L-DOPA biotransformation: correlations of dosage, erythrocyte catechol O-methyltransferase and platelet SULT1A3 activities with metabolic pathways in Parkinsonian patients.

The objectives of this study were to determine (1) the effects of dose and drug absorption on pathways of biotransformation of L-DOPA in Parkinsonian patients treated with Sinemet, and (2) the extent to which genetically-determined variations in the activities of erythrocyte catechol O-methyltransferase and/or platelet phenol sulfotransferase might be reflected in individual differences in L-DOPA metabolism. In the 19 patients studied, there were negative correlations between dosage or absorption and extent of O-methylation and of sulfation of L-DOPA or its metabolites. Levels of activity for erythrocyte COMT were also reflected in individual variation in the metabolism of L-DOPA. In contrast, differences in platelet phenol sulfotransferase were not reflected in differences in sulfation of L-DOPA or of its metabolites. If such a relationship did exist, it might have been obscured by the effects of high dosage of L-DOPA, effects which might have resulted from a deficiency of the sulfation cosubstrate 3'-phosphoadenosine 5'-phosphosulfate in patients taking higher doses of drug.

Nicotine patch use in pregnant smokers: smoking abstinence and delivery outcomes.

OBJECTIVE: To describe smoking abstinence and fetal effects of pregnant smokers who received 8 weeks of nicotine patch therapy. METHODS: One-sample study of 21 pregnant women smoking > or = 15 cigarettes/day during their third trimester of pregnancy despite physician advice to stop. Nicotine patch therapy (22 mg/24 h) was initiated during the first day of a 4-day in-hospital study and continued for a total of 8 weeks. Subjects returned weekly until delivery, at 4 weeks after delivery, and at 6 and 12 months after patch therapy. Fetal growth and well-being were assessed using ultrasound examinations and non-stress tests. RESULTS: Eight of 21 subjects completed all 8 weeks of patch therapy according to the protocol. Five subjects (24%) discontinued using the nicotine patch, owing to adverse skin reactions. There were eight subjects (38%) who were biochemically confirmed abstinent from smoking at the time of delivery; of these, seven were continuously abstinent from the start of patch therapy. Centile weight for gestational age did not change significantly over time for 12 subjects with serial ultrasound measurements available at baseline, 4 weeks and 8 weeks following initiation of patch therapy. In all cases, non-stress tests remained reactive or became reassuring with observation. No significant preterm deliveries occurred (gestational ages of 36.3-41.1 weeks). Three infants suffered severe neonatal morbidity; however, these problems were unrelated to nicotine patch therapy. CONCLUSION: Nicotine patch therapy has potential benefit for pregnant smokers who continue to smoke despite physician advice to stop.

A prospective, randomized, double-blind, placebo-controlled study of orbital radiotherapy for Graves' ophthalmopathy.

CONTEXT: Although widely used for more than 85 years, the efficacy of radiotherapy for Graves' ophthalmopathy (GO) has not been established convincingly. OBJECTIVE: To evaluate the efficacy of radiotherapy for GO. DESIGN: Prospective, randomized, internally controlled, double-blind clinical trial in a tertiary care academic medical center. PARTICIPANTS: The patients were ethnically diverse males and females over age 30 seen in a referral practice. The patients had moderate, symptomatic Graves' ophthalmopathy (mean clinical activity score, 6.2) but no optic neuropathy, diabetes, recent steroid treatment, previous decompression, or muscle surgery. Forty-two of 53 consecutive patients were enrolled after giving informed consent and fulfilling study entry criteria. Eleven eligible patients declined to participate because of inconvenience, desire for alternative therapy, or concern about radiation. INTERVENTION: One randomly selected orbit was treated with 20 Gy of external beam therapy; sham therapy was given to the other side. Six months later, the therapies were reversed. MAIN OUTCOME MEASURES: Every 3 months for 1 year, we measured the volume of extraocular muscle and fat, proptosis, range of extraocular muscle motion, area of diplopia fields, and lid fissure width. Effective treatment for GO will modify one or more of these parameters. RESULTS: No clinically or statistically significant difference between the treated and untreated orbit was observed in any of the main outcome measures at 6 months. At 12 months, muscle volume and proptosis improved slightly more in the orbit that was treated first. CONCLUSIONS: In this group of patients, representative of those for whom radiotherapy is frequently recommended, we were unable to demonstrate any beneficial therapeutic effect. The slight improvement noted in both orbits at 12 months may be the result of natural remission or of radiotherapy, but the changes are of marginal clinical significance.

