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Smoking is usually initiated in adolescence, and is the leading preventable cause of death in the United States. Little is known, however, about the links between smoking and neurobiological function in adolescent smokers. This study aimed to probe prefrontal cortical function in late adolescent smokers, using a response inhibition task, and to assess possible relationships between inhibition-related brain activity, clinical features of smoking behavior, and exposure to cigarette smoking. Participants in this study were otherwise healthy late adolescent smokers (15-21 years of age; n=25), who reported daily smoking for at least the 6 months before testing, and age- and education-matched nonsmokers (16-21 years of age; n=25), who each reported smoking fewer than five cigarettes in their lifetimes. The subjects performed the Stop-signal Task, while undergoing functional magnetic resonance imaging. There were no significant group differences in prefrontal cortical activity during response inhibition, but the Heaviness of Smoking Index, a measure of smoking behavior and dependence, was negatively related to neural function in cortical regions of the smokers. These findings suggest that smoking can modulate prefrontal cortical function. Given the late development of the prefrontal cortex, which continues through adolescence, it is possible that smoking may influence the trajectory of brain development during this critical developmental period.

Background: A two-year quality improvement campaign at a teaching hospital was launched to improve the identification and accurate documentation of pressure ulcers (PUs) after the Centers for Medicare & Medicaid Services (CMS) changed reimbursement regarding hospital-acquired PUs., Method: The campaign consisted of (1) reference materials, (2) new documentation templates, (3) staff education, and (4) hospitalwide mattress replacement., Results: The campaign significantly increased the proportion of PUs completely documented by nurses from 27% to 55% following mattress replacement and resident education (odds ratio [OR] 3.68; p = .001; 95% confidence interval [CI]:1.68-8.08). A similar improvement was observed for physician documentation, increasing from 12% to 36% following the same interventions; however, this change was not statistically significant (OR 2.11; p = .12; 95% CI:0.82-5.39). These improvements were short-lived because of the implementation of electronic medical records (EMRs) for nursing notes. Although the percentage of PUs completely documented by nurses decreased following EMR implementation, it increased in the following months to above the precampaign baseline as nurses adapted to the new documentation system. However, after EMR implementation, complete PU documentation by physicians decreased to a nadir of 0% and did not recover., Conclusions: A multicomponent campaign to improve the quality of PU documentation by both physicians and nurses can yield positive gains. However, these improvements were short-lived because of EMR implementation, which acutely worsened documentation of PUs. This emphasizes the importance of frequent and repeated interventions to sustain quality improvement successes.

Purpose: When comparing chronic obstructive lung disease (COPD) interventions in database research, it is important to adjust for severity. Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines grade severity according to lung function. Most databases lack data on lung function. Previous database research has approximated COPD severity using demographics and healthcare utilization. This study aims to derive an algorithm for COPD severity using baseline data from a large respiratory trial (UPLIFT)., Methods: Partial proportional odds logit models were developed for probabilities of being in GOLD stages II, III and IV. Concordance between predicted and observed stage was assessed using kappa-statistics. Models were estimated in a random selection of 2/3 of patients and validated in the remainder. The analysis was repeated in a subsample with a balanced distribution across severity stages. Univariate associations of COPD severity with the covariates were tested as well., Results: More severe COPD was associated with being male and younger, having quit smoking, lower BMI, osteoporosis, hospitalizations, using certain medications, and oxygen. After adjusting for these variables, co-morbidities, previous healthcare resource use (eg, emergency room, hospitalizations) and inhaled corticosteroids, xanthines, or mucolytics were no longer independently associated with COPD severity, although they were in univariate tests. The concordance was poor (kappa = 0.151) and only slightly better in the balanced sample (kappa = 0.215)., Conclusion: COPD severity cannot be reliably predicted from demographics and healthcare use. This limitation should be considered when interpreting findings from database studies, and additional research should explore other methods to account for COPD severity.

Introduction: Adherence to long-acting bronchodilator therapy for management of chronic obstructive pulmonary disease (COPD) is a critical clinical and cost issue. Low adherence is associated with relatively higher exacerbation rates and illness burden., Purpose: To compare adherence between patients with COPD initiating therapy on tiotropium or fluticasone/salmeterol and examine the association between adherence and respiratory-related costs., Patients and Methods: This retrospective claims data analysis evaluated patients initiating tiotropium or combination fluticasone/salmeterol from December 1, 2004 to December 31, 2005. Patients had ≥1 COPD diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] 491.xx, 492.x, 496) and were observed during 6-month pre-index and variable (12-18-month) post-index periods. Outcomes were adherence to and discontinuation of therapy, and respiratory-related inpatient, medical, and total health care costs. Adherence was medication possession ratio ≥0.80. Discontinuation, adherence, and costs were analyzed with Cox proportional hazards regression, logistic regression, and generalized linear model regressions, respectively. Regressions controlled for demographic, sociodemographic, and health status factors., Results: The study population comprised 1561 tiotropium and 2976 fluticasone/salmeterol patients. In unadjusted comparisons: 19.5% and 8.5% of tiotropium and fluticasone/salmeterol patients, respectively, were adherent (P < 0.001); tiotropium patients versus fluticasone/salmeterol patients had higher mean respiratory-related pharmacy costs (US$1080 versus US$974, P = 0.002) and health care costs (US$3751 versus US$2932, P = 0.031). Regression analysis showed tiotropium patients were 31.6% less likely to discontinue therapy (95% confidence interval [CI]: 0.64-0.73) and had 2.25 times higher odds of adherence (CI: 1.85-2.73) versus fluticasone/salmeterol patients. The associations between index therapy and costs were not significant. Adherence versus nonadherence was associated with: 46.9% higher health care costs (CI: 1.13-1.91); 37.1% lower medical costs (CI: 0.43-0.91); and 53.4% lower inpatient costs (CI: 0.30-0.72)., Conclusion: Patients with COPD initiating long-acting bronchodilator therapy were more likely to be adherent to tiotropium than to fluticasone/salmeterol. Adherence to either tiotropium or to fluticasone/salmeterol was associated with lower respiratory-related medical and inpatient costs, and with higher respiratory-related total health care costs.

