Predictors of expressed breast milk volume in mothers expressing milk for their preterm infant.

BACKGROUND: An understanding of predictors of breast milk production may enable the provision of better advice and support to mothers with preterm infants who may need to express milk for long periods. OBJECTIVE: To investigate factors predicting the amount of milk expressed by mothers for their preterm infant (1) during the first 10 days and (2) during the infant's whole hospital stay. METHODS: 62 mothers with preterm infants <34 weeks who participated in a randomised trial comparing two breast pumps completed 10-day diaries including weight of milk expressed and questionnaires giving their opinion of the breast pump; 47 mothers provided data on milk expression up to the infant's hospital discharge. RESULTS: Significant predictors of 10-day milk weight in multivariate models were the number of episodes of 'breast feeding' (17 g (95% CI 8 to 26, p=0.001) increase per episode), the use of double versus single pumping (109 (31-186, p=0.007) g/day more) and the number of complete daily records (17 (1-33, p=0.04) g increase/day). Significant multivariate predictors of total milk production were double versus single pumping (491 (55) mL/day vs 266 (44) mL/day), expressing 500 mL/day by day 10 (525 (53) mL/day vs 232 (43) mL/day) and a higher score for breast pump 'comfort' (best=489 (39) mL/day, middle=335 (57) mL/day, worst=311 (78) mL/day). CONCLUSIONS: These results suggest that relatively simple, modifiable factors can favourably impact milk production in the neonatal intensive care unit setting and emphasise the importance of double pumping, early establishment of milk production and design features of the breast pump that promote comfort. TRIAL REGISTRATION NUMBER: NCT00887991.

Abstinence rates among college cigarette smokers enrolled in a randomized clinical trial evaluating Quit and Win contests: The impact of concurrent hookah use.

OBJECTIVE: To examine baseline characteristics and biochemically verified 1-, 4-, and 6-month tobacco quit rates among college students enrolled in a Quit and Win cessation trial, comparing those who concurrently smoke both hookah and cigarettes with those who deny hookah use. METHODS: Analyses were conducted on data from 1217 college students enrolled in a Quit and Win tobacco cessation randomized clinical trial from 2010-2012. Multivariable logistic regression (MLR) analyses examined group differences in baseline characteristics and cotinine verified 30-day abstinence at 1, 4, and 6-month follow-up, adjusting for baseline covariates. RESULTS: Participants smoked 11.5(±8.1) cigarettes per day on 28.5(±3.8) days/month, and 22% smoked hookah in the past 30days. Hookah smokers (n=270) were more likely to be male (p<0.0001), younger (p<0.0001), report more binge drinking (p<0.0001) and score higher on impulsivity (p<0.001). MLR results indicate that hookah users, when compared to non-users, had a 36% decrease in odds of self-reported 30-day abstinence at 4-months (OR=0.64, 95% CI=0.45-0.93, p=0.02) and a 63% decrease in odds in biochemically verified continuous abstinence at 6-months (OR=0.37, CI=0.14-0.99, p=0.05). CONCLUSION: College cigarette smokers who concurrently use hookah display several health risk factors and demonstrate lower short and long-term tobacco abstinence rates.

Association of CHRNA5-A3-B4 SNP rs2036527 with smoking cessation therapy response in African-American smokers.

Associations between CHRNA5-A3-B4 variants and smoking behaviors exist; however, the association with smoking abstinence is less understood, particularly that among African Americans. In 1,295 African Americans enrolled in two clinical trials, we investigated the association between CHRNA5-A3-B4 and smoking abstinence. The rs2056527(A) allele was associated with lower abstinence with active pharmacotherapy (during treatment: odds ratio (OR) = 0.42, P < 0.001; end of treatment (EOT): OR = 0.55, P = 0.004), or with nicotine gum alone (during treatment: OR = 0.31, P < 0.001; EOT: OR = 0.51, P = 0.02), but not significantly with bupropion, although similar directions and magnitudes were observed (during treatment: OR = 0.54, P = 0.05; EOT: OR = 0.59, P = 0.08). In addition, the rs588765(T) allele was associated with abstinence with gum during treatment (OR = 2.31, P < 0.01). The SNP rs16969968 occurred at a low frequency and was not consistently associated with abstinence. CHRNA5-A3-B4 variants were not associated with tobacco consumption, and adjustments for smoking behaviors did not alter the associations with smoking abstinence. Together, our data suggest that among African Americans, CHRNA5-A3-B4 variants are not associated with baseline smoking but can influence smoking abstinence during active pharmacotherapy.

