Postpartum return to smoking: who is at risk and when

PURPOSE: Despite high rates of spontaneous and assisted smoking cessation during pregnancy, postpartum maintenance is disappointingly low. Predictors of return to smoking remain unclear, thus limiting the development of interventions that could protect the health of women and their children. This study followed women who had participated in a prenatal smoking cessation intervention trial and successfully stopped smoking to address two aims: (1) describe the probability of relapse in confirmed quitters during the first 6 months after the birth, and (2) identify factors that increase relapse. DESIGN: Prospective design during pregnancy and retrospective report at 6 months postpartum used survival analysis with return to smoking as the dependent variable and the Cox proportional hazards regression technique. MEASURES: Questionnaires were used at the first prenatal visit and telephone interviews at the 26th week of pregnancy and 6 months postpartum. Nonsmoking after the 20th week was measured by urine cotinine tests (m = 3); nonsmoking postpartum was measured by retrospective self-report. SETTING: The setting was an HMO-based group practice in Los Angeles. SUBJECTS: Subjects were white, black, and Hispanic women (n = 127) available for follow-up. RESULTS: The proportion of the sample classified as relapsers at 6 months postpartum was 62.9%. The final model identified the following risk factors for smoking: taking puffs in late pregnancy and having friends who smoke at the first prenatal visit, less confidence in mid-pregnancy that they could maintain nonsmoking postpartum, and a partner who smokes postpartum. CONCLUSIONS: Intervention should begin in late pregnancy, and smoking networks, including partner smoking, should be addressed.     

Long-term enteral access in aspiration-prone patients

Aspiration pneumonia is a serious complication of enteral feeding. Many critically ill patients are particularly at risk for aspiration. Few studies have rigorously compared various access devices. Risk factors for aspiration and studies examining aspiration associated with enteral feeding devices are reviewed. We recommend a surgical jejunostomy for all patients at high risk for aspiration who require more than 3 weeks of enteral nutrition support.     

The vasa vasorum and angioplasty

Interruption of flow in the vasa vasorum may lead to medial necrosis and aneurysm formation. The purpose of this study was to determine whether angioplasty produces significant alterations in the morphology or blood flow of the vasa vasorum of the dilated artery. The morphology of the canine vasa vasorum was studied before and after angioplasty; in a separate experiment vessel wall blood flow (VWBF) in canine carotid arteries was measured after angioplasty to determine whether physiologic regulation of the blood flow was disrupted by arterial dilation. No morphologic changes could be demonstrated in the vasa vasorum of the dilated artery; however, VWBF was increased by 1194 +/- 215% (mean +/- standard error, p less than 0.01) between 90 and 120 minutes after angioplasty. VWBF in the adjacent nondilated arterial segment was also increased (720 +/- 177% between 10-30 minutes, p less than 0.01) but returned toward normal after 60 minutes. Adenosine caused a "paradoxical" decrease in VWBF (p less than 0.05) of the dilated arterial segment while causing increased VWBF (p less than 0.05) in the thoracic aorta. Angioplasty appears to produce persistent hyperemia in the dilated arterial wall. A paradoxical response to adenosine suggests that vasa vasorum in the dilated arterial segment are maximally vasodilated. This may be due to mechanical disruption of vasomotor tone or to release of vasoactive substances.     

Women who stop smoking spontaneously prior to prenatal care and predictors of relapse before delivery

This study explores the experience of pregnant women who quit smoking prior to initiating prenatal care. These "spontaneous quitters" comprised 41% of a socioeconomically and ethnically diverse population of prepregnancy smokers enrolled in a health maintenance organization. Compared to women who were smoking at the start of prenatal care, spontaneous quitters had been lighter smokers, were less likely to have another smoker in their household, indicated a stronger belief in the harmful effect of maternal smoking, had a history of fewer miscarriages, and entered prenatal care earlier. Biochemical validation of smoking status over the course of pregnancy found that 21% of the spontaneous quitters relapsed prior to delivery. Characteristics reported at the first prenatal visit that were associated with maintenance included having achieved cessation for a longer period of time without smoking even a puff, higher self-efficacy for maintenance, stronger belief in the harmful effect of maternal smoking, primigravida, and greater frequency of nausea. The identification of spontaneous quitters and selected intervention for those at greatest risk of relapse is recommended for inclusion in routine prenatal care.     

Acute hyperesthesia after spinal trauma.

Four cases of acute hyperesthesia after spinal trauma are presented. An attempt is made to characterize the natural history of this syndrome. In the three cases with truncal sensory aberration, hyperesthetic zones developed only anteriorly. All four patients demonstrated spontaneous relief of pain within 2 weeks after injury. The pain was modified by transcutaneous stimulation in one case and by l-dopa in another case. It is suggested that the "lesion" responsible for the hyperesthetic response is partial damage to dorsal root fibers at a point medial to the dorsal root ganglion.     

Disposition and metabolic fate of atomoxetine hydrochloride: pharmacokinetics, metabolism, and excretion in the Fischer 344 rat and beagle dog.

These studies were designed to characterize the disposition and metabolism of atomoxetine hydrochloride [(-)-N-methyl-gamma-(2-methylphenoxy)benzenepropanamine hydrochloride; formerly know as tomoxetine hydrochloride] in Fischer 344 rats and beagle dogs. Atomoxetine was well absorbed from the gastrointestinal tract and cleared primarily by metabolism with the majority of its metabolites being excreted into the urine, 66% of the total dose in the rat and 48% in the dog. Fecal excretion, 32% of the total dose in the rat and 42% in the dog, appears to be due to biliary elimination and not due to unabsorbed dose. Nearly the entire dose was excreted within 24 h in both species. In the rat, low oral bioavailability was observed (F = 4%) compared with the high oral bioavailability in dog (F = 74%). These differences appear to be almost purely mediated by the efficient first-pass hepatic clearance of atomoxetine in rat. The biotransformation of atomoxetine was similar in the rat and dog, undergoing aromatic ring hydroxylation, benzylic oxidation (rat only), and N-demethylation. The primary oxidative metabolite of atomoxetine was 4-hydroxyatomoxetine, which was subsequently conjugated forming O-glucuronide and O-sulfate (dog only) metabolites. Although subtle differences were observed in the excretion and biotransformation of atomoxetine in rats and dogs, the primary difference observed between these species was the extent of first-pass metabolism and the degree of systemic exposure to atomoxetine and its metabolites.