Changes in smoking associated with an acute health event: Theoretical and practical implications

Background: Experiencing a serious adverse behavior-related consequence may motivate behavior change.Purpose: To examine how a sentinel health event is associated with changes in smoking.Methods: We used a prospective cohort design. Adult emergency department (ED) patients provided demographic data, a smoking history, ratings of quit intentions, and endorsement of self-identified smoking-related health problems. A chart review collected data on acuity, ED disposition, and medical diagnoses. Smoking was reassessed 1 month postvisit. Hierarchical regression analyses were conducted to predict (a) intention to quit, (b) any quit attempt of 24 hr or more, and (3) 7-day abstinence.Results: Of 717 smokers enrolled, 189 (26%) intended to quit within the next month. Of the 253 participants reached 1 month postvisit, 126 (50%) reported they had attempted to quit, with 44 (19%) reporting 7-day abstinence. After controlling for other predictors, several event-related variables, such as having a smoking-related ED visit and being admitted to the hospital, were strong predictors of outcomes.Conclusion: Compared to community-based estimates, many more smokers in our sample attempted to quit and achieved 7-day abstinence. This was especially true among smokers who attributed their ED visit to a smoking-related health problem and who were admitted to the hospital. We discuss the implications for tobacco intervention design in medical settings. This study was supported by a NIH/NID K23 Research Career Award (EDB) Grant (DA-16698-01) and a UMDNJ Foundation Seed Grant.     

D-Fenfluramine-Induced Prolactin Responses in Postwithdrawal Alcoholics and Controls

Serum prolactin response to the serotonin agonist d -fenfluramine were measured in 19 DSM-111-R male alcoholics, 2.5 or more weeks postalcohol withdrawal. Prolactin responses were compared with nine healthy nonalcoholic male controls. After an overnight fast, each subject received 30 mg of d -fenfluramine orally, and serial samples of serum prolactin were taken over a 4-hr period. d -fenfluramine caused a significantly attenuated peak δ-prolactin response in the alcoholics relative to the controls ( p = 0.05). A repeated-measures ANOVA of δ-prolactin yielded a significant within-subjects effect of time ( p < 0.05), a within-subjects effect of group that reached significance ( p = 0.05), and a nonsignificant group by time interaction. The δ-prolactin value at time points 60 and 240 min postadministration of the probe was significantly attenuated in the alcoholic group, with p < 0.05. There was also some evidence for a diminished serotonergic response in those alcoholics with a negative family history. The δ-prolactin response did not correlate with subjects'age, duration of alcohol use, duration of abstinence from alcohol, severity of alcohol dependence, or age of onset. Results imply a relative sub-sensitivity of the serotonin system in postwithdrawal alcoholics, and this may be primarily of the 5-HT₂ receptor.     

Evidence for Reduced Dopamine D2 Receptor Sensitivity in Postwithdrawal Alcoholics

Dopamine D2 receptor sensitivity was assessed in the postwithdrawal period in alcoholics. Growth hormone (GH) responses to dopamine D2 agonist bromocriptine were measured in eight DSM-III-R alcohol-dependent subjects who were 2 weeks or more postalcohol withdrawal. Their responses were compared with eight nonalcoholic controls. After an overnight fast, each subject received 1.25 mg of bromocriptine orally, and serial samples of GH were taken over a 3-hr period. There was a significantly blunted delta GH response (mean ± SE) in the alcoholic group, 2.3 mU/liter (±1.4) relative to controls, 7.7 mU/liter (±1.2) ( t = 2.96, df = 14, p = 0.01). There was a significantly blunted peak GH response (mean ± SE) in the alcoholic group, 5.36 mU/liter (±2.1) relative to controls, 9.04 mU/liter (±5.0). This difference also reached statistical significance ( t = 2.32, df = 14, p = 0.035). A repeated-measures ANOVA yielded a significant within-subjects effect of time [ F (4,54) = 4.08, p = 0.0057], a significant with-in-subjects effect of group [ F (1,14) = 5.6, p = 0.0329], and an almost significant group x time interaction [ F (4,54) = 2.45, p = 0.056]. This result implies a relative dopamine D2 receptor subsensitivity in alcoholics in the postwithdrawal period.     