Intent to quit among daily and non-daily college student smokers.

Given the high prevalence of young adult smoking, we examined (i) psychosocial factors and substance use among college students representing five smoking patterns and histories [non-smokers, quitters, native non-daily smokers (i.e. never daily smokers), converted non-daily smokers (i.e. former daily smokers) and daily smokers] and (ii) smoking category as it relates to readiness to quit among current smokers. Of the 4438 students at six Southeast colleges who completed an online survey, 69.7% (n = 3094) were non-smokers, 6.6% (n = 293) were quitters, 7.1% (n = 317) were native non-daily smokers, 6.4% (n = 283) were converted non-daily smokers and 10.2% (n = 451) were daily smokers. There were differences in sociodemographics, substance use (alcohol, marijuana, other tobacco products) in the past 30 days and psychosocial factors among these subgroups of students (P < 0.001). Among current smokers, there were differences in cigarettes smoked per day, recent quit attempts, self-identification as a smoker, self-efficacy and motivation to quit (P < 0.001). After controlling for important factors, converted non-daily smokers were more likely to be ready to quit in the next month versus native non-daily smokers (OR = 2.15, CI 1.32-3.49, P = 0.002). Understanding differences among young adults with different smoking patterns and histories is critical in developing interventions targeting psychosocial factors impacting cessation among this population.

CYP2B6 and bupropion's smoking-cessation pharmacology: the role of hydroxybupropion.

Bupropion is indicated to promote smoking cessation. Animal studies suggest that the pharmacologic activity of bupropion can be mediated by its major metabolite, hydroxybupropion. We measured plasma bupropion and its metabolite levels in a double-blind, placebo controlled, randomized smoking-cessation trial. Among the treatment-adherent individuals, higher hydroxybupropion concentrations (per µg/ml) resulted in better smoking-cessation outcomes (week 3, 7, and 26 odds ratio (OR) = 2.82, 2.96, and 2.37, respectively, P = 0.005-0.040); this was not observed with bupropion levels (OR = 1.00-1.03, P = 0.59-0.90). Genetic variation in CYP2B6, the enzyme that metabolizes bupropion to hydroxybupropion, was identified as a significant source of variability in hydroxybupropion formation. Our data indicate that hydroxybupropion contributes to the pharmacologic effects of bupropion for smoking cessation, and that variability in response to bupropion treatment is related to variability in CYP2B6-mediated hydroxybupropion formation. These findings suggest that dosing of bupropion to achieve a hydroxybupropion level of 0.7 µg/ml or increasing bupropion dose for CYP2B6 slow metabolizers could improve bupropion's cessation outcomes.

Smoking patterns, attitudes and motives: unique characteristics among 2-year versus 4-year college students.

Given the previously documented higher rates of smoking among 2-year college students in comparison with 4-year university students, this study compares smoking patterns, attitudes and motives among 2-year and 4-year college students. Two thousand two hundred and sixty-five undergraduate students aged 18-25 years at a 2-year college and a 4-year university completed an online survey in 2008. Current (past 30-day) smoking was reported by 43.5% of 2-year and 31.9% of 4-year college students, and daily smoking was reported by 19.9% of 2-year and 8.3% of 4-year college students. Attending a 2-year college was associated with higher rates of current smoking [odds ratio (OR) = 1.72] and daily smoking (OR = 2.84), and with less negative attitudes regarding smoking, controlling for age, gender, ethnicity and parental education. Also, compared with 4-year college student smokers, 2-year college smokers had lower motivation to smoke for social reasons, but more motivation to smoke for affect regulation, after controlling for age, gender, ethnicity and parental education. Two- and 4-year college students report different smoking patterns, attitudes and motives. These distinctions might inform tobacco control messages and interventions targeting these groups of young adults.

Association of nicotine metabolite ratio and CYP2A6 genotype with smoking cessation treatment in African-American light smokers.