Objective: To evaluate chronic obstructive pulmonary disease (COPD)-related expenditure and hospitalisation in COPD patients treated with tiotropium versus alternative long-acting bronchodilators (LABDs)., Methods: Data were from the Thomson Reuters MarketScan Research Databases. COPD patients ≥ 35 years with at least one LABD claim between July 1, 2004 and June 30, 2006 were classified into five cohorts based on index LABD: monotherapy with tiotropium, salmeterol/fluticasone propionate, formoterol fumarate, or salmeterol or combination therapy. Demographic and clinical characteristics were evaluated for a 6-month pre-period and COPD-related utilisation and total costs were evaluated for a 12-month follow-up period. LABD relationship to COPD-related costs and hospitalisations were estimated by multivariate generalised linear modelling (GLM) and multivariate logistic regression, respectively., Results: Of 52,274 patients, 53% (n = 27,457) were male, 71% (n = 37,271) were ≥ 65 years, and three LABD cohorts accounted for over 90% of the sample [53% (n = 27,654) salmeterol/fluticasone propionate, 23% (n = 11,762) tiotropium, and 15% (n = 7755) combination therapy]. Patients treated with salmeterol/fluticasone propionate (p < 0.001), formoterol fumarate (p = 0.032), salmeterol (p = 0.004), or with combination therapy (p < 0.001) had higher COPD-related costs and a greater risk of inpatient admission (p < 0.01 for all) versus tiotropium., Limitations: These data are based on administrative claims and as such do not include clinical information or information on risk factors, like smoking status, that are relevant to this population., Conclusions: Patients treated with tiotropim had lower COPD-related expenditures and risk of hospitalisation than patients treated with other LABDs.

Background: Vulnerabilities in the medication manage ment process can lead to serious patient harm. In intensive care units (ICUs), nurses represent the last line of defense against medication errors. Proactive risk assessment (PRA) offers methods for determining how processes can break down and how people involved in such processes can contribute to or recover from a breakdown. Such methods can also be used to identify ICU nurses' contribution to the quality and safety of medication management., Methods: Observation and interview data of ICU nurses work were used to develop a rich description of the nursing medication management process. A PRA method was conducted in a cardiovascular ICU to identify and evaluate failure modes in the nursing medication management process. The contributing factors to the failure modes and the recovery processes used by nurses were also characterized., Results: A total of 54 failure modes were identified across the seven steps of the medication management process. For the 5 most critical failure modes, nurses listed 21 contributing factors and 21 recovery processes. Ways were identified to redesign the medication management process, one of which consists of dealing with work system factors that contribute to the most critical failure modes., Conclusions: From a data-analysis viewpoint, this PRA method permits one to address a variety of objectives. Different scoring methods can be used to focus on either frequency or criticality of failure modes; one may also focus on a specific step of the process under study. Efforts in eliminating or mitigating contributing factors would help reduce the criticality of the failure modes in terms of their likelihood and impact on patients and/or nurses. Developing systems to support the recovery processes used by nurses may be another approach to process redesign.

Background: Previous research using the National Health and Nutrition Examination Surveys (NHANES) data documented a significant downward trend in secondhand smoke (SHS) exposure between 1988 and 2002. The objective of this study was to assess whether the downward trend in exposure continued from 2001 through 2006., Methods: We analyzed data from the 2001-2006 NHANES to estimate exposure of nonsmokers to SHS. Geometric means of serum cotinine levels for all nonsmokers were computed., Results: Overall serum cotinine levels (95% Confidence Intervals) in 2001-2002, 2003-2004, and 2005-2006 were 0.06 ng/mL (0.05-0.07), 0.07 ng/mL (0.06-0.09), and 0.05 ng/mL (0.05-0.06), respectively. Subgroup analysis by age, gender, and race/ethnicity groups showed similar trends in cotinine levels. Children, males, and non-Hispanic Blacks had higher cotinine levels than adults, females, and non-Hispanic Whites and Mexican Americans, respectively. Insignificant P values from the Wald test indicate that serum cotinine levels did not differ over time., Conclusions: The long-term trend of declining exposure to SHS among nonsmokers appears to have leveled off. However, disparities noted in previous research persist today, with the young, non-Hispanic Blacks, and males experiencing higher levels of exposure.