Point prevalence of alcoholism in hospitalized patients: continuing challenges of detection, assessment, and diagnosis.

OBJECTIVE: To measure a 1-day point prevalence of alcohol dependence among hospitalized patients and to assess practices of detection, evaluation, and diagnosis of alcohol problems. PATIENTS AND METHODS: On April 27, 1994, a total of 795 adult inpatients at 2 midwestern teaching hospitals were asked to complete a survey that included the Self-administered Alcoholism Screening Test (SAAST). The records of SAAST-positive patients were reviewed to determine the numbers of patients receiving laboratory screening for alcoholism, addiction consultative services, and a discharge diagnosis of alcoholism. RESULTS: The survey response rate was 84% (667/795). Of the 569 patients who provided SAAST information, 42 (7.4%) had a positive SAAST score and thus were identified as alcohol dependent. Thirteen (31%) of the 42 alcoholic patients received addiction or psychiatric consultative services during their hospitalization. Serum gamma-glutamyltransferase was measured in 4 (11%) of the 38 actively drinking alcoholic patients. Three (7%) of 42 alcoholic patients received a discharge diagnosis of alcohol abuse or dependence. CONCLUSIONS: The alcoholism prevalence rate was lower than those observed in several other US hospitals. Laboratory testing may be underutilized in identifying hospitalized patients who may be addicted to alcohol. Physician use of consultative services and diagnosis of alcohol dependence had not improved from similar observations more than 20 years earlier. These findings may indicate persistent problems in physician detection, assessment, and diagnosis of alcoholism.

Bupropion for smoking cessation : predictors of successful outcome.

OBJECTIVES: To identify predictors of smoking abstinence at the end of medication use that could assist in the optimal use of a sustained-release (SR) form of bupropion for treating cigarette smokers. DESIGN: A double-blind, placebo-controlled, dose-response trial. SETTING: Multicenter (three sites) study conducted in the United States. PARTICIPANTS: Six hundred fifteen healthy men and women (> or = 18 years of age) who were smoking > or = 15 cigarettes per day and who were motivated to stop smoking. INTERVENTION: Random assignment of patients to placebo or SR bupropion treatment, 100, 150, or 300 mg/d, for 7 weeks (total duration of study was 52 weeks: 7 weeks of treatment and 45 weeks of follow-up). MEASUREMENTS AND RESULTS: Logistic regression was used to identify predictors of abstinence at the end of the medication phase. Univariate predictors included the following: bupropion dose (p < 0.001); older age (p = 0.024); lower number of cigarettes smoked per day (cpd) (p < 0.001); lower Fagerström Tolerance Questionnaire score (p = 0.011); longest time previously abstinent that was < 24 h or > 4 weeks (p < 0.001); absence of other smokers in the household (p = 0.021); greater number of previous stop attempts (p = 0.019); and study site (p = 0.004). Multivariate predictors of abstinence at the end of the medication phase were the following: higher bupropion dose (p < 0.001); lower number of cpd (p < 0.001); longest time previously abstinent from smoking (p = 0.002); male gender (p = 0.014); and study site (p = 0.021). CONCLUSION: Bupropion SR therapy was effective in treating cigarette smokers independently of all other characteristics studied. Lower smoking rate, brief periods (ie, < 24 h) or long periods (ie, > 4 weeks) of abstinence with previous attempts to stop smoking, and male gender were predictive of better outcomes, independent of the dose of bupropion that was used.