Cytochrome P450 2A6 (CYP2A6) is the main nicotine (NIC)-metabolizing enzyme in humans. We investigated the relationships between CYP2A6 genotype, baseline plasma trans- 3'-hydroxycotinine/cotinine (3HC/COT) (a phenotypic marker of CYP2A6 activity), and smoking behavior in African-American light smokers. Cigarette consumption, age of initiation, and dependence scores did not differ among 3HC/COT quartiles or CYP2A6 genotype groups. Slow metabolizers (SMs; both genetic and phenotypic) had significantly higher plasma NIC levels, suggesting that cigarette consumption was not reduced to adjust for slower rates of NIC metabolism. Individuals in the slowest 3HC/COT quartile had higher quitting rates with both placebo and NIC gum treatments (odds ratio 1.85, 95% confidence interval (CI) 1.08-3.16, P = 0.03). Similarly, the slowest CYP2A6 genotype group had higher quitting rates, although this trend did not reach significance (odds ratio 1.61, 95% CI 0.95-2.72, P = 0.08). The determination of the 3HC/COT ratio, and possibly CYP2A6 genotype, may be useful in the future for personalizing the choice of smoking cessation treatment in African-American light smokers.

A randomized trial of targeted educational materials for smoking cessation in African Americans using transdermal nicotine

This study examines the efficacy of targeted versus standard care smoking cessation materials among urban African American smokers. Five hundred smokers (250 to each group) are randomized to receive a culturally targeted or standard care videotape and print guide. Both groups receive 8 weeks of nicotine patches and reminder telephone calls at Weeks 1 and 3. Process outcomes include material use and salience at 1 and 4 weeks postbaseline. Smoking outcomes include 7-day abstinence, smoking reduction, and readiness to quit at 4 weeks and 6 months postbaseline. Despite greater use of the targeted guide (68.8 per cent vs. 59.6 per cent, p < .05), intervention participants do not perceive the targeted materials as more salient, and no significant differences are found between groups on the smoking outcomes. Findings point to the importance of greater audience segmentation and individual tailoring to better match intervention materials to the needs of the priority population. (AU)

Impact of volume guarantee ventilation on arterial carbon dioxide tension in newborn infants: a randomised controlled trial.

OBJECTIVE: To compare the effects of the two modes of ventilation, synchronous intermittent positive pressure ventilation (SIPPV) and SIPPV with Volume Guarantee (VG), on arterial carbon dioxide tension (PaCO(2)) immediately after neonatal unit admission. STUDY DESIGN: Randomised study of ventilation mode for premature inborn infants admitted to two tertiary neonatal units. After admission, infants were randomised to receive either SIPPV or VG using a Dräger Babylog 8000 plus ventilator. In the SIPPV group, peak airway pressure was set clinically. In the VG group, desired tidal volume was set at 4 ml/kg, with the ventilator adjusting peak inspiratory pressure to deliver this volume. The study was completed once the first arterial PaCO(2) was available, with the desirable range defined as 5-7 kPa. RESULTS: PaCO(2) was significantly higher in the VG group (VG: 5.7 kPa, SIPPV: 4.9 kPa; p=0.03). The VG group had fewer out-of-range PaCO(2) values (VG: 42%, SIPPV: 57%) and fewer instances of hypocarbia <5 kPa (VG: 32%, SIPPV: 57%) but neither difference achieved statistical significance. Regression analysis showed PaCO(2) was negatively correlated with gestation (r=-0.41, p=0.01) and also with the mode of ventilation (r=0.32, p<0.05). In the VG group, all infants 23-25 weeks' gestation had out-of-range PaCO(2) values. VG significantly reduced the incidence of out-of-range PaCO(2) and hypocarbia in infants over 25 weeks' gestation (VG: 27%, SIPPV: 61%; p<0.05). CONCLUSION: Using this strategy, VG appears feasible in the initial stabilisation of infants over 25 weeks' gestation, with a halving of the incidence of hypocarbia. In the small number of babies studied below this gestation, VG was not found to be effective.

Fecal occult blood test use by Kansas medicare beneficiaries.