Background: While population-based breast screening for women over the age of 50 years is a generally accepted and proven health strategy, the role of breast screening specifically among women at high risk of familial breast cancer has remained controversial. Indeed, there are very few services specifically offering a breast-screening program for women at high risk of familial breast cancer., Methods: In 1999 a Familial Breast Cancer Screening Clinic (FBCSC) was established at the North Brisbane BreastScreen Queensland Service to provide a regular multimodality screening program utilizing clinical breast examination, breast ultrasound, and mammography for women at higher risk of hereditary breast cancer and with entry into the program commencing from the age of 30 years., Results: Since its inception, a total of 2440 women have participated in the FBCSC. A total 7051 breast-screening examinations have been performed on these participants, with 53 breast cancers being diagnosed, including 8 in situ ductal carcinomas, 38 invasive ductal carcinomas, and 7 invasive lobular carcinomas. The mean size of the cancers was 16 mm (range = 1-45 mm), and of the 45 invasive cancers, 60% were less than or equal to 15 mm in size. The overall axillary node positive rate was 24.5% (13/53). The invasive cancer detection rate for first-round screening was 8.3 cancers per 1000 women screened, with 5.2 cancers per 1000 women detected on subsequent round screening., Conclusions: The results from this service demonstrate that multimodality screening for women at high risk of familial breast cancer and including women of younger age is effective and appropriate, with very acceptable cancer detection rates and pathological cancer characteristics being observed consistent with early-stage detection. The colocated siting of this service within a BreastScreen Queensland facility has proven to be efficient and cost effective.

Background: In July 2006, a 16-year-old patient came to the hospital to deliver her baby. During the process of her care, an infusion intended exclusively for the epidural route was connected to the patient's peripheral intravenous line and infused by pump. The patient experienced cardiovascular collapse. A cesarean section resulted in the delivery of a healthy infant, but the medical team was unable to resuscitate the mother. The media attention surrounding the error accelerated through the national provider and safety community when the nurse was charged with a criminal offense. These events set in motion intense internal and external scrutiny of the hospital's medication and safety procedures., Root Cause Analysis (rca): To further understanding about latent systems gaps and process failure modes, an independent RCA of the event was conducted in June 2007. An external consultant team conducted a one-week evaluation of the medication use system and the organization's current environment, systems and processes, staffing patterns, leadership, and culture to help shape the recommended improvements. For each of the four proximate causes of the event, performance-shaping factors were identified. Although the hospital's organizational learning was painful, this event offered an opportunity for increasing organizational competency and capacity for designing and implementing patient safety. Structures and processes, including safety nets and fail-safe mechanisms, were implemented to promote safer behavioral choices for providers., Actions Taken: The hospital took a number of clinical steps to improve the safety of medication administration, including removing the barriers to scanning medication bar codes, implementing consistent scanning-compliance tracking, and providing teamwork training for all nursing and physician staff practicing in the birth suites.

Objectives: This study aimed to estimate the cost-effectiveness of an extended (12+12 weeks) course of varenicline using the (Benefits of Smoking Cessation on Outcomes) BENESCO smoking cessation model., Methods: Data on the efficacy of 12+12 weeks varenicline therapy in aiding smoking cessation were analyzed in conjunction with the efficacy data for 12 weeks of varenicline, bupropion, and placebo previously included in the BENESCO model, by using a mixed treatment comparison. This analysis provided updated efficacy estimates for all the interventions, and these were used to update the model to estimate the relative cost-effectiveness of all smoking cessation interventions considered, now including 12+12 weeks of varenicline., Results: The updated 1-year abstinence estimates derived from the mixed treatment comparison were, for 12+12 weeks of varenicline, 12 weeks of varenicline, 12 weeks of bupropion, and 12 weeks of placebo, respectively: 27.7%, 22.9%, 15.9%, and 9.3%. The average cost of the course of 12+12 weeks of varenicline was estimated at $603.89, based on a 12-week course followed by a further 12 weeks for successful quitters. Over all subjects' lifetimes, 12+12 weeks of varenicline is less costly and more effective than (dominates) all other strategies compared in the updated BENESCO model, with the exception of 12 weeks of varenicline. In this comparison, 12+12 weeks of varenicline is a very cost-effective alternative to the 12-week course, with an incremental cost of less than $1000 per quality-adjusted life year (QALY) gained., Conclusions: A total of 12 weeks of varenicline followed by a further 12-week course for successful quitters is a highly cost-effective alternative compared with currently available smoking cessation options.

Background: Tiotropium has been shown to reduce exacerbations and improve quality of life for patients with chronic obstructive pulmonary disease (COPD), a lung disease characterized by a persistent and progressive airflow limitation., Objectives: To present a systematic literature review of the cost effectiveness of treatment with tiotropium compared with other currently used treatments for COPD., Methods: A systematic search was performed via PubMed, the Cochrane database, and EMBASE from 2002 to 2009. Methods and results by study design and by country were compared., Results: Seventeen studies were included in the review. Study designs were characterized as follows: modeling based on clinical trial data, and empirical analysis based on either clinical trial or observational data. Comparing monotherapy regimens (12 studies), all study designs found that treatment with tiotropium was associated with lower costs for hospitalisation and other non-drug services. Total costs, including the costs of maintenance drugs, were lower with tiotropium in some, but not all, of the studies. Tiotropium was shown to be cost effective based on commonly accepted benchmark values. Limitations of the review included the wide variety of outcome measures used in different studies, the limited number of observational database studies for monotherapy, and limited data for combination therapy regimens., Conclusions: The main conclusions of the economic evaluations derived from clinical trial data at the time of product approval and from later observational data reflecting clinical use are similar: use of tiotropium monotherapy is associated with lower hospital and other non-drug costs and better health outcomes and is either cost saving or cost effective compared with other maintenance monotherapies.