The New York Policy on Smoking in Addiction Treatment: Findings After 1 Year

Objectives. We assessed changes in smoking prevalence and other measures associated with the July 2008 New York Office of Alcoholism and Substance Abuse Services tobacco policy, which required that all publicly funded addiction treatment programs implement smoke-free grounds, have “no evidence” of smoking among staff, and make tobacco dependence treatment available for all clients.Methods. In a random sample of 10 programs, staff and clients were surveyed before the policy and 1 year later. Measures included tobacco-related knowledge, attitudes, and practices used by counselors and received by clients.Results. Client smoking decreased from 69.4% to 62.8% (P = .044). However, response to the policy differed by program type. Outpatient programs showed no significant changes on any of the staff and client survey measures. In methadone programs, staff use of tobacco-related practices increased (P < .01), client attitudes toward tobacco treatment grew more positive (P < .05), and clients received more tobacco-related services (P < .05). Residential clients were more likely to report having quit smoking after policy implementation (odds ratio = 4.7; 95% confidence interval = 1.53, 14.19), but they reported less favorable attitudes toward tobacco treatment (P < .001) and received fewer tobacco-related services from their program (P < .001) or their counselor (P < .001).Conclusions. If supported by additional research, the New York policy may offer a model that addiction treatment systems can use to address smoking in a population where it has been prevalent and intractable. Additional intervention or policy supports may be needed in residential programs, which face greater challenges to implementing tobacco-free grounds.Persons with substance abuse and dependence smoke at higher rates1–3 and smoke more heavily4,5 than do persons in the general population. They may be more physically dependent on nicotine,6 less successful in quit attempts,7 and may die from smoking-related causes more frequently than from drug- or alcohol-related causes.8 For 30 years, research has noted the high rate of smoking among persons with other addictive disorders9–12 and several authors have argued that addiction treatment programs should address tobacco.13–16 Although this is reflected in clinical guidelines17 and policy statements,18,19 several studies have found that tobacco dependence is often not addressed in addiction treatment.20–22Treatment of tobacco dependence in addiction settings may be accelerating.23 Veteran Affairs Medical Centers implemented smoking cessation practice guidelines for all patients, including those in addiction clinics,24 and New Jersey required tobacco-free grounds for residential drug treatment.25 Following the New Jersey initiative, all programs provided more tobacco-related treatment, half adopted smoke-free grounds, and 41% of smokers did not smoke during their residential stay.25In 2008, the New York Office of Alcoholism and Substance Abuse Services (OASAS) required all state-certified addiction treatment programs to implement tobacco-free grounds, to have no-evidence (of smoking) policies for staff, and to provide tobacco dependence intervention for clients on request.26 Tobacco-free grounds means no smoking anywhere on program grounds, including outdoor areas. No evidence of smoking means staff do not come to work smelling of tobacco smoke, or have cigarettes or other tobacco products or paraphernalia in view in the work area. Tobacco dependence intervention means smoking cessation counseling and nicotine replacement therapy (NRT). Tobacco dependence services are free to clients, with costs bundled into program contracts with the state. The policy affects 1550 programs, 20 000 staff, and 250 000 annual admissions. To support the policy, the state committed $4 million to deliver staff training and $4 million to provide NRT to treatment programs. The OASAS Web site listed volunteer mentors to help programs implement the policy, and offered online tobacco dependence training for counselors. Program licensing visits included review and grading on policy compliance. We report findings from staff and client surveys conducted in a random sample of programs before and after the policy was implemented.     