The effect of changing transfusion practice on rates of perioperative stroke and myocardial infarction in patients undergoing carotid endarterectomy: a retrospective analysis of 1114 Mayo Clinic patients. Mayo Perioperative Outcomes Group.

OBJECTIVE: To evaluate changes in the institution's red blood cell (RBC) transfusion practice during the past 15 years and the influence of these changes on neurologic or cardiac morbidity after carotid endarterectomy. PATIENTS AND METHODS: Based on a retrospective analysis of the Mayo Clinic database, 1,114 patients who underwent carotid endarterectomy were stratified into 1 of 2 groups: (1) 1980 to 1985 (ie, pre-human immunodeficiency virus screening, early-practice group [n=552]) and (2) 1990 to 1995 (ie, recent-practice group [n=562]). Data were compared between time periods using the chi2 test for categorical variables and the rank sum test for continuous variables. Logistic regression was used to assess the association between perioperative transfusion practice and the occurrence of stroke or myocardial infarction. Two-tailed P values < or = 05 were considered statistically significant. RESULTS: Patients in the recent-practice group were significantly older (mean +/- SD age, 69.6 +/- 8.7 years) vs 65.9 +/- 8.3 years in the early-practice group (P<.001). The proportion of patients receiving perioperative RBC transfusion decreased dramatically from 72.9% in 1980-1985 to 8.7% in 1990-1995 (P<.001). Additionally, the mean +/- SD number of RBC units transfused decreased from 1.10 +/- 1.30 U in 1980-1985 to 0.27 +/- 1.22 U in 1990-1995 (P<.001). Mean +/- SD discharge hemoglobin concentration decreased from 13.7 +/- 1.4 g/dL in 1980-1985 to 11.8 +/- 1.5 g/dL in 1990-1995 (P<.001). Rates of perioperative stroke and myocardial infarction did not differ between the 2 time periods (early-practice group vs recent-practice group: stroke, 5.1% vs 3.6% [P=.22]; myocardial infarction, 1.5% vs 2.3% [P=.29]). CONCLUSIONS: Our results suggest that elderly patients undergoing carotid endarterectomy (ie, individuals known to be at high risk for cerebral and cardiac ischemia) can tolerate modest perioperative anemia despite a considerable change in the institution's transfusion practice (lower "transfusion trigger," the hemoglobin concentration or hematocrit value below which RBC transfusion is indicated).

Effect of current tobacco use and history of an alcohol problem on health status in hospitalized patients.

This prospective study assessed the relationship between current tobacco use and history of an alcohol problem to health status in hospitalized patients. Factors associated with current tobacco use and history of an alcohol problem were also evaluated. Data were collected using a self-administered survey distributed by nursing staff to adult inpatients registered on April 27, 1994 at the Mayo Clinic, Rochester, Minnesota affiliated hospitals. Respondents (N = 589, 45% female) were classified into 4 subgroups based on current tobacco use status and history of an alcohol problem: (a) current tobacco use only (n = 94, 16%); (b) history of an alcohol problem only (n = 30, 5%); (c) both (n = 27, 5%); or (d) neither (n = 438, 74%). Patients with both current tobacco use and an alcohol problem history reported markedly lower scores on health status measures of general and mental health compared to the other three subgroups. Moreover, current tobacco use and history of an alcohol problem were each associated with increased psychological distress. Current tobacco use was predictive of a history of an alcohol problem and vice versa.

Residential (inpatient) treatment compared with outpatient treatment for nicotine dependence.