Background: COPD is a common progressive and debilitating medical condition. Mental health difficulties, such as anxiety and depression, have been reported in 25-50% of all patients with COPD. Interventions that reduce anxiety and depressive symptoms may affect COPD outcomes. Little data exists on the effect of managing these psychological difficulties in this group., Method: We studied the effects of a respiratory nurse-led cognitive behavioural therapy programme in 10 patients with COPD, assessing goal achievement, Hospital Anxiety and Depression Scale scores and medical admission rates., Results: We used CBT in 10 patients with COPD across a range of severities. All 10 patients completed the CBT programme, with an average of four sessions (range 2-13). The mean score in the anxiety domain fell from 10.6 (range 6-15) before CBT to 3.8 after the intervention (range 1-7; p < 0.001). Similar improvements were seen in the depression domain, with a mean score before CBT of 10.9 (range 2-17), falling to a mean score after treatment of 5.2 (range 3-12; p < 0.001). A statistically significant reduction in the number of admissions was seen, with a mean of 1.1 admissions (total 11) before CBT to a mean of 0.2 admissions (total 2), p = 0.02., Conclusion: In this non-randomised study, a programme of individualised CBT in patients with COPD resulted in marked improvements in psychosocial impairment and a significant reduction in service use.

In this article, we discuss Shared Governance as the foundation of our nursing professional practice model. Through the use of case examples and reflections from our management team, we demonstrate how this accountability-based practice model promotes excellence through developing, connecting, and engaging people, clarifying and communicating goals, using data to make decisions, and even shaping our organizational response to a critical incident. We close with a look to our future as our hospital embraces whole-system shared decision making.

Aim: To investigate whether levels of psychosocial impairment and psychological distress at diagnosis in those with vasovagal syncope (VVS) predict subsequent response to conventional treatment., Methods and Results: This is a prospective, observational new patient cohort study, which includes consecutive patients with head-up tilt-confirmed VVS (September 2004-March 2006). Subjects completed the Hospital Anxiety and Depression Scale, State and trait anxiety inventory, and an Adapted Syncope Functional Status Questionnaire at diagnosis and at 3 months. A total of 108 participants [mean (SD) age 52 (21) years, 70.4% were female] completed baseline assessments. Response status was ascertained for 103 individuals; 70 were responders and 33 non-responders. Eighty-three of 103 participants (81%) completed the follow-up questionnaires. At follow-up, compared with responders, non-responders reported higher levels of Impairment (P = 0.001), negative cognitions (P = 0.01), and depression scores (P = 0.006). At diagnosis those who ultimately did not respond to treatment reported significantly higher levels of Impairment (P < 0.001) and negative cognitions (P = 0.03). Those who did not respond to treatment were significantly more depressed (P = 0.001) with higher Trait anxiety scores (P = 0.007). Multivariate analysis confirmed increased impairment predicted poor response status (z = 9.82, P = 0.002) with participants being 3% more likely to be a non-responder with each 1% increase in self-reported level of impairment., Conclusion: Higher levels of psychosocial impairment reliably predict non-response to treatment, suggesting that psychological factors have an important role in VVS. Screening individuals at diagnosis may enable identification of those at risk of non-response and delivery of targeted psychological interventions to reduce the impact of VVS and its sequelae.

Objectives: To estimate the budgetary impact of varenicline in the United Kingdom (UK) in the first 5 years after its introduction to the smoking-cessation aid market, from the National Health Service (NHS) pharmacy perspective., Methods: The economic impact of varenicline to the national health budget is estimated in a population of current, former, and new smokers. The analyses are based on data from a variety of secondary sources including national health data, clinical trials, and meta-analyses of smoking-cessation aids. The number of patients seeking aid and the treatment patterns are estimated using 2004 national health surveys, costs for medications from national prescription drug pricing tariffs, and efficacy of the various smoking-cessation aids from clinical trial data. Sensitivity analyses were performed to evaluate the impact of varying the patient parameters and costs., Results: Model estimates suggest that the budgetary impact of varenicline would be 3.6 million pound in the second year after its introduction, with a 95% confidence interval of 0.63 to 7.2 million pound, and a resultant increase of 0.05% to the total NHS pharmacy budget. The model predicts that the addition of varenicline to the market would result in an additional 162,000 successful smoking-cessation attempts and 103,000 fewer smokers over 5 years, when compared to the world without varenicline., Conclusion: The introduction of varenicline is likely to result in greater numbers of individuals succeeding at smoking cessation, with an approximately 3.6 million pound (0.05%) increase in the NHS pharmacy budget.