Molecular characterization of lymphatic endothelial cells

The lymphatic microvasculature is uniquely adapted for the continuous removal of interstitial fluid and proteins and is an important entry point for leukocytes and tumor cells. Specialized functions of lymphatics suggest differences in the molecular composition of the lymphatic and blood vascular endothelium. However, the extent to which the two cell types differ is still unclear, and few molecules that are truly specific to lymphatic endothelial cells have been identified to date. We have isolated primary lymphatic and blood microvascular endothelial cells from human skin by immunoselection with the lymphatic marker LYVE-1 and demonstrate that the two cell lineages express distinct sets of vascular markers and respond differently to growth factors and extracellular matrix. Comparative microarray analysis of gene-expression profiles revealed a number of unique molecular properties that distinguish lymphatic and blood vascular endothelium. The molecular profile of lymphatic endothelium seems to reflect characteristic functional and structural features of the lymphatic capillaries. Classification of the differentially expressed genes into functional groups revealed particularly high levels of genes implicated in protein sorting and trafficking, indicating a more active role of lymphatic endothelium in uptake and transport of molecules than previously anticipated. The identification of a large number of genes selectively expressed by lymphatic endothelium should facilitate the discovery of hitherto unknown lymphatic vessel markers and provide a basis for the analysis of the molecular mechanisms accounting for the characteristic functions of lymphatic capillaries.     

SEM evidence that one ameloblast secretes one keyhole-shaped enamel rod in monkey teeth

Primate enamel is subdivided into inner enamel, having Hunter–Schreger bands, and outer enamel with all rods parallel to each other. Outer inter-rod enamel may surround each rod, lie between rows of rods, or be absent, as in the 'keyhole pattern', which is composed entirely of rods. One theory on the formation of the 'keyhole' pattern overlays the hexagonal cross-sectional shape of four or more ameloblasts over the keyhole shape of the enamel rod. This ignores the likelihood that Tomes processes have a different shape from the cell body, and also ignores the observation that paths of enamel rods sometimes diverge. Scanning electron microscopy (SEM) revealed the keyhole shape of the forming face of monkey enamel. These forming rods were arranged in stepped rows with the head regions in each row separated by the tails of the preceding row. Consequently, each forming face of a rod was surrounded on three sides by previously formed enamel. The apical surface of the Tomes process was shaped exactly like the forming rod face, permitting direct apposition of one rod and one Tomes process. The conclusion was that, in the monkey, each rod of the keyhole enamel configuration is produced by one ameloblast.     

Overexpression of Thrombospondin-1 Decreases Angiogenesis and Inhibits the Growth of Human Cutaneous Squamous Cell Carcinomas

The function of the endogenous angiogenesis inhibitor thrombospondin-1 (TSP-1) in epithelial tumor development has remained controversial. We studied the in vitro growth characteristics and the in vivo tumor xenograft growth of the human squamous cell carcinoma cell lines A431 and SCC-13, stably transfected to overexpress human TSP-1. Overexpression of TSP-1 inhibited tumor growth of A431 xenotransplants, and completely abolished tumor formation by SCC-13 cells. TSP-1 overexpressing A431 tumors were characterized by extensive areas of necrosis and by decreased tumor vessel number and size. The effects of TSP-1 on tumor cell growth were indirect since tumor cell proliferation rates in vivo and in vitro, anchorage-dependent and -independent growth in vitro, and susceptibility to induction of apoptosis by serum withdrawal were unchanged in TSP-1 overexpressing tumor cells. However, TSP-1 overexpression up-regulated the TSP-1 receptor CD36, leading to enhanced adhesion of A431 cells to TSP-1. These findings establish TSP-1 as a potent inhibitor of angiogenesis and tumor growth in carcinomas of the skin.     

Psycho-physiological response to pain among individuals with comorbid pain and opioid use disorder: Implications for patients with prolonged abstinence

Background: Individuals with comorbid opioid addiction and pain (COAP) relapse 3–5 times more often than patients with opioid use disorder (OUD) but without pain. However, psychophysiological responses to pain among a COAP population are unknown.

Objectives: We hypothesized that those on Medications for Opioid Use Disorder (MOUD) with chronic pain, relative to opioid-naïve chronic pain individuals, would show greater psycho-physiological pain reactivity and slower recovery when exposed to acute pain.

