Relationship between employment and quality of life and self-perceived health in people with spinal cord injury: an international comparative study based on the InSCI Community Survey.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: Work-related disability is common in persons with spinal cord injury (SCI). The aims of this study are to examine the associations of employment with self-perceived health (SPH) and quality of life (QoL) across 22 countries and to explore the covariates around employment and SPH and QoL. SETTING: Community. METHODS: We analyzed 9494 community-dwelling persons with SCI aged 18-65. We performed an adjusted regression and path analysis. The independent variable was 'employment' and the dependent variables were two single items: QoL (very poor to very good) and SPH (excellent to poor). Covariates included the Gross Domestic Product (GDP), education, time since SCI, age, gender, years of employment after SCI, SCI level (paraplegia, tetraplegia), and completeness of SCI. RESULTS: Participants' mean age was 47, 74% were male, and 63% had paraplegia. We found an association between employment and QoL and SPH. While the magnitude of the effect of employment on QoL did not differ across GDP quartiles, its perceived effect on QoL was found to be significant in the highest GDP quartile. Employment was predictive of good SPH in two GDP quartiles (Q1 and Q4), but significant across all quartiles when predicting poor perceptions, with the magnitude of effect varying significantly. CONCLUSIONS: Employment is closely related to QoL and SPH depending on the GDP. We may positively influence the QoL and SPH in the SCI population to promote better employment outcomes by considering the infrastructure and economy.

Increasing Pediatric Morning Report Educational Value Through Quality Improvement.

BACKGROUND: Morning report (MR) is a common case-based conference in graduate medical education. Recent studies highlight participant dissatisfaction with the educational value of MR, but data are lacking on means for improvement. We aimed to increase MR quality and participant satisfaction at our academic pediatric residency program. METHODS: Improvement science was used to develop and implement a new standardized pediatric MR process (intervention), with 5 core educational elements and structured resident-faculty mentorship. Educational elements were measured via feedback forms and tracked using a run chart. Residents and faculty were surveyed regarding MR quality and satisfaction at baseline and 6 months postintervention; responses were analyzed using mixed effects logistic regression. RESULTS: The median of educational elements increased from 3 to 5 (5 maximum) during the 6-month study period and 12-months poststudy. Baseline and postintervention survey response rates were 90% (18 of 20) for residents and 66% (51 of 77) for faculty. Residents reporting high quality MR changed from 50% to 72% (P = .20), and faculty from 29% to 85% (P <.001). Satisfaction with MR content increased for both residents (50%-89%, P = .03) and faculty (25%-67%, P <.001). Resident satisfaction with faculty mentorship before MR increased from 28% to 78% (P = .01); satisfaction with faculty feedback after MR increased from 11% to 56% (P = .02). CONCLUSIONS: Improvement science can be used to develop a new pediatric graduate medical education process. Requiring core educational elements and providing structured mentorship were associated with improvements in pediatric MR quality and participant satisfaction.

Creation and validation of the harmonized Arabic version of the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP).

Objectives: Tocreate and validate a translated Arabic version of the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP), a validated patient-reported outcome (PRO) widely used for assessing the quality of life in patients with prostate cancer (PCa). Patients and Methods: Using the established protocol as defined by the Professional Society for the Health Economics and Outcomes Research (ISPOR) for translating patient care questionnaires, a harmonised translated Arabic version of EPIC-CP was created. The questionnaire was tested in native Arabic speakers from four different Arabic countries (Saudi Arabia, United Arab Emirates, Jordan, and Kuwait). Cronbach's alpha and interclass coefficient correlation (ICC) analyses were used to test the internal consistency and test-retest reliability, respectively. In addition, PCa characteristics were collected for participants. Results: In total, 168 patients with PCa participated in the study (39 from Saudi Arabia, 23 from United Arab Emirates, 65 from Jordan, and 41 from Kuwait). In all, 52 (31%) participants repeated the questionnaire for test-retest reliability analysis. The median (interquartile range [IQR]) age of patients included in the study was 66 (61-71) years. The median (IQR) PSA level was 9.8 (6-19) ng/mL. Most patients had Grade Group 2 PCa at diagnosis (31%), clinical stage cT1 (42%), managed primarily by urology (79%), and the primary treatment was radical prostatectomy (71%). The total Cronbach's alpha coefficient was 0.84 demonstrating an acceptable internal consistency. The total ICC was also acceptable at 0.64. Conclusion: The Arabic version of the EPIC-CP is a reliable and valid tool for assessing health-related quality of life for Arabic patients with PCa.