PURPOSE: The aim of this study was to examine utilization of and trends in fecal occult blood testing (FOBT) among beneficiaries since Medicare began FOBT coverage on January 1, 1998. METHODS: We identified Kansas Medicare beneficiaries ages 65-79. Using Medicare claims, we determined which beneficiaries received FOBT during 1998-1999. We examined demographic variables associated with FOBT and rate changes over time. We linked beneficiaries to primary care practices (PCPs) and examined FOBT variations among 483 PCPs. RESULTS: FOBT use remained unchanged during the study period. Of the 215,322 beneficiaries, 11% received at least one FOBT in 1998 and 11% in 1999; 18% had at least one test during the 2-year period, but only 4% had a test during both years. Caucasians and females had the highest FOBT rates. Although FOBT rates among PCPs ranged from 0 to 71%, only 19% of the practice rates exceeded 10%. CONCLUSIONS: Few beneficiaries obtain annual FOBT and little change in rates has occurred since Medicare reimbursement began. Although FOBT rates vary widely between PCPs, most either do not provide FOBT or do not bill Medicare for FOBT. The FOBT claims rate is much lower than reported in patient surveys and may indicate that Medicare should reexamine its reimbursement policy.

Impact of smoking cessation on ambulatory blood pressure and heart rate in postmenopausal women.

BACKGROUND: Smoking and hypertension interact to increase the incidence of cardiovascular disease; however, little is known about the effects of smoking cessation on blood pressure (BP) control. We prospectively evaluated the impact of smoking cessation on clinic and ambulatory BP and heart rate (HR) in stage 1 hypertensive and normotensive postmenopausal women. METHODS: A total of 66 women were randomly assigned using a 3:1 randomization scheme to immediate smoking cessation or to a wait list control group. Clinic and ambulatory BP and HR, and 24-h urinary catecholamine concentrations were obtained at baseline and again at 6 weeks. Carbon monoxide levels and self-report were used to assess compliance with smoking cessation. RESULTS: Ambulatory monitoring showed that the awake SBP decreased by 3.6+/-1.9 mm Hg in the treated subjects who quit smoking (n=19), whereas in the control group (n=15) there was an increase of 1.7+/-2.4 mm Hg (P=.045). Awake HR decreased after smoking cessation by 7+/-1 beats/min and did not change (0+/-1 beat/min) in the control group (P=.001). Blood pressure and HR did not significantly change during sleep after smoking cessation. Changes in the awake HR correlated with changes in urinary epinephrine concentrations (r= 0.58, P=.001), and norepinephrine concentrations (r= 0.45, P=.001), There was no significant change in clinic systolic BP, diastolic BP, or HR between groups. CONCLUSIONS: Smoking cessation reduces systolic BP and HR during the daytime, when patients typically smoke. These hemodynamic changes are due in part to reductions in sympathetic nervous system activity.

Direct observation of counseling on colorectal cancer in rural primary care practices.

To better understand colorectal cancer (CRC) screening practices in primary care, medical students directly observed physician-patient encounters in 38 physician offices. CRC was discussed with 14% of patients >or=50 years of age; 87% of discussions were initiated by the physician. The rate of discussions varied among the practices from 0% to 41% of office visits. Discussions were more common for new patient visits, with younger patients, and in the 24% of offices that utilized flow sheets. The frequency of CRC discussions in physician offices varies widely. More widespread implementation of simple office systems, such as flow sheets, is needed to improve CRC screening rates.

Smoking in urban African Americans: behaviors, gender differences, and motivation to quit.

OBJECTIVE: This study describes smoking behaviors and gender differences, and correlates these factors with motivation to quit smoking among African-American smokers at a community-based health center. DESIGN: A 62-item survey assessed depression, hassles, readiness to change, and demographics. METHODS: Participants (N = 81) were interviewed in an adult clinic waiting room. RESULTS: On average, participants smoked 13 cigarettes per day. Many reported attempts to reduce smoking-related health risks: 46% switched brands, 57% reduced their smoking, and 19% smoked only on some days. Fifty-nine percent indicated depressive symptoms. For women vs men, noteworthy differences were: reduction in number of cigarettes smoked (66.7% vs 40.0%; P = .023), switching brands (58.8% vs 23.3%; P = .003), number of attempts to quit in the past year (2.7 vs 1.2; P = .034), and high concern about weight gain (52.9% vs 26.7%; P = .047). Cigarettes smoked per day was negatively correlated with motivation to quit (P = .022). Variables positively correlated with motivation to quit included: harm reduction strategies (P = .002), intention to quit in 30 days (P<.0001), and intention to quit in 6 months (P<.0001). CONCLUSIONS: Women showed more potential indications of readiness to quit, including more attempts to quit, reductions in number of cigarette smoked, and brand switching. Knowledge of cessation barriers, gender differences, and correlates to motivation may prove useful for investigators conducting research in this population.