Objective: To examine the relationship between two measures that can be used to examine quality life among pediatric burn survivors., Design: Prospective, correlational study., Setting: Acute and rehabilitation pediatric burn care facility., Participants: Eighty young adult survivors of pediatric burns, who were 18-28 years of age, with burns of 30% or greater, and were at least 2 years after burn., Interventions: Not applicable., Main Outcome Measures: The SF-36 and the Quality of Life Questionnaire (QLQ) were used to assess participant's self-reported general health and long-term adjustment., Results: Significant correlations (p< or =0.001) were found between the total quality of life score of the QLQ and the mental component scale of the SF-36. However, no significant correlations were found between the total quality of life score of the QLQ and the SF-36 physical component scale., Conclusions: Approximately 100,000 children are treated for burns annually, with a high percentage surviving, creating a challenge for health care professionals who need to prepare burn survivors with their psychosocial and physical well-being as adults. This study found that the SF-36 and QLQ are measuring somewhat different aspects of psychosocial and physical adjustment. It is recommended that both tools could be useful to the burn practitioner in assessing quality of life.

Background: The variability in the clinical or pathological presentation of transmissible spongiform encephalopathies (TSEs) in sheep, such as scrapie and bovine spongiform encephalopathy (BSE), has been attributed to prion protein genotype, strain, breed, clinical duration, dose, route and type of inoculum and the age at infection. The study aimed to describe the clinical signs in sheep infected with the BSE agent throughout its clinical course to determine whether the clinical signs were as variable as described for classical scrapie in sheep. The clinical signs were compared to BSE-negative sheep to assess if disease-specific clinical markers exist., Results: Forty-seven (34%) of 139 sheep, which comprised 123 challenged sheep and 16 undosed controls, were positive for BSE. Affected sheep belonged to five different breeds and three different genotypes (ARQ/ARQ, VRQ/VRQ and AHQ/AHQ). None of the controls or BSE exposed sheep with ARR alleles were positive. Pruritus was present in 41 (87%) BSE positive sheep; the remaining six were judged to be pre-clinically infected. Testing of the response to scratching along the dorsum of a sheep proved to be a good indicator of clinical disease with a test sensitivity of 85% and specificity of 98% and usually coincided with weight loss. Clinical signs that were displayed significantly earlier in BSE positive cases compared to negative cases were behavioural changes, pruritic behaviour, a positive scratch test, alopecia, skin lesions, teeth grinding, tremor, ataxia, loss of weight and loss of body condition. The frequency and severity of each specific clinical sign usually increased with the progression of disease over a period of 16-20 weeks., Conclusion: Our results suggest that BSE in sheep presents with relatively uniform clinical signs, with pruritus of increased severity and abnormalities in behaviour or movement as the disease progressed. Based on the studied sheep, these clinical features appear to be independent of breed, affected genotype, dose, route of inoculation and whether BSE was passed into sheep from cattle or from other sheep, suggesting that the clinical phenotype of BSE is influenced by the TSE strain more than by other factors. The clinical phenotype of BSE in the genotypes and breed studied was indistinguishable from that described for classical scrapie cases.

Aims: To examine the effect of varenicline, a selective alpha4-beta2 nicotinic acetylcholine receptor (nAChR) partial agonist, on craving and withdrawal symptoms in smokers making a quit attempt and the rewarding effects of smoking during a lapse after the target quit date (TQD)., Materials and Methods: Pooled data were analysed from two identical double-blind, randomised trials comparing varenicline 1 mg BID, bupropion (sustained release) 150 mg BID and placebo using measures of craving and withdrawal in the first week after the TQD (in abstinent [n = 612] and non-abstinent participants [n = 1,155]) and of the rewarding effects of the first cigarette smoked in non-abstinent participants., Results: In abstinent and non-abstinent participants combined, varenicline reduced craving more than bupropion (p < 0.01) and placebo (p < .001); the effect did not differ by whether or not subjects were abstinent; bupropion reduced craving more than placebo (p < 0.001). Among abstinent participants, both varenicline and bupropion reduced negative affect more than those receiving placebo (p < 0.005). Neither active drug reduced restlessness, insomnia or appetite vs placebo. Varenicline reduced ratings of satisfaction and psychological reward after the first cigarette smoked after the TQD vs bupropion (p < 0.005) and placebo (p < 0.001); bupropion also reduced these more than placebo (p < 0.05)., Conclusions: Varenicline significantly reduces craving and the rewarding effects of smoking after the TQD to a greater extent than bupropion, which may contribute to varenicline's greater efficacy for smoking cessation. Varenicline's lack of effect in reducing insomnia, restlessness and increased appetite in this analysis suggests that receptors other than the alpha4-beta2 nAChR subtype may be implicated in these withdrawal symptoms.

Background: Of 1 346 700 total deaths each year in the US, an estimated 440 100 are smoking related, making it the leading preventable cause of premature death in the US. Despite the health and economic benefits of smoking cessation being well documented, reimbursement coverage for smoking cessation therapies is generally limited in the US and elsewhere., Objectives: To evaluate the cost effectiveness of varenicline, an alpha 4 beta 2 nicotinic acetylcholine receptor partial agonist, recently approved to aid smoking cessation., Methods: A Markov model, the Benefits of Smoking Cessation on Outcomes (BENESCO) model, was developed to simulate the lifetime direct costs and consequences of a hypothetical cohort of US adult smokers who make a one-time attempt to quit smoking. The smoking cessation strategies compared were varenicline, bupropion, nicotine replacement therapy and unaided quitting. The model used the hazard ratios from the Cancer Prevention Study (CPS)-II study for the mortality of smoking-related diseases as a proxy to calculate the relative risks of the incidence and prevalence of these diseases, following previously developed methodology. The costs (year 2005 values) and utilities for the included smoking-related diseases (lung cancer, chronic obstructive lung disease [COPD], coronary heart disease [CHD], stroke and asthma exacerbations), and the efficacies of the smoking cessation strategies, were sourced from the published literature. Costs and benefits were discounted at 3% pa. Probabilistic and univariate sensitivity analyses were conducted., Results: Varenicline was found to dominate all other smoking cessation strategies that were investigated for both the 20-year and lifetime timeframe. Furthermore, if 25% of the current population of US smokers made a one-time attempt to quit using varenicline compared with unaided cessation, almost 144 000 smoking-related deaths and over 261 000 cases of asthma exacerbations, COPD, CHD, stroke and lung cancer could be avoided compared with an unaided smoking cessation strategy., Conclusions: Varenicline, a recently approved therapy for smoking cessation, is likely to be a cost-effective alternative compared with currently available options.