OBJECTIVE: To compare smoking abstinence outcomes between smokers treated in a residential (inpatient) program and those treated in an outpatient program to determine if residential treatment was superior to outpatient treatment in smokers with moderate to severe nicotine dependence. PATIENTS AND METHODS: Patients treated in the residential nicotine dependence program at the Mayo Clinic, Rochester, Minn., between May 1, 1992, and January 31, 1996, were selected for this study. Each patient in the residential treatment group (n=146) was matched to 2 patients who received an outpatient nicotine dependence consultation by a trained counselor (n=292). Each patient was matched on age, sex, year seen, number of cigarettes smoked per day, longest previous abstinence, education, and marital status. Abstinence at 6 and 12 months was determined by self-report. For the purposes of analysis, each patient with missing outcome data was considered to be smoking. RESULTS: The 6-month abstinence rates for the residential group compared with the outpatient group were 45% and 26%, respectively (P<.001), and the 12-month abstinence rates were 45% and 23%, respectively (P<.001). After adjusting for matching variables that were not exactly matched (age, baseline number of cigarettes smoked per day, and longest previous abstinence) and the baseline variables, including education, age when started smoking, and degree of nicotine dependence, there was a significant effect of residential treatment on 6- and 12-month abstinence rates (P<.001). Odds ratio of 6-month abstinence in the residential group was 2.74 (95% confidence interval, 1.60-4.71; P<.001) and at 12 months was 3.03 (95% confidence interval, 1.74-5.27; P<.001). CONCLUSION: Residential treatment for tobacco dependence is superior to outpatient treatment in some smokers who are moderately to severely nicotine dependent.

Carbidopa/levodopa for smoking cessation: a pilot study with negative results.

The mesolimbic dopamine system is thought to be a critical substrate for drugs of addiction including nicotine. Since dopamine may play a critical role in mediating the reinforcing effects of nicotine, we hypothesized that administering levodopa in its therapeutic form (carbidopa/levodopa) might be effective for smoking cessation by replacing the effects of dopamine that smokers may seek during smoking. A pilot open-label study using carbidopa/levodopa for smokers wanting to stop smoking was carried out at the Mayo Clinic Nicotine Research Center, Rochester, MN. The dosing schedule was one tablet TID for 1 week, 1 1/2 tablets TID for 1 week, then two tablets TID for 6 weeks. Each tablet contained 25 mg of carbidopa and 100 mg of levodopa. The subjects were 40 adult smokers smoking > or = 20 cigarettes per day for 3 or more years. Self-reported abstinence from smoking was confirmed by expired air CO level of < or = 8 ppm. Nicotine withdrawal symptoms were assessed at baseline and daily during the medication phase. Smoking abstinence rates and withdrawal symptom relief were compared to the placebo (n = 153) arm of a previously reported bupropion smoking cessation trial. The biochemically confirmed, 7-day point-prevalence smoking abstinence rate at the end of carbidopa/levodopa treatment was 20.0% versus 19.0% for the placebo group (p > 0.10), and 12.5% of the carbidopa/levodopa group were abstinent versus 15.7% for the placebo group (p > 0.10) at 6 months. Subjects from both studies had significant increases in withdrawal scores from baseline, but there were no significant differences between the two groups at any time period. We found no differences in smoking abstinence rates or nicotine withdrawal symptom relief in smokers receiving carbidopa/levodopa compared to placebo. Despite the theoretical reasons why carbidopa/levodopa might be effective as a pharmacological adjunct in treating smokers, it was not observed in this group of smokers at this dose.

Influence of ventricular morphology on outcome after the Fontan procedure.

The modified Fontan procedure has gained wide acceptance in the treatment of various congenital heart defects. Determination of risk factors for mortality remains an important issue for optimizing patient selection for the Fontan procedure. Conflicting results have been reported about whether ventricular morphology is a risk factor in these patients. Survival free of Fontan takedown or cardiac transplantation was assessed in the first 500 patients undergoing the Fontan procedure at our institution. This survival was correlated with ventricular morphology as evaluated by angiography. Both multivariate and univariate analyses indicated ventricular morphology was predictive of early survival free of Fontan takedown or cardiac transplantation following the procedure. However, there was no statistical evidence for ventricular morphology being a risk factor for mortality in patients alive 6 months after the procedure. Ventricular morphology is a risk factor for early survival in patients undergoing a Fontan procedure, with left ventricular morphology associated with a better early survival than right ventricular morphology.

Risk of surgery and anesthesia for ischemic stroke.