Methods: Four groups with chronic pain were recruited (N = 120; 60% Female): 1) MOUD-methadone; 2) MOUD-buprenorphine; 3) history of completed MOUD with prolonged opioid abstinence (PA; M_abstinence = 121 weeks; SD = 23.3); and 4) opioid-naïve. We assessed heart rate (HR), galvanic skin conductance (GSC), peripheral temperature, and frontalis electromyography (EMG) during a cold pain task.

Results: MOUD subjects had delayed HR reactivity to pain compared to those not on MOUD (PA & opioid-naïve; F(3,119) = 2.87, p < .04). The PA group showed a normal HR reactivity pattern, but had higher HR compared to the opioid-naïve group. The GSC group x time analysis showed the PA group had greater baseline levels and pain reactivity than the other groups (F(3,119) = 3.84, p < .02). The opioid-naïve group had lower reactivity on peripheral temperature compared to other groups (F(3,119) = 9.69, p < .001).

Conclusion: Greater psychophysiological reactivity to pain was experienced by co-morbid OUD/chronic pain subjects who had been opioid abstinent for an extended period, possibly due to the lack of a buffering effect of opioid agonists. These subjects may develop coping skills to tolerate pain distress, thereby avoiding relapse in response to pain triggers. Understanding how pain creates more intense psychophysiological responses among COAP patients may lead to better treatments.     

Posttraumatic Stress Disorder and Substance Use Disorder Comorbidity Among Individuals With Physical Disabilities:Findings From the National Comorbidity Survey Replication

Co‐occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) affects multiple domains of functioning and presents complex challenges to recovery. Using data from the National Comorbidity Study Replication, a national epidemiological study of mental disorders (weighted N = 4,883), the current study sought to determine the prevalence of PTSD and SUD, the symptom presentation of these disorders, and help‐seeking behaviors in relation to PTSD and SUD among individuals with physical disabilities (weighted n = 491; nondisabled weighted n = 4,392). Results indicated that individuals with physical disabilities exhibited higher rates of PTSD, SUD, and comorbid PTSD/SUD than nondisabled individuals. For example, they were 2.6 times more likely to meet criteria for lifetime PTSD, 1.5 times more likely for lifetime SUD, and 3.6 times more likely for lifetime PTSD/SUD compared to their nondisabled peers. Additionally, individuals with physical disabilities endorsed more recent/severe PTSD symptoms and more lifetime trauma events than nondisabled individuals with an average of 5 different trauma events compared to 3 in the nondisabled group. No significant pattern of differences was noted for SUD symptom presentation, or for receipt of lifetime or past‐year PTSD or SUD treatment. Implications of these findings and recommendations for future research are discussed.     

Screening for Oesophageal Adenocarcinoma: An Evaluation of a Surveillance Program for Columnar Metaplasia of the Oesophagus

Background: Screening patients with columnar metaplasia of the oesophagus for adenocarcinoma is controversial owing to the low cancer incidence and diverging opinions as to whether screening improves the prognosis of these patients. Our aim was to evaluate a screening program for adenocarcinoma in patients with columnar metaplasia in the oesophagus, with focus on cancer incidence and costs. Methods: One hundred and ninety-nine patients with columnar metaplasia of the oesophagus were identified through an endoscopy database, and the original patient records were reviewed. Results: The patients were followed up for 797 years in total and during this time were subjected to 1071 upper gastrointestinal endoscopies. During the screening period 5 patients presented with adenocarcinoma; thus the cancer-incidence was 1 in 159 patient-years. The cost of detecting one cancer was 294,950 SEK (US$ 37,815). However, only four of the five patients were suitable for oesophagectomy, and of these, one patient turned out to have an advanced cancer. All patients developing cancer had columnar metaplasia of the oesophagus longer than 3 cm and specialized columnar epithelium (intestinal metaplasia/Barrett oesophagus). Conclusions: Low cancer incidence, high costs, and the doubtful prognosis for the patients with identified cancer question the benefits and cost-effectiveness of cancer screening among patients with columnar metaplasia in the oesophagus.