Direct observation of smoking cessation activities in primary care practice.

OBJECTIVE: Our goals were to determine how often family physicians incorporate smoking cessation efforts into routine office visits and to examine the effect of patient, physician, and office characteristics on the frequency of these efforts. STUDY DESIGN: Data was gathered using direct observation of physician-patient encounters, a survey of physicians, and an on-site examination of office systems for supporting smoking cessation. POPULATION: We included patients seen for routine office visits in 38 primary care physician practices. OUTCOMES MEASURED: The frequency of tobacco discussions among all patients, the extent of these discussions among smokers, and the presence of tobacco-related systems and policies in physicians' offices were measured. RESULTS: Tobacco was discussed during 633 of 2963 encounters (21%; range among practices = 0%-90%). Discussion of tobacco was more common in the 58% of practices that had standard forms for recording smoking status (26% vs 16%; P=.01). Tobacco discussions were more common during new patient visits but occurred less often with older patients and among physicians in practice more than 10 years. Of 244 smokers identified, physicians provided assistance with smoking cessation for 38% (range among practices = 0%-100%). Bupropion and nicotine-replacement therapy were discussed with smokers in 31% and 17% of encounters, respectively. Although 68% of offices had smoking cessation materials for patients, few recorded tobacco use in the "vital signs" section of the patient history or assigned smoking-related tasks to nonphysician personnel. CONCLUSIONS: Smoking cessation practices vary widely in primary care offices. Strategies are needed to assist physicians with incorporating systematic approaches to maximize smoking cessation rates.

Randomized trial comparing the efficacy of a novel manual breast pump with a standard electric breast pump in mothers who delivered preterm infants.

OBJECTIVE: The benefits of human milk for preterm infants are widely recognized, yet technological advances in milk expression have been slow. We compared the efficacy of a standard electric pump (EP; Egnell) used in 94% of United Kingdom neonatal units with a novel manual pump (MP; Avent ISIS) designed to operate more physiologically by simulating the infant's compressive action on the areola during breastfeeding. METHODS: We randomized 145 women who delivered infants of <35 weeks' gestation to use the MP or the EP and measured total milk volume expressed while using the randomized pump during the infant's hospital stay, pattern of milk output and creamatocrit of milk expressed during a test period in the second week, and pump characteristics by maternal questionnaire. RESULTS: Mothers who used the EP, who frequently double pumped, showed shorter expression times but produced no more milk than mothers who used the MP. When both pumped sequentially, however, mothers who used the MP showed significantly greater milk flow and total volume over 20 minutes. Creamatocrit was unaffected by pump type. The MP was rated significantly higher than the EP on 5 major characteristics. CONCLUSIONS: When compared on equal terms (sequential pumping), mothers who used the MP showed greater milk flow, perhaps reflecting more physiologic pump design. Even with double pumping, mothers who used the EP did not advantage their infants with greater milk production. We believe that this novel, effective MP, preferred by mothers and costing a fraction of the EP price, reflects a significant advance in milk expression for high-risk infants.breast pumps, randomized trial, preterm infants.

Feasibility of tidal volume-guided ventilation in newborn infants: a randomized, crossover trial using the volume guarantee modality.