BACKGROUND: The goal of this study was to determine if the combination of surgery and anesthesia is an independent risk factor for the development of incident (first-time) ischemic stroke. METHODS: All residents of Rochester, MN, with incident ischemic stroke from 1960 through 1984 (1,455 cases and 1,455 age- and gender-matched controls) were used to identify risk factors associated with ischemic stroke. Cases and controls undergoing surgery involving general anesthesia or central neuroaxis blockade before their stroke/index date of diagnosis were identified. A conditional logistic regression model was used to estimate the odds ratio of surgery and anesthesia for ischemic stroke while adjusting for other known risk factors. RESULTS: There were 59 cases and 17 controls having surgery within 30 days before their stroke/index date. After adjusting for previously identified risk factors, surgery within 30 days before the stroke/index date (perioperative period) was found to be an independent risk factor for stroke (P<0.001; odds ratio, 3.9; 95% confidence interval, 2.1-7.4). In an analysis that excluded matched pairs where the case and/or control underwent surgery considered "high risk" for stroke (cardiac, neurologic, or vascular procedures), "non-high-risk surgery" was also found to be an independent risk factor for perioperative stroke (P = 0.002; odds ratio, 2.9; 95% confidence interval, 1.5-5.7). CONCLUSION: Our results suggest that there is an increased risk of ischemic stroke in the 30 days after surgery and anesthesia. This risk remains elevated even after excluding surgeries (cardiac, neurologic, and vascular surgeries) considered to be high risk for ischemic stroke.

Optimists vs pessimists: survival rate among medical patients over a 30-year period.

OBJECTIVE: To examine explanatory style (how people explain life events) as a risk factor for early death, using scores from the Optimism-Pessimism scale of the Minnesota Multiphasic Personality Inventory (MMPI). SUBJECTS AND METHODS: A total of 839 patients completed the MMPI between 1962 and 1965 as self-referred general medical patients. Thirty years later, the vital status of each of these patients was ascertained. RESULTS: Of the 839 patients, 124 were classified as optimistic, 518 as mixed, and 197 as pessimistic. Follow-up was available for 723 patients. Among these, a 10-point T-score increase on the Optimism-Pessimism scale (e.g., more pessimistic) was associated with a 19% increase in the risk of mortality. CONCLUSION: A pessimistic explanatory style, as measured by the Optimism-Pessimism scale of the MMPI, is significantly associated with mortality.

Does smoking reduction result in reduction of biomarkers associated with harm? A pilot study using a nicotine inhaler.

The aim of the study was to determine if smoking reduction using a nicotine inhaler in heavy cigarette smokers who wanted to reduce but not stop smoking results in decreased levels of known biomarkers of harm. The study design was a one-sample within-subject comparative open-label study of 23 (10 male and 13 female) subjects using a nicotine inhaler to reduce smoking, with follow-up at 24 weeks. A structured protocol was used with a smoking-reduction schedule from 40 or more cigarettes per day to 10 cigarettes per day by week 9. Behavioral counseling was provided by a research assistant and ad lib use of the nicotine inhaler for 12 weeks was permitted. Blood thiocyanate, cotinine, 4-aminobiphenyl hemoglobin adducts; urine NNAL and NNAL-glucuronide; and expired air carbon monoxide were measured. On average, the subjects were able to reduce their smoking by over 50% at week 12, but only two were able to reduce to 10 cigarettes per day. The reported reduction in smoking was not associated with a consistent reduction in the biomarkers. There was no reduction in the NNAL, 4-aminobiphenyl hemoglobin adducts nor carbon monoxide levels of expired air. There was a significant reduction of NNAL-glucuronide and the sum of NNAL and NNAL-glucuronide but only at week 24. Thiocyanate levels increased. Before widely promoting harm reduction as a treatment strategy for heavy smokers, more research needs to be performed to prove conclusively that such smokers who want to reduce but not stop can actually reduce and maintain their smoking rate at a level which is likely to reduce harm. It also needs to be determined whether a reduction in the smoking rate translates into reduction of harm. At the present, for heavy smokers, an abstinence approach seems to be more scientifically sound.