Objective: To report physical and psychologic outcomes for young adult survivors of pediatric burns., Design: Prospective, correlational study., Setting: Acute and rehabilitation pediatric burn care facility., Participants: Eighty-three young adult survivors of pediatric burns, who were 18 to 28 years of age, with total body surface area (TBSA) burns of 30% or greater, and were at least 2 years postburn., Interventions: Not applicable., Main Outcome Measures: Physical outcomes were assessed by muscle strength tests, grip and pinch measurements, mobility levels, and self-care (activities of daily living) skills. Psychologic outcomes included behavioral problems, personality disorder, and incidence of psychiatric illness. An individually administered Structured Clinical Interview for Diagnosis, based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, for psychiatric diagnosis, was used to assess mental health, and behavioral problems were assessed with the Young Adult Self-Report. Participants reported educational achievement, employment status, state of transition from family of origin (home) to independent living, and pair bonding. The Short-Form 36-Item Health Survey and the Quality of Life Questionnaire were used to assess each participant's self-reported general health and quality of life., Results: The majority of subjects had physical and psychologic outcomes that were within the normal range when compared with age-mates who had not experienced burns. The areas that were most likely to be impaired involved peripheral strength (wrist and grip). These deficits affected some self-care skills and correlated with TBSA. Standardized diagnostic interviews showed that greater than 50% of subjects qualified for a psychiatric diagnosis, with anxiety disorders as the most frequently occurring diagnosis. There were few significant correlations of the physical measurements or self-care skills with the burn size, psychologic problems, or social outcomes, and none appeared to be clinically important., Conclusions: Most of the people in this sample were functioning physically and psychosocially within normal limits as they reached adulthood. Although they appeared to function well as measured by standardized assessments, there were indications of private suffering that suggested they may not be functioning at an optimal level. The findings suggest that rehabilitation professionals could improve outcomes by including programs to develop overall muscle strength in severely burned children and by addressing concerns related to anxiety and other symptoms of psychologic distress.

We conducted an investigation of the 10-item Brief Questionnaire of Smoking Urges (QSU-Brief) to confirm its hypothesized two-factor structure and to assess the validity and reliability of its total score and these factors. Data were obtained from a 7-week clinical trial on smoking cessation (N=626). The hypothesized two-factor structure of the QSU-Brief was supported by fit indexes (>0.90) from a confirmatory factor analysis at each of three relevant time points (baseline, Week 2, Week 4). Corresponding values of Cronbach's alpha were acceptable (>0.75) on the Total Craving Score and on Factors 1 and 2. This research supports the validity and reliability of the instrument and confirms the proposed two-dimensional structure of self-reported craving as measured by the QSU-Brief.

Fatigue impairs the quality of life of primary biliary cirrhosis (PBC) patients. In this study, we explored the psychological factors and coping strategies in fatigued PBC patients. Patients participated in a semi-structured interview examining thoughts regarding the impact of fatigue and coping strategies. All completed the disease-specific quality-of-life tool, PBC-40, the Penn State Worry Questionnaire (PSWQ) (degree of habitual worry) and Hospital Anxiety and Depression Scale (HADS) (current anxiety and depression). PBC patients were allocated into high (>38, n=10) and low-fatigue (<38, n=14) groups. No differences were seen between high-fatigue and low-fatigue groups regarding age, marital status, employment status, PBC stage, years with diagnosis and years experiencing fatigue. High-fatigue participants were significantly more anxious (P=0.008), more depressed (P<0.001), and more likely to worry (<0.05). High-fatigue participants had more frequent thoughts about the impact of fatigue (P<0.005) and lower self-efficacy scores (P<0.001). In conclusion, PBC patients can experience profound distress associated with fatigue. PBC patients with high levels of fatigue seem to be more vulnerable to emotional distress, more likely to perceive that their quality of life has been negatively affected and are less confident to engage in everyday activities compared with those with low levels of fatigue.

