-smokers aged 35 years or older selected randomly from a community in Japan were interviewed. The response rate was 85%. Measurements. The WHO Composite International Diagnostic Interview (CIDI) was used to make diagnoses of tobacco/nicotine dependence according to ICD-10, DSM-III-R and DSM-IV. The Fagerstrom Tolerance Questionnaire (FTQ) was also administered and those who had a FTQ score of 7 or above were identified. Findings. The life-time prevalence rates of tobacco/nicotine dependence in male ever-smokers were 42%, 26% and 32% according to ICD-10, DSM-III-R and DSM-IV criteria, respectively; 19% had a FTQ score of 7 or above. The ICD-10 diagnosis was significantly and negatively associated with quitting smoking ( p 0.05). Multiple logistic regression analyses indicated that number of cigarettes per day when they smoked the most was significantly associated with higher life-time risks of the disorder according to DSM-III-R, DSM-IV and Fagerstrom's classification ( p 0.05). The length of cigarette smoked was associated with higher life-time risks of ICD-10 and DSM-IV diagnoses, and years of smoking were associated with higher life-time risks of ICD-10, DSM-III-R and DSM-IV diagnoses ( p 0.05). Younger birth cohorts had higher cumulative rates of the disorder according to DSM-IV ( p for trend 0.05). Conclusions. Life-time prevalence rates of tobacco/nicotine dependence according to ICD-10, DSM-III-R and DSM-IV in male ever-smokers in Japan were within the range of rates reported in previous US studies; rates of FTQ score of 7 or above were lower. Fagerstrom scores and diagnostic criteria appear to reflect different aspects of dependence.     

The Safety and Efficacy of Varenicline in Cocaine Using Smokers Maintained on Methadone: A Pilot Study

In this double‐blind, placebo‐controlled trial, we compared varenicline (2 mg) to placebo for treatment for cocaine and tobacco dependence in 31 methadone‐maintained subjects. Subjects received weekly counseling during the 12‐week study participation. Our results indicate that varenicline is safe to give to this subject population, as there were no adverse events related to medication during this study. Varenicline was no more effective than placebo for abstinence from cocaine. Treatment with varenicline was associated with a reduced number of cigarettes smoked per day, even though subjects received only a brief education for smoking cessation. The self‐report reduction in smoking was corroborated by CO levels and the Fagerström Test of Nicotine Dependence. However, self‐ratings of positive mood on the Positive Affect Negative Affect Schedule did significantly decrease in the varenicline group as compared to the placebo group, although this appears to be due to randomization differences related to lifetime depression diagnosis. These preliminary findings may point to potential therapeutic value of varenicline for smoking cessation in cocaine users maintained on methadone. (Am J Addict 2010;19:401–408)     

Areca nut dependence among chewers in a South Indian community who do not also use tobacco

Aims Previously reported research suggests a dependence syndrome for areca nut use, though well‐designed studies are virtually non‐existent. The goal of this study was to examine evidence of areca dependence in a sample of areca‐only (i.e. no tobacco) chewers using modified measurement scales. Design A purposive sample of chewers, identified via local informants and advertisements, was surveyed from January to March of 2005. Setting Six villages in Dakshina Kannada District, Karnataka State, India. Participants Fifty‐nine daily areca chewers who do not also currently use any form of tobacco. Measurements Questionnaires included modified versions of the Fagerström Tolerance Questionnaire, Cigarette Dependence Scale (CDS‐5) and the Smokeless Tobacco Dependence Scale (STDS). Additional questions assessed demographic characteristics and patterns of use. Findings Approximately half of respondents reported 1–3 chews/day (mean = 1.9; SD = 0.98). The average number of chewing episodes/day was 4.4 (SD = 3.4) and the average number of nuts/day was 1.2 (SD = 1.1). Users’ typical chew lasts up to 20 minutes and includes spitting out the juices and rinsing the mouth with water. Overall, the levels of reported dependence symptoms were quite low, but approximately 44% of chewers endorsed at least one of the following items: continued use despite illness or mouth wounds, difficulty refraining from chewing in forbidden places, or craving during periods of abstinence. Approximately 15.4% of chewers reported at least one intentional quit attempt and a subset had summary scores indicative of dependence (13.6% had scores >16 on the CDS‐5 and 5.3% had scores >11 on the STDS). Dependence scores were positively correlated with frequency of chews/day. Conclusions The symptoms of dependence observed in a subset of areca‐only chewers warrant further investigation. Next steps should include well‐controlled laboratory evaluation of dependence features.     