Over-the-counter nicotine patch therapy for smoking cessation: results from randomized, double-blind, placebo-controlled, and open label trials.

OBJECTIVES: The purpose of this study was to determine the efficacy and safety of the nicotine patch for smoking cessation in an over-the-counter environment. The years of study were 1994 to 1995. METHODS: Parallel 6-week trials were conducted: a placebo-controlled trial of no-cost 22-mg, 24-hour nicotine patch therapy and an open label trial of the same therapy with patches purchased by subjects. Participants (n = 958) were 18 years or older, had smoked at least 15 cigarettes daily for at least 6 months, and were enrolled at 3 study sites. The main outcome measure was self-reported smoking abstinence confirmed by expired carbon monoxide measurements. RESULTS: Smoking cessation rates in the placebo-controlled trial were 16.8% and 9.6% at week 6 and 8.7% and 4.3% at week 24 for the active patch and placebo groups, respectively. Smoking cessation rates in the open label-pay trial were 19.0% and 10.8% at weeks 6 and 24, respectively. A slight increase in adverse cardiovascular events was noted only in the open label-pay group in comparison with the placebo group. CONCLUSIONS: In an over-the-counter environment, the 22-mg, 24-hour nicotine patch is effective and safe for smoking cessation treatment.

Consultation for asthma: results of a generalist survey.

BACKGROUND: There are few studies that examine referral patterns for asthma and few studies that examine the referring physicians' reasons for consultation. OBJECTIVE: The purpose of this study was to survey generalist physicians on their referral patterns for adult patients with asthma. METHODS: We mailed a questionnaire to all the staff (faculty) in the Department of Family Medicine and the Division of Community Internal Medicine at the Mayo Clinic in Rochester, Minnesota. There were 37 completed questionnaires (18 family medicine and 19 internal medicine) out of a total of 58 for a response rate of 64%. The survey asked what were reasons for consultation, whether allergists or pulmonologists were preferred, and the characteristics of a good consultation. RESULTS: We asked respondents to indicate "how often you consult a specialist for an adult asthma patient" for a variety of clinical indications. The percentage responding "always" (for the top five indications) were if the patient requests one (46%), for allergen immunotherapy (38%), for single life-threatening attack (27%), for allergy testing (14%), and for steroid-dependent asthma or poorly controlled asthma (11%). Twenty-seven percent of respondents generally consulted allergists only, 22% generally consulted pulmonologists only, 3% indicated both, while 46% had no preference. Respondents did express a preference for a pulmonologist when the reported reason for the consultation was diagnosis of asthma uncertain, chronic cough, asthma in smoker, exercise training, or for an allergist when the reported reason for consultation was allergy evaluation or immunotherapy. The respondents indicated that the top six characteristics of a good consultation were the following: clear recommendations, clinically appropriate recommendations, high patient satisfaction, including recommendations for future management scenarios, including educational content in the consultation, and calling the referring physician before requesting a secondary consultation. CONCLUSIONS: These results suggest that while consultation occurs often for severe or uncontrolled asthma, some asthma patients who may benefit from consultation may not be seeing the specialist. There were no systematic preferences for consultations with allergists versus pulmonologists for asthma although for some clinical indications pulmonologists or allergists were favored. Referring physicians value clear, clinically appropriate recommendations.

Nicotine patch use in pregnant smokers: nicotine and cotinine levels and fetal effects.