We examined the validity and reliability of the modified Cigarette Evaluation Questionnaire (mCEQ) that assesses the degree to which subjects experience the reinforcing effects of smoking. Data came from three phase II clinical trials (n=626, n=627, n=312) on varenicline for smoking cessation. Comparative fit indexes and non-normed fit indexes from a confirmatory factor analysis exceeded 0.90. Cronbach's alpha for internal consistency reliability exceeded 0.70 for the Smoking Satisfaction domain and the Psychological Reward domain but was less than 0.70 for the Aversion domain; test-retest reliability generally exceeded 0.70 on the three multi-item domains and two single items. The validity and, in general, the reliability of the postulated multidimensional framework of the mCEQ are confirmed and supported by the analyses of three independent studies, with multi-item domains on Smoking Satisfaction (satisfying, taste good, enjoy smoking), Psychological Reward (calm down, more awake, less irritable, help concentrate, reduce hunger), and Aversion (dizziness, nauseous), as well as the single-item assessment on Enjoyment of Respiratory Tract Sensations and on Craving Reduction.

Phosducin-like protein (PhLP) is a widely expressed binding partner of the G protein betagamma subunit complex (Gbetagamma) that has been recently shown to catalyze the formation of the Gbetagamma dimer from its nascent polypeptides. Phosphorylation of PhLP at one or more of three consecutive serines (Ser-18, Ser-19, and Ser-20) is necessary for Gbetagamma dimer formation and is believed to be mediated by the protein kinase CK2. Moreover, several lines of evidence suggest that the cytosolic chaperonin complex (CCT) may work in concert with PhLP in the Gbetagamma-assembly process. The results reported here delineate a mechanism for Gbetagamma assembly in which a stable ternary complex is formed between PhLP, the nascent Gbeta subunit, and CCT that does not include Ggamma. PhLP phosphorylation permits the release of a PhLP x Gbeta intermediate from CCT, allowing Ggamma to associate with Gbeta in this intermediate complex. Subsequent interaction of Gbetagamma with membranes releases PhLP for another round of assembly.

Aims: Studies have established a link between vasovagal syncope (VVS) and anxiety, depression, and functional impairment. This study examines the prevalence of psychological problems in patients with VVS and whether non-responders are psychologically different from those whose symptoms respond to conservative treatment., Methods and Results: Subjects with tilt-confirmed VVS completed the hospital anxiety and depression scale (HADS) (measures current levels of anxiety and depression) and the syncope functional status questionnaire (SFSQ) (syncope-specific quality-of-life measure) and participated in a semi-structured interview to ascertain potential triggers, thought content, and coping strategies. In this study, 41 subjects participated. There was no difference in gender and age duration of symptoms between responders (n=21) and non-responders (n=20). Non-responders were significantly more anxious (P=0.003) and depressed (P=0.003) and had a higher level of state (P=0.008) and trait (P=0.004) anxiety than responders. Non-responders reported more fear/worry (P=0.02), a significantly higher degree of impairment owing to syncope (P=0.01), and a greater number of perceived triggers (P=0.039); on average, participants reported eight negative thoughts about the consequences of VVS, with particular emphasis on threats of physical harm or death. Non-responders had higher levels of avoidance/protection coping and rumination., Conclusion: This study has confirmed that patients with VVS have a significant degree of psychological distress, which is worthy of consideration in its own right, out with management purely aimed at reducing syncopal or pre-syncopal symptoms. Further, this distress may actually influence the natural history of what is a chronic relapsing condition and may in fact be more relevant to the patient than the number of syncopal episodes that they are experiencing.

Functional and anatomical relationships among primary afferent fibers, blood vessels, and cancers are poorly understood. However, recent evidence suggests that physical and biochemical interactions between these peripheral components are important to both tumor biology and cancer-associated pain. To determine the role of these peripheral components in a mouse model of cancer pain, we quantified the change in nerve and blood vessel density within a fibrosarcoma tumor mass using stereological analysis of serial confocal optical sections of immunostained hind paw. To this end we introduced the Discoma coral-derived red fluorescent protein (DsRed2) into the NCTC 2472 fibrosarcoma line using the Sleeping Beauty transposon methodology, thus providing a unique opportunity to visualize tumor-nerve-vessel associations in context with behavioral assessment of tumor-associated hyperalgesia. Tumors from hyperalgesic mice are more densely innervated with calcitonin gene related peptide (CGRP)-immunoreactive nerve fibers and less densely vascularized than tumors from non-hyperalgesic mice. As hyperalgesia increased from Day 5 to 12 post-implantation, the density of protein gene product 9.5 (PGP9.5)-immunoreactive nerves and CD31-immunoreactive blood vessels in tumors decreased, whereas CGRP-immunoreactive nerve density remained unchanged. Importantly, intra-tumor injection of a CGRP1 receptor antagonist (CGRP 8-37) partially blocked the tumor-associated mechanical hyperalgesia, indicating that local production of CGRP may contribute to tumor-induced nociception through a receptor-mediated process. The results describe for the first time the interaction among sensory nerves, blood vessels and tumor cells in otherwise healthy tissue, and our assessment supports the hypothesis that direct tumor cell-axon communication may underlie, at least in part, the occurrence of cancer pain.