Perspectives on the Form, Magnitude, Certainty, Target, and Frequency of Financial Incentives in a Weight Loss Program.

PURPOSE: Financial incentives are a promising approach to enhance weight loss outcomes; however, little guidance exists on the optimal incentive structure. DESIGN: Mixed methods. SETTING: An online weight management trial, combining outcome (i.e., weight loss) and behavioral (i.e., self-weighing, dietary self-monitoring, and steps) incentives over 12 months (up to $665). SUBJECTS: 116 participants who completed the incentive preference assessment at the 18-month follow-up visit. METHOD: Response distributions on the form, magnitude, certainty, and target of the incentives and content analysis of the qualitative responses. RESULTS: Nearly all (96.6%) participants indicated they liked receiving electronic Amazon gift cards, more so than the alternatives presented. Most participants (81.0%) thought they would have lost a similar amount of weight if the incentives were smaller. Few (18.1%) indicated they would have preferred a lottery structure, but 50.8% indicated the variable incentive schedule was beneficial during the maintenance period. Most (77.6%) felt incentives were most helpful when starting to lose weight. In both phases, most participants (85.3% and 72.4%, respectively) indicated appropriate behaviors were incentivized. Participants had mixed views on whether outcome or behavioral incentives were most motivating. CONCLUSION: There was notable variation in preferences for the magnitude, duration, and timing of incentives; it will be important to examine in future research whether incentive design should be tailored to individual preferences.

Randomized controlled trial of financial incentives during weight-loss induction and maintenance in online group weight control.

OBJECTIVE: This study examined the impact of a financial incentive scheme integrating process and outcome incentives across weight-loss induction and weight maintenance on 18-month weight outcomes. METHODS: This was a randomized controlled trial. Participants with overweight or obesity (n = 418; 91% female; 28% racial/ethnic minority) were randomized to an 18-month, online, group-based behavioral weight-control program (Internet-Only) or the same program with financial incentives provided for 12 months, contingent on self-regulatory weight-control behaviors (self-weighing, dietary self-monitoring, and physical activity) and weight-outcome benchmarks (Internet+Incentives). No financial incentives were provided from Months 13 to 18 to examine the durability of weight-control behaviors and outcomes without incentives. RESULTS: Weight-loss induction at Month 6 was significantly greater for Internet+Incentives than Internet-Only (6.8% vs. 4.9%, respectively, p = 0.01). Individuals receiving incentives were significantly more likely to maintain weight loss ≥ 5% at Month 12 (45% in Internet+Incentives vs. 32% in Internet-Only, p < 0.02) and remain weight stable (39% vs. 27%, respectively, p < 0.01). Internet+Incentives participants also reported significantly greater behavioral engagement through Month 12. However, once incentives ceased, there were no differences in sustained weight outcomes (Month 18), and engagement declined dramatically. CONCLUSIONS: Despite promoting greater treatment engagement and initial weight loss, financial incentives as offered in this study did not promote better extended weight control.

Urine specific gravity to identify and predict hydration need in ALS.

Introduction: Multiple factors contribute to increased risk of dehydration in amyotrophic lateral sclerosis (ALS), which contributes to shortened survival independent of nutritional status. The assessment of hydration by doubly labeled water is restricted due to the limited availability of this gold standard technique for clinical use. This prompted us to examine the utility of urine-specific gravity (USG) as a predictor of hydration need in ALS subjects. Material and Methods: Using data from a multicenter study of 80 ALS subjects with 250 visits, we conducted a secondary analysis of the original data set from doubly labeled water experiments. We used a cross-section of the data (one visit per 75 subjects) in the model selection step ("test set"), and a repeated measures analysis in the validation step with data from 63 subjects and 142 follow-up visits. The sensitivity to detect inadequate water turnover rate (a surrogate for water intake) was the goal of the predictive model presented for clinical use. Results and discussion: The final predictive model to estimate water requirement included USG, gender, body mass index, and the ALSFRS gross motor subscale score. We developed a best-fit equation to estimate water intake from USG, determine hydration status, and improve clinical care of real-world ALS subjects.

Longitudinal Resilience and Burnout in Radiology Residents.