A smoking cessation intervention for the methadone-maintained

Aim To test, in combination with the nicotine patch, the incremental efficacy of a maximal, tailored behavioral treatment over a minimal treatment for smoking cessation. Design Randomized clinical trial with 6‐month follow‐up. Setting Five methadone maintenance treatment centers in Rhode Island. Participants Three hundred and eighty‐three methadone‐maintained smokers. Intervention Participants were assigned randomly to nicotine patch (8–12 weeks) plus either (1) a baseline tailored brief motivational intervention, a quit date behavioral skills counseling session and a relapse prevention follow‐up session (Max) or (2) brief advice using the National Cancer Institute's 4 As model (Min). An intent‐to‐treat analysis with those lost to follow‐up assumed to smoke was used. Measurements Carbon monoxide (CO)‐confirmed 7‐day point smoking cessation prevalence at 3 and 6 months, and self‐reported numbers of cigarettes smoked per day. Findings Participants had a mean age of 40 years, were 53% male, 78% Caucasian, smoked 26.7 (± 12.2) cigarettes/day and had a mean methadone dose of 95.5 mg. At 3 months, 317 (83%) were reinterviewed; at 6 months, 312 (82%) were reinterviewed. The intent‐to‐treat, 7‐day point prevalence estimate of cessation was 5.2% in the Max group and 4.7% in the Min group (P = 0.81) at 6 months. In logistic models with treatment condition, age, gender, race, Fagerström Test for Nicotine Dependence and cigarettes per day as covariates, males were more likely to be abstinent at 3 months (OR 4.67; P = 0.003) and 6 months (OR 4.01; P = 0.015). Conclusion A tailored behavioral intervention did not increase quit rates over patch and minimal treatment. Smoking cessation rates in methadone‐maintained smokers are low, with men having greater success.     

Nicotine dependence is associated with compulsive alcohol craving

Aims To investigate a possible association of nicotine dependence and alcohol craving. Design A prospective cross‐sectional study on patients diagnosed with alcohol dependence. Setting Detoxification unit of a regional psychiatric hospital. Participants A total of 127 smoking male patients were included in the study at admission for detoxification from alcohol. Measurements The Fagerström Test for Nicotine Dependence (FTND) was used to assess the severity of nicotine dependence while the Obsessive Compulsive Craving Scale (OCDS) was used to measure alcohol craving. The OCDS was assessed at admission and after 7 days of withdrawal treatment, distinguishing the total score, the obsessive and the compulsive subscale. Findings Spearman’s correlation revealed a significant association between the extent of alcohol craving and the FTND score (day 0, n = 127: OCDS total score r = 0.238, P = 0.007; OCDS compulsive score r = 0.280, P = 0.001; day 7; n = 94: OCDS total score r = 0.212, P = 0.040; OCDS compulsive score r = 0.225, P = 0.029). Conclusions The severity of nicotine dependence is associated with higher craving in alcohol‐dependent patients. These results point towards shared pathophysiological mechanisms in alcohol craving and nicotine addiction.     