Objectives: The version of the Minnesota Nicotine Withdrawal Scale (MNWS) under consideration consists of nine items. No psychometric analyses of this version have been published. The objectives of this investigation were to perform a factor analysis and to further assess the psychometric properties of the MNWS., Research Design and Methods: Data came from three Phase II clinical trials on varenicline, developed for smoking cessation, in a sample of smokers. Exploratory factor analysis was used to examine the structure of the MNWS in the first completed study (n = 626) over various time periods. The postulated factor structure was then tested in a set of confirmatory analyses conducted on two subsequent studies (n = 627, n = 312). The proposed structure was further evaluated through construct validity and reliability analyses., Main Outcome Measures: The nine items of the MNWS included the following: urge to smoke (craving); depressed mood; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; increased appetite; difficulty going to sleep; and difficulty staying asleep. Each item was rated by a subject on an ordinal scale from 0 (not at all) to 4 (extreme)., Results: Scree plots and rotated factor patterns from the exploratory factor analyses revealed two multi-item domains--Negative Affect with four items and Insomnia with two items--and three individual items (Craving, Restlessness, Increased Appetite). Confirmatory factor analyses supported the structure with fit indexes exceeding 0.90. The multidimensional framework of the MNWS correlated as expected with health status, depicted an expected course of withdrawal symptoms over time, predicted the sensitivity of withdrawal symptoms on subsequent cessation, and produced internal reliability estimates above 0.70., Conclusions: Evidence is obtained to support the validity and reliability of the multidimensional structure of the nine-item MNWS. The data suggest that the MNWS has individual constructs on Negative Affect (depressed mood; irritability, frustration, or anger; anxiety; difficulty concentrating), Insomnia (difficulty going to sleep; difficulty staying asleep), Craving, Restlessness, and Increased Appetite. As such, analyzing each construct separately would strengthen the analysis of the popular MNWS.

Aim: This paper presents a critical review of research literature on the impact of international placements on the lives and practice of nurses., Background: Health care institutions are progressively more aware of the need to respond to diverse patient populations and cultivate leaders to enrich the nursing profession, both locally and globally. One response has been to establish international exchange programmes for nursing students to give them experience of different cultures and health care systems., Methods: A search of the literature from 1980 to 2003 using electronic databases was undertaken using the databases CINAHL, ERIC, British Nursing Index, Web of Science, the BIDS Social Science Citation Index and Medline. The keywords used were 'international exchange experience', 'international studies', 'international education', 'international placement(s)', 'exchange programme(s)', combined with 'nurses/nursing', combined with 'evaluation', 'practice', 'education' and/or 'policy'. The papers retrieved used both qualitative and quantitative approaches and were scrutinized for recurring themes., Findings: Nurses reported significant changes in their personal development, perspectives on nursing practice and critical appraisal of health care systems. They also indicated an increased appreciation and sensitivity towards cultural issues and cross-cultural care. Moreover, differences in placement programmes, such as duration, preparation and debriefing were found to have affected the reported overall international placement experience. However, the primary effects of international placements were identified as personal development and transcultural adaptation., Conclusion: Students should be exposed to a variety of nursing experiences within the host country. This would give them a broad spectrum for comparisons between cultures, nursing practice and health care delivery in those cultures. Therefore, educational institutions are strongly encouraged to provide opportunities for students to participate in nursing care and education in another country.

Background: Few South American studies have examined current prevalence rates of psychiatric disorders., Aims: To examine prevalence rates in a nationally representative adult population from Chile., Method: The Composite International Diagnostic Interview was administered to a stratified random sample of 2978 individuals from four provinces representative of the country's population. Six-month and 1-month prevalence rates were estimated. Demographic correlates, comorbidity and service use were examined., Results: Nearly a fifth of the Chilean population had had a psychiatric disorder during the preceding 6 months. The 6-month and 1-month prevalence rates were 19.7% and 16.7% respectively. For the 6-month prevalence the five most common disorders were simple phobia, social phobia, agoraphobia, major depressive disorder and alcohol dependence. Less than 30% of those with any psychiatric diagnosis had a comorbid psychiatric disorder and the majority of them had sought treatment from mental health services., Conclusions: Current prevalence studies are useful indicators of service needs. People with comorbid psychiatric conditions have high rates of service use. The low rate of comorbidity in Chile merits further study.

ABSTRACT The Ceratocystis fimbriata complex includes many undescribed species that cause wilt and canker diseases of many economically important plants. Phylogenetic analyses of DNA sequences have delineated three geographic clades within Ceratocystis fimbriata. This study examined host specialization in the Latin American clade, in which a number of lineages were identified using sequences of the internal transcribed spacer (ITS) region of the rDNA. Three host-associated lineages were identified from cacao (Theobroma cacao), sweet potato (Ipomoea batatas), and sycamore (Platanus spp.), respectively. Isolates from these three lineages showed strong host specialization in reciprocal inoculation experiments on these three hosts. Six cacao isolates from Ecuador, Trinidad, and Columbia differed genetically from other cacao isolates and were not pathogenic to cacao in inoculation tests. Further evidence of host specialization within the Latin American clade of Ceratocystis fimbriata was demonstrated in inoculation experiments in growth chambers using sweet potato, sycamore, Colocasia esculenta, coffee (Coffea arabica), and mango (Mangifera indica) plants; inoculation experiments in Brazil using Brazilian isolates from cacao, Eucalyptus spp., mango, and Gmelina arborea; and inoculation experiments in Costa Rica using Costa Rican isolates from cacao, coffee, and Xantho-soma sp. Hosts native to the Americas appeared to be colonized by only select pathogen genotypes, whereas nonnative hosts were colonized by several genotypes. We hypothesize that local populations of Ceratocystis fimbriata have specialized to different hosts; some of these populations are nascent species, and some host-specialized genotypes have been moved to new areas by humans.