PURPOSE: The aims of this study were to determine resilience levels of radiology residents at the start of radiology residency, investigate changes in resilience and burnout during residency, and assess the relationship between resilience and burnout among radiology residents. METHODS: Diagnostic radiology residents were invited to participate in online surveys from 2016 to 2019. Resilience was assessed using the Connor-Davidson Resilience Scale. Burnout was assessed using the Maslach Burnout Inventory-Human Services Survey. For each data set, genders' scores were compared using either analysis of variance or Kruskal-Wallis tests. Pearson correlation coefficients were calculated to explore the correlations between resilience and burnout. RESULTS: Women and men had no statistically significant difference among baseline resilience scores (P = .78). However, there was a statistically significant overall decrease in resilience scores among women (P = .002). Baseline Maslach Burnout Inventory-Human Services Survey scores indicated that residents began residency without frequent symptoms of burnout. There was no statistically significant temporal change across subjects among burnout scores in any scale (P ≥ .09 for all) or between women and men (P ≥ .37 for all interactions). However, among women, there was a statistically significant difference in depersonalization scores during training (P = .009). Additionally, higher resilience scores were associated with a greater sense of personal achievement (r = .52) and less emotional exhaustion (r = -.56) and depersonalization (r = -.59). CONCLUSIONS: The results of this study demonstrate that gender differences in resilience and burnout occur during radiology residency and that resilience has a protective effect against experiencing symptoms of burnout. Radiology residency programs should consider building longitudinal resilience for all trainees, especially women.

Effect of riluzole on weight in short-term and long-term survivors of amyotrophic lateral sclerosis.

INTRODUCTION: Riluzole is the first disease-modifying therapy for amyotrophic lateral sclerosis (ALS) approved in 1995 by the Food and Drug Administration in the USA, and is now available worldwide. It delays time to tracheostomy or death and prolongs survival. The precise mechanism of the survival prolonging effect is unknown. Malnutrition and ensuing weight loss are associated with shorter survival in ALS. Given the life-prolonging effects of riluzole and nutritional maintenance, we examined the relationship between riluzole and weight in ALS patients. Materials and Methods: Using data from the National ALS Center of Excellence clinic database at the University of Vermont Medical Center, we stratified 244 patients into cohorts based on riluzole use, and duration of survival from the baseline visit into short-term (≤3 years) and long-term (>3 years) survivors. We examined average monthly weight change in patients during the first year after the baseline visit, and the last year before death. Results and Discussion: In 156 short-term survivors taking riluzole compared to those not taking riluzole, there was a 37% attenuation of weight loss in the first year after baseline, and 46% attenuation of weight loss in the last year before death. Seventy-four n long-term survivors on riluzole showed reduced weight decline in the first year after the baseline visit. We speculate that one mechanism by which riluzole may affect survival is by attenuating weight loss and possibly maintaining nutritional status and body composition, although this warrants prospective study.

Prospective associations between nicotine beliefs and tobacco-related susceptibility, curiosity, and use in U.S. adults.

Low harm perceptions of tobacco products have been associated with use of those products in youth and adults, but this relationship has not been assessed for nicotine beliefs. This study used data from a national sample of adults aged 18-40 in Wave 9 (Spring 2016) of the Truth Initiative Young Adult Cohort Study to examine correlations and prospective associations between the latent classes of nicotine beliefs and susceptibility, curiosity, and use of tobacco products in 3122 adults who also completed Wave 10 (Fall 2016). At Wave 9, four latent classes of beliefs characterized the role of nicotine in the health risks of smoking: Class 1, large role, 51%; Class 2, large role/don't know, 9.4%; Class 3, small role in health, 32.5%; and Class 4, none/small role in cancer, 7.5%. Latent classes of nicotine beliefs were highly correlated with susceptibility and curiosity to use cigarettes, e-cigarettes, and hookah, as well as past 30-day use of a range of tobacco products at Wave 9 among never users. Classes 3 and 4 had the highest prevalence of past 30-day tobacco use; never users in these classes reported the greatest susceptibility to try cigarettes, hookah, and e-cigarettes at Wave 9. Class 4 had higher odds of increased e-cigarettes use at follow-up compared to Class 1. There were few prospective associations between nicotine beliefs latent class, susceptibility, and curiosity at Wave 10. Nicotine beliefs are associated with tobacco-related outcomes and, if assessed, may provide novel information to guide tobacco prevention and intervention efforts.

Adding Financial Incentives to Online Group-Based Behavioral Weight Control: An RCT.