OBJECTIVE: The aims of this study were (1) to determine whether nicotine patch therapy for pregnant women smokers acutely compromises fetal well-being and (2) to determine the serum and urine nicotine and cotinine levels in pregnant women while smoking, while abstinent from smoking, and while receiving nicotine patch therapy compared with levels in a historical control group of nonpregnant women smokers who abstained from smoking while receiving comparable doses of nicotine patch therapy. STUDY DESIGN: Pregnant cigarette smokers (n = 21) aged >/=18 years whose fetuses were beyond 24 weeks' gestational age were recruited for this 1-sample, repeated-measures study. Serial measurements of the mother and fetus were made at baseline while the mother was smoking, while abstaining from smoking, and while using nicotine patch therapy for 4 days in a special care hospital unit. Nonpregnant women smokers of similar age were used for comparison. Morning and afternoon serum and 24-hour urine levels of nicotine and cotinine were obtained during hospitalization. Indicators of fetal well-being assessed were fetal heart rate and reactivity, systolic/diastolic ratio of blood flow in the umbilical artery, and fetal activity seen on ultrasonography and quantitated as biophysical profiles. RESULTS: No evidence of fetal compromise was seen during the inpatient phase while nicotine patch therapy was administered. Steady state (inpatient day 4) serum levels of nicotine were similar to smoking levels and to those seen in historical control subjects (ie, nonpregnant women of child-bearing age who were abstinent from smoking and who used the same nicotine patch). Morning serum cotinine levels were significantly higher (P =.038) in the nonpregnant subjects than in the pregnant subjects, whereas afternoon levels were not significantly different. Steady state urinary levels of nicotine and cotinine were also not significantly different in pregnant versus nonpregnant patients. On inpatient days 2, 3, and 4, when the women were not smoking and were wearing the nicotine patch, the morning fetal heart rates were significantly reduced relative to baseline when the subjects were smoking. CONCLUSIONS: Nicotine patch therapy was not found to be associated with indications of fetal compromise during the in-hospital phase of nicotine patch therapy in pregnant smokers who were abstaining. Although not conclusive because of the small sample sizes, serum nicotine levels (morning and afternoon) appear similar in pregnant and nonpregnant subjects and similar for both groups when smoking (baseline) as compared to the steady state of nicotine patch use.

Recruitment of house staff into anesthesiology: factors responsible for house staff selecting anesthesiology as a career and individual training program.

STUDY OBJECTIVE: To identify factors responsible in the selection of anesthesiology as a career by Mayo Clinic house staff (i.e., residents and clinical fellows); to evaluate their level of satisfaction with their choice of career and training program, and their perceptions of the future for anesthesiology trainees. DESIGN: Cross-sectional analysis using a questionnaire survey of 67 house staff enrolled in the anesthesiology training program during the 1995-1996 academic year. SETTING: Mayo Clinic, Rochester, MN. MEASUREMENTS AND MAIN RESULTS: Forty-eight (72%) of those surveyed responded to the questionnaire. Data were analyzed using the Chi-square and Mann-Whitney rank sum tests. A p-value less than or equal to 0.05 was considered statistically significant. The most frequently cited reasons for selecting anesthesiology as a career included the following: it is a "hands-on" specialty, it involves clinical application of physiology and pharmacology, and it provides immediate gratification in one's work. The most frequently cited reasons for selecting our training program were the diversity of training experience, prestige associated with Mayo Clinic, and employment opportunities following training. Forty-four (92%) felt downsizing of anesthesiology training programs was a national trend, 26 (54%) anticipated difficulty obtaining a job following training, and 16 (33%) felt they had future job security. Overall, 47 (98%) were happy with their career choice, and 40 (83%) would choose anesthesiology as a career if they were now graduating from medical school. All 1996 graduates found suitable employment without difficulty. CONCLUSIONS: Our data indicate that selection of a career in anesthesiology and training program are strongly associated with concerns regarding educational experiences and postgraduate employment opportunities.

Efficacy of bupropion for smoking cessation in smokers with a former history of major depression or alcoholism.