BACKGROUND AND AIM: Volume guarantee (VG) is a new composite mode of pressure-limited ventilation, available on the Dräger Babylog 8000 ventilator, which allows the clinician to set a target mean tidal volume to be delivered while still maintaining control over peak airway pressures. This study aimed to investigate the feasibility and efficacy of this mode of ventilation in premature newborn infants with respiratory distress syndrome (RDS). METHODS: Two groups of infants were studied: those receiving synchronized intermittent positive pressure ventilation (SIPPV) in early phase of RDS (group 1) and those in recovery phase of RDS being weaned from artificial ventilation through synchronized intermittent mandatory ventilation (SIMV; group 2). Both groups of infants were studied over a 4-hour period. Before the start of the study, the infants were either receiving SIPPV (group 1) or SIMV (group 2). Infants in group 1 were randomized to either continue on SIPPV for the first hour of the study or to receive SIPPV plus VG for the first hour. Subsequently, the 2 modes were used alternately for the remaining three 1-hour periods. Similarly, infants in group 2 were randomized to either continue on SIMV for the first hour of the study or to receive SIMV plus VG for the first hour. Data on ventilation parameters and transcutaneous carbon dioxide and oxygen were collected continuously. RESULTS: Forty infants were studied, 20 in each group. The mean (standard error) gestational age was 27.9 (0.3) weeks; birth weight was 1064 (60) g. No adverse events were observed during the study. Fractional inspired oxygen during SIMV plus VG was 0.31 (0.3); during SIMV, 0.31 (0.3); during SIPPV plus VG, 0.41 (0.4); and during SIPPV, 0.40 (0.4). Transcutaneous carbon dioxide pressure during SIMV plus VG was 6.0 (2.2) kPa; during SIMV, 5.9 (2.2) kPa; during SIPPV plus VG, 6.4 (2.9) kPa; and during SIPPV, 6.4 (2.8) kPa. Transcutaneous partial pressure of oxygen during SIMV plus VG was 8.4 (8.7) kPa; during SIMV, 8.6 (8.8) kPa; during SIPPV plus VG, 7.6 (4.0) kPa; and during SIPPV, 7.7 (4.2) kPa. None of these differences was statistically significant. The mean (standard error) peak inspiratory pressure used during SIMV was 17.1 (3.4) cm of water; during SIMV plus VG, 15.0 (7.5) cm of water; during SIPPV plus VG, 17.1 (9.3) cm of water; and during SIPPV, 18.7 (8.3) cm of water. The mean airway pressure during SIMV plus VG was 6.5 (3.1) cm of water; during SIMV, 6.9 (2.8) cm of water; during SIPPV plus VG, 9.6 (4.5) cm of water; and during SIPPV, 9.8 (4.6) cm of water. CONCLUSION: VG seems to be a stable and feasible ventilation mode for neonatal patients and can achieve equivalent gas exchange using statistically significant lower peak airway pressures both during early and recovery stages of RDS.ventilation, airway pressure, volume guarantee, tidal volume.

Risk factor distribution among sociodemographically diverse African American adults.

Because African Americans tend to have lower socioeconomic status (SES) than whites and numerous health indicators are related to SES variables, it is important when examining between-group differences in health indices to account for SES differences. This study examined the effects of income and education on several biologic and behavioral risk factors in a sample of sociodemographically diverse African American adults. Approximately 1,000 African American adults (aged 18-87) were recruited from 14 churches with predominantly black membership to participate in a nutrition education intervention. Demographics, height, weight, blood pressure, self-reported cigarette and alcohol use, self-reported diet by food frequency questionnaire, serum carotenoids, serum total cholesterol, and nutrition knowledge were assessed. The association of these risk factors were examined by four levels of education and income. For men, body mass index, blood pressure, total cholesterol, daily intake of fruits and vegetables, serum carotenoids, heavy alcohol use, or exercise were not associated significantly with income or education using analysis of variance (ANOVA). Past month alcohol use and nutrition knowledge were associated positively with education, but not income. For women, body mass index and smoking were associated inversely with income, but not with education. Blood pressure, total cholesterol, intake of fruits and vegetables, heavy alcohol use, and exercise were not associated with either income or education using ANOVA. Serum carotenoids, any 30-day alcohol use, and nutrition knowledge were associated positively with both income and education. Results using linear regression generally were similar for men and women, although a few more variables were associated significantly with SES compared to ANOVA analyses. Several health indicators that have been associated with socioeconomic variables in whites were not associated or only weakly associated in this diverse sample of African Americans. One interpretation of these findings is that SES factors may function differently among blacks and whites.