INTRODUCTION: Internet-delivered behavioral weight control is promising for expanding the reach and availability of weight management, but online programs produce lower weight losses than typically achieved in person. Financial incentives have been shown to increase weight losses. This study examined whether adding financial incentives for self-monitoring and achieving target weight losses increases weight losses attained in a fully online, group-based behavioral weight management program compared with the same program alone. STUDY DESIGN: This study was an RCT. SETTING/PARTICIPANTS: Adults with overweight and obesity (n=418; 91% female; 28% minority) were recruited from 2 clinical centers. INTERVENTION: The intervention was a 24-session online group-based behavioral weight control program with weekly synchronous chat sessions (Internet-only) or the same program with weekly financial incentives for self-monitoring body weight and dietary intake daily and for achieving target weight losses at 2 and 6 months (Internet + incentives). MAIN OUTCOME MEASURES: This study measured weight loss at 6 months and treatment engagement (attendance, self-monitoring of body weight, dietary intake, and physical activity). Data were collected between February 2016 and August 2018, and analyses were completed in 2019. RESULTS: Participants randomized to the Internet + incentives group lost more weight (-6.4 [SD=5.5] kg) than those in the Internet-only group (-4.7 [SD=6.6] kg; p<0.01). Further, a higher proportion of the Internet + incentives group achieved ≥5% weight loss (55%) than those in the Internet-only group (40%; p<0.05). Treatment engagement was higher in the Internet + incentives condition, with greater self-monitoring of behaviors targeted by incentives, as well as higher rates of behaviors not targeted and higher self-reported physical activity. Study retention was higher among those in the Internet + incentives condition (91%) than those in the Internet-only condition (81%; p=0.003). CONCLUSIONS: Adding financial incentives to a program delivered fully online increases weight losses compared with the program alone and can achieve weight losses comparable to in-person programs, offering potential for substantial geographic reach. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02688621.

Study Characteristics Influence the Efficacy of Substance Abuse Treatments: A Meta-analysis of Medications for Smoking Cessation.

BACKGROUND: Understanding study characteristics' influence on treatment efficacy could improve interpretation of trials' outcomes. We examined study characteristics as predictors of outcomes in clinical trials of medications for tobacco use. METHODS: We obtained and analyzed data on 44 trials of nicotine gum, 37 trials of nicotine patch, 27 trials of varenicline, and 43 trials of bupropion from Cochrane reviews. We extracted and analyzed data for 15 study characteristics, odds ratios (ORs), and percent abstinent in control and medication conditions. We used general linear models to determine which study characteristics explained the variability among outcomes after controlling for medication characteristics. RESULTS: Study characteristics accounted for 12% of the variance in odds ratios among patch trials, 16% among gum trials, 16% among varenicline trials, and 34% among bupropion trials above and beyond medication characteristics. Patch and gum trials with industry funding had larger odds ratios than those without. Among patch trials, this appeared to be due to less abstinence in industry-funded trials' control conditions. Bupropion trials published earlier had larger odds ratios, which appeared to be due to less abstinence in control conditions. The reason for study characteristics' influence on varenicline trials was unclear. DISCUSSION: Study characteristics influenced the assessment of treatment efficacy above and beyond medication characteristics in smoking cessation trials. Our findings that study characteristics are associated with higher or lower efficacy does not suggest that the effect size under one versus another condition is the more valid outcome. Future studies are needed to determine which study characteristics reliably influence efficacy because this would help investigators and clinicians interpret trials. IMPLICATIONS: Study characteristics influenced the estimates of treatment efficacy but individual characteristics' influence on efficacy appeared to differ among different medications for smoking cessation. We encourage researchers to report study characteristics to improve interpretation of findings and systematic reviews, and to account for nontreatment-related variables to better estimate the efficacy of treatments.

Latent Classes of Nicotine Beliefs Correlate with Perceived Susceptibility and Severity of Nicotine and Tobacco Products in US young adults.