BACKGROUND: A past history of major depression or alcoholism has been associated with poorer smoking treatment outcomes. AIM: To evaluate the efficacy of bupropion for smoking cessation in smokers with a former history of major depression or alcoholism, and changes in depressive symptoms during smoking abstinence. METHOD: Data were drawn from a multicentre trial of bupropion for smoking cessation. Smokers (n = 615) received placebo or bupropion sustained-release at 100, 150, or 300 mg/day for six weeks after target quit date (TQD). The primary outcome was the point prevalence smoking abstinence at the end of treatment and at one year. The Beck Depression Inventory (BDI) was used to assess depressive symptoms. RESULTS: A significant dose-response effect of bupropion for smoking cessation was found. This was independent of history of major depression or alcoholism. Among those continuously abstinent from smoking for two weeks following TQD, an increase in BDI score was associated with a return to smoking at end of treatment. CONCLUSIONS: Bupropion is efficacious for smoking cessation independently of a former history of major depression or alcoholism. Increases in depressive symptoms during an initial period of abstinence are associated with a return to smoking.

The effect of anesthetic patient education on preoperative patient anxiety.

BACKGROUND AND OBJECTIVES: Preoperative time spent with patients has been abbreviated with the advent of same-day admission requirements and outpatient surgery. This study was conducted to evaluate the effects that materials mailed to the home relating to anesthetic-focused patient education may have on preoperative patient anxiety. METHODS: Patients scheduled for a total hip arthroplasty or for a total knee arthroplasty were screened via telephone for inclusion in a prospective, randomized study. Patients were asked about their access to a video cassette recorder/player (VCR) and their limitations regarding hearing or vision. Subjects were randomly assigned to either the intervention group and received two pamphlets and a video describing general and regional anesthesia or to the usual care group. All subjects were mailed a preoperative demographic questionnaire and a State Trait Anxiety Inventory (STAI), as developed by CD Spielberger. Questionnaires were completed at least 96 hours prior to admission and again preoperative on the day of surgery. RESULTS: Of 236 patients screened, 26 had no access to a VCR, 6 were hearing or visually impaired, and 4 declined participation. Of 200 subjects randomized, 134 completed both sets of questionnaires and thus form the basis of this report. A statistically significant difference between the subjects who received the video and pamphlets and the usual care subjects was detected with respect to change in STAI-assessed anxiety from baseline to immediately prior to surgery (P = .035). The intervention subjects experienced a smaller mean increase in anxiety. Forty-nine percent of the usual care subjects expressed interest in having additional information. CONCLUSIONS: Increase in preoperative anxiety is diminished when additional anesthesia information in printed and video format is made available. Useful information can be provided to patients to view or read prior to surgery.

Airway obstruction and perioperative complications in smokers undergoing abdominal surgery.

BACKGROUND: The goal of this study was to determine whether airway obstruction determined by preoperative spirometry predicts perioperative complications in smokers undergoing abdominal surgery whose treatment is managed according to current clinical practice. METHODS: A pulmonary function database identified patients undergoing abdominal surgery who met the following criteria for airway obstruction (n = 135): a forced expiratory volume less than 40% of predicted normal value, a forced expiratory volume:forced vital capacity ratio less than the lower limit of predicted normal, a smoking history of more than 20 pack-years, and an age older than 35 yr. A group of patients without airway obstruction (n = 135) was matched for gender, surgical site (upper vs. lower abdominal), smoking history, and age. Medical records were reviewed by an abstractor to identify perioperative complications that occurred within 30 days after surgery. RESULTS: The forced expiratory volume values were 0.9+/-0.21 (mean +/- SD) and 2.9+/-0.61 in patients with and without airway obstruction, respectively. When analyzed by conditional logistic regression using the 1:1 matched-pairs feature, including age, pack-year smoking history, site of incision, and current smoking status as covariates, in patients with airway obstruction bronchospasm was more likely to develop (odds ratio, 6.9 [95% confidence interval, 1.2 to 38.4]) but the patients were not more likely to need prolonged endotracheal intubation (odds ratio, 1.1 [95% confidence interval, 0.4 to 3.2]). They were also no more likely to need prolonged intensive care admission or readmission. The frequency of other complications was less than 5%. CONCLUSION: When other factors were considered, preoperative airway obstruction predicted the occurrence of bronchospasm, but not prolonged endotracheal intubation, in smokers undergoing abdominal surgery who are treated according to current clinical practices.