Evaluation of patients followed up in a cigarette cessation clinic

Objectives: The aim of this study was to evaluate the demographic characteristics and factors determining success in a smoking cessation clinic in smokers who completed a 1‐year follow up. Method: A total of 349 patients were assessed retrospectively. Results: There were 238 men (mean age: 41 ± 13.5 years) and 111 women (mean age: 37 ± 11.9 years) (t‐test P = 0.004). The average age at which they began to smoke, number of years of smoking and the number of cigarettes/day were 17.5 ± 5.2 years (median 17), 22.1 ± 13.3 years, 23.5 ± 12.0, respectively. Cigarette smoking was mostly observed in university graduates (56.8%) and a moderate negative correlation existed between education status and smoking duration (r = ?0.27, P = 0.000). Patients with a Fagerström Tolerance Questionnaire score of ≥6 and those exposed to cigarette smoke in childhood tended to commence and become commited smokers later in life (χ² = 4.915, P = 0.027). In all, 151 patients (43.26%) were successful in quitting (χ² = 36.4, P = 0.000). Of these, 87 (24.93%) used medication such as nicotine patches (13.5%), bupropion (7.2%), nicotine patches + bupropion (4.3%) and 64 (18.33%) refused medication, but came for professional support. Conclusion: Increased education level, behavioural therapy and intensive motivational support, follow‐up visits and phone calls all appear to play important roles in smoking cessation. Families also play a major role.     

Genes, time to first cigarette and nicotine dependence in a general population sample of young adults

Aim To examine variation in nicotine dependence scores and covariation between different dependence symptoms. Design A 12‐year, nationally representative, probability‐based survey of adolescent health‐related behaviors and their outcomes during young adulthood in the United States. The genetic contribution to nicotine dependence was evaluated in the sibling‐pairs sample of the US National Longitudinal Study of Adolescent Health. Measurements Nicotine dependence (ND) was assessed using the Fagerström Test for Nicotine Dependence (FTND) and Heaviness of Smoking Index (HSI) in 1154 young adults, between the ages of 18 and 25 years, who were from twin, full sibling and half‐sibling pairs. Findings Dependence in this sample was common and varied in degree. Total HSI scores evidenced moderate to large heritable contributions (61%, 95% confidence interval (CI): 0.46–0.72), as did the quantity of cigarettes smoked (52%, 95% CI: 0.39–0.63) and urgency to smoke (55%, 95% CI: 0.38–0.68). Multivariate modeling identified a highly heritable underlying factor (76%, 95% CI: 0.56–0.91) that influenced the covariation of dependence symptoms and loaded most heavily on how soon after waking a smoker uses his or her first cigarette. The quantity of cigarettes smoked per day also evidenced residual genetic influences that were not common to other dependence‐related behaviors. Conclusions In this sample of young adults from the general population, both genes and individual‐specific environments are important etiological factors in ND. The urgency to smoke, as measured by the time to first cigarette, may be the most informative measure on the FTND for genetic studies of nicotine dependence.     

Properties of the Cigarette Dependence Scale and the Fagerstr?m Test of Nicotine Dependence in a representative sample of smokers in Norway

AIMS: To compare the properties of four measures of dependence to nicotine/tobacco, the 12-item Cigarette Dependence Scale (CDS-12), the six-item Fagerstr?m Test of Nicotine Dependence (FTND) and two shorter versions of the same measures. METHODS: In a cross-sectional telephone survey of smokers in a representative general population sample in Norway, we compared the measures. We assessed (i) internal consistency reliability with Cronbach's alpha; (ii) compared item scores; and (iii) tested the validity of the questionnaires. Test-retest reliability was assessed in a smaller convenience sample. RESULTS: Among 1265 respondents (64%), 290 (23%) were daily smokers and included in further analysis. Their mean age was 42 years [standard deviation (SD) 15] and 46% were female. They smoked on average 13 cigarettes per day (SD 6). Internal consistency reliability was 0.61 for the FTND (n = 267) and 0.81 for the CDS-12 (n = 266). Score distributions suggested a floor effect for the FTND. Test-retest reliability was 0.90 for the FTND and 0.97 for the CDS-12 (n = 31). The correlation between the scale scores and a question about the maximum willingness to pay for a cigarette after not smoking all day was 0.36 (P < 0.001) for the FTND (n = 262) and 0.45 (P < 0.001) for the CDS-12 (n = 263). There was little difference in the associations of the two scales or their abbreviated versions with external variables. CONCLUSIONS: Telephone administration was acceptable for both questionnaires, and we have established population reference values for the four scales. The questionnaires were associated with each other and showed similar properties. The findings support the construct validity of the scales.     

Elevation of biochemical markers for myocardial damage prior to hospital admission in patients with acute chest pain or other symptoms raising suspicion of acute coronary syndrome

Abstract. Svensson L, Axelsson C, Nordlander R, Herlitz J (South Hospital, Stockholm; and Sahlgrenska University Hospital, Göteborg; Sweden). Elevation of biochemical markers for myocardial damage prior to hospital admission in patients with acute chest pain or other symptoms raising suspicion of acute coronary syndrome. J Intern Med 2003; 253: 311–319. Objectives. To evaluate the occurrence of elevation of serum biochemical markers for myocardial damage in the prehospital setting amongst patients who called for an ambulance due to a suspected acute coronary syndrome (ACS). Design. Prospective observational study. Subjects. All the patients who called for an ambulance due to suspected ACS. Setting. South Hospital's catchment area in Stockholm and in the Municipality of Göteborg, Sweden between January and November in the year 2000, were included. Interventions. On arrival of the ambulance crew, a blood sample was drawn for bedside analysis of serum myoglobin, creatine kinase MB and troponin I. A 12‐lead electrocardiogram (ECG) was simultaneously recorded. Main outcome measures. Elevation of biochemical markers prior to hospital admission. Results. In all, 511 patients participated on 538 occasions. Elevation of any biochemical marker was observed in 11% of all patients. The corresponding figure for patients developing myocardial infarction was 21%; for patients with myocardial ischaemia 8%; for patients with a possible myocardial ischaemia 4% and for patients with other diagnoses 5%. Amongst those who had a final diagnosis of acute myocardial infarction (AMI), 47% had ST‐elevation on initial ECG and 57% had either ST‐elevation or elevation of any biochemical marker. Conclusion. Bedside analysis of biochemical markers in serum is already feasible prior to hospital admission amongst patients with a suspected ACS. About 20% of patients with AMI have elevated biochemical markers at that stage. When found this data might increase the possibility of diagnosing an AMI very early in the course. However, false positives were found and whether this strategy will improve the triage of these patients in the prehospital setting remains to be proven.     

Treatment of opioid-dependent pregnant women with buprenorphine

Aims: To assess the maternal and fetal acceptability of buprenorphine and neonatal abstinence syndrome (NAS) in children born to buprenorphine-maintained mothers. Design and setting: Open-label, flexible dosing, inpatient induction with outpatient maintenance, conducted at the University of Vienna within the existing pregnancy and drug addiction program. Participants: Fifteen opioid-dependent pregnant women. Intervention. Sublingual buprenorphine tablets (1-10 mg/day). Measurements: Mothers: withdrawal symptoms (Wang Scale), nicotine dependence (Fagerstrom Scale: FTQ) and urinalysis. Neonates: birth outcome and NAS (Finnegan Scale). Findings: All subjects were opioid-, nicotine- and cannabis-dependent. Buprenorphine was well tolerated during induction (Wang Score \< = 4) and illicit opioid use was negligible (91% opioid-negative). All maternal, fetal and neonatal safety laboratory measures were within normal limits or not of clinical significance. Mean birth outcome measures including gestational age at delivery (39.6 ± 1.5 weeks), Apgar scores (1 min = 8.9; 5 min = 9.9; and 10 min = 10), birth weight (3049 ± 346 g), length (49.8 ± 1.9 cm) and head circumference (34.1 ± 1.8 cm) were within normal limits. The NAS was absent, mild (without treatment) and moderate (with treatment) in eight, four and three neonates, respectively. The mean duration of NAS was 1.1 days. Conclusions: Buprenorphine appears to be well accepted by mother and fetus, and associated with a low incidence of NAS. Further investigation of buprenorphine as a maintenance agent for opioid-dependent pregnant women is needed.