BACKGROUND: Pervasive misperceptions about nicotine may influence uptake of quit smoking aids and the impact of policies addressing nicotine as a tobacco product constituent. METHODS: Latent class analyses were conducted using four items on nicotine beliefs asked of 4037 adults aged 18-40 in wave 9 (February-March 2016) of the Truth Initiative Young Adult Cohort Study. Confirmatory factor analyses identified three factors from 12 items: nicotine susceptibility (NSUS), nicotine severity (NSEV), and tobacco severity (TSEV). Analyses assessed correlations between latent classes, sociodemographics, and nicotine/tobacco factor scores. RESULTS: A four-class model of nicotine beliefs was the best fit, with the largest class believing that nicotine plays a major part in smoking risks (class 1, n = 2070; 52%). Class 2 shared that belief but also responded "Don't know" to addiction questions (class 2, n = 382; 11%). Fewer belonged in class 3, who reported that nicotine plays a small part in health risks (n = 1277; 30%), and class 4, who perceived nicotine as not cancer causing (n = 308; 7%). Latent class membership was correlated with sociodemographics, peer smoking, and past 30-day tobacco use. Classes 1 and 2 had similar NSUS scores and classes 3 and 4 had similar NSEV and TSEV scores. DISCUSSION: Differences in the perceptions of nicotine and tobacco-related harms can be partially explained by clustering of underlying nicotine beliefs. These classes of beliefs are correlated with sociodemographic predictors of smoking. These findings may help to identify specific beliefs or groups to be targeted by public education efforts on nicotine. IMPLICATIONS: The current study supports that underlying nicotine beliefs are associated with perceived harms of specific nicotine and tobacco products (relative to cigarettes), with greater false beliefs about nicotine correlated with greater perceived susceptibility to nicotine addiction. Two important inferences emerge from this study: first, that education to address nicotine beliefs may also reframe perceptions of the harms of nicotine and tobacco products; and second, that this type of education may differentially impact perceptions of the harms of nicotine products (e.g., nicotine replacement therapy and e-cigarettes) and tobacco products (e.g., cigars, smokeless, and hookah).

Prevalence and correlates of nicotine and nicotine product perceptions in U.S. young adults, 2016.

INTRODUCTION: Nicotine is not a human carcinogen and combustion compounds in tobacco smoke, rather than nicotine, cause tobacco-related cardiovascular disease. Few recent studies examine the public's beliefs about nicotine in relation to smoking. METHODS: Participants aged 18-40 (n = 4,091) in Wave 10 (Fall 2016) of the Truth Initiative Young Adult Cohort Study responded to nineteen items on nicotine and nicotine product perceptions, including addictiveness and health harms of nicotine patch/gum and e-cigarettes compared to cigarettes. Analyses conducted in 2018 examined prevalence of perceptions and sociodemographic and tobacco use correlates of selected perceptions. RESULTS: The majority of young adults reported that nicotine was responsible for a "relatively" or "very large" part of the health risks (66%) and cancer (60%) caused by smoking. More than half of young adults (55%) believed that nicotine is a cause of cancer. Between 23% and 43% of young adults responded "don't know" to items on nicotine. Females, blacks, Hispanics, and those with less than some college education were more likely to report true or "don't know" vs. false to "nicotine is a cause of cancer" and had higher odds of believing that nicotine was responsible for a "relatively" or "very large" part of the health risks of smoking and cancer caused by smoking. Past 30-day tobacco users had lower odds of reporting these beliefs. CONCLUSIONS: Misperceptions of nicotine are widespread in young adults. Public education is needed to maximize the public health impact of FDA's required nicotine warning label and proposed nicotine reduction policies.

Clinical and Demographic Trends in Cardiac Rehabilitation: 1996-2015.

PURPOSE: Clinical interventions in programs such as cardiac rehabilitation (CR) are guided by clinical characteristics of participating patients. This study describes changes in CR participant characteristics over 20 yr. METHODS: To examine changes in patient characteristics over time, we analyzed data from 1996 to 2015 (n = 5396) garnered from a systematically and prospectively gathered database. Linear, logistic, multinomial logistic or negative binomial regression was used, as appropriate. Effects of sex and index diagnosis were considered both as interactions and as additive effects. RESULTS: Analyses revealed that mean age increased (from 60.7 to 64.2 yr), enrollment of women increased (from 26.8% to 29.6%), and index diagnosis has shifted; coronary artery bypass surgery decreased (from 37.2% to 21.6%), whereas heart valve repair/replacement increased (from 0% to 10.6%). Risk factors also shifted with increases in body mass index (28.7 vs 29.6 kg/m), obesity (from 33.2% to 39.6%), hypertension (from 51% to 62.5%), type 2 diabetes mellitus (from 17.3% to 21.7%), and those reporting current smoking (from 6.6% to 8.4%). Directly measured peak aerobic capacity remained relatively stable throughout. The proportion of patients on statin therapy increased from 63.6% to 98.9%, coinciding with significant improvements in lipid levels. CONCLUSIONS: Compared with 1996, participants entering CR in 2015 were older, more overweight, and had a higher prevalence of coronary risk factors. Lipid values improved substantially concurrent with increased statin use. While the percentage of female participants increased, they continue to be underrepresented. Patients with heart valve repair/replacement now constitute 10.6% of the patients enrolled. Clinical programs need to recognize changing characteristics of attendees to best tailor interventions.

Risk Factors for the Development of Stent-Associated Cholangitis Following Endoscopic Biliary Stent Placement.

BACKGROUND AND AIM: To elucidate the overall risk and risk factors for developing cholangitis following biliary stent placement by endoscopic retrograde cholangiopancreatography (ERCP) and to determine the clinical outcomes of these individuals. METHODS: We performed a retrospective review of 796 patients who had undergone 1127 ERCPs with biliary stent placement between 2007 and 2015 at a single tertiary care center. There were 91 episodes of stent-associated cholangitis (SAC) during the study period. Data obtained through the medical records included ERCP indication, patient factors (biliary anatomy, demographics, and comorbidities), stent characteristics (material, length, and design), change in serum bilirubin, stent indwelling time, rates and etiologies of bacteremia, and the mortality rate. RESULTS: Those with SAC were more likely to have an anatomic biliary stricture (13.1% vs. 2.3%, p < .0001), with hilar and multiple strictures having the highest risk (19.1% vs. 11.6%, p = .04). The ERCP indication of malignant biliary obstruction was associated with higher rates of SAC (15.6% vs. 3.4%, p = < .0001). Rates of SAC were higher in those who failed to normalize total bilirubin (16.9% vs. 7.8%, p = .0005), and these episodes occurred earlier compared to those who normalized total bilirubin (median 30.5 days vs. 140.5 days, p < .0001). CONCLUSIONS: Patients at increased risk of SAC include those with an anatomic stricture, malignant biliary obstruction, and those who fail to normalize total bilirubin after biliary stent placement. Future protocols should be designed to reduce the risk of cholangitis in these populations.

Reduction in Cigarettes per Day Prospectively Predicts Making a Quit Attempt: A Fine-Grained Secondary Analysis of a Natural History Study.

INTRODUCTION: Reducing cigarettes per day (CPD) aided by medication increases quit attempts (QA) among smokers not trying to quit. If this is due to reducing CPD per se, then a greater reduction should predict making a QA. AIMS AND METHODS: In this secondary analysis, 132 smokers completed nightly calls to report CPD, intention to quit tomorrow, and QAs over 12 weeks. We provided no treatment. We identified episodes of reduction and tested whether (1) percent reduction in CPD, (2) absolute reduction in CPD, (3) duration of reduction, or (4) CPD on the final day predicted a QA immediately after a reduction episode. We tested this separately among reduction episodes that began with and without an intention to quit. RESULTS: Among the 1179 episodes that began without intention to quit, all four measures of reduction predicted making a QA. Greater percent reduction, longer duration, and fewer CPD on the final day were retained in a multivariate model (all p < .05). Among the 85 episodes that began with intention to quit, greater percent reduction and greater absolute reduction predicted making a QA. Only mean percent reduction was retained in a multivariate model (p < .001). CONCLUSIONS: Our results replicate and extend earlier studies by using fine-grained analyses and examining immediately proximal QAs in a sample of self-quitters. Findings suggest that reducing CPD per se increases the probability of a QA among smokers without intention to quit in a dose-related manner. Whether this is the case among smokers who intend to quit remains unclear. IMPLICATIONS: Reducing CPD appears to be an effective strategy to increase the probability of making a QA for the majority of smokers who do not intend to quit in the near future. However, our findings are mixed regarding the effectiveness of reducing among smokers who intend to quit. Clinical interventions and policies that promote reducing CPD are likely to be an effective way to increase QAs. Reduction may be especially helpful for smokers who have not responded to traditional advice to stop abruptly.

The impact of the interventionist-participant relationship on treatment adherence and weight loss.

Little is known about the impact of the relationship built between interventionists and their participants on weight loss. Our objective is to determine whether stronger early (i.e., 4 weeks) participant-interventionist bond is associated with significantly greater weight loss success and treatment adherence. Three hundred and ninety-eight participants received an online group behavioral weight control program over 18 months. Weight was measured objectively at baseline and at 6 and 18 months. At 4 weeks, participants completed the Working Alliance Inventory (WAI) bonding subscale, which measures the collaborative bond with the interventionist. Adherence (i.e., session attendance and online self-monitoring diary completion) was recorded by the interventionists. Participant-interventionist bond at 4 weeks was significantly associated with weight loss at 6 months (t(322) = -2.14, p = .03) but not at 18 months (t(290) = 0.53, p = .60). The model indicated that participant-interventionist bond at 4 weeks was a significant predictor of adherence at 6 months (b = .063, standard error [SE] = .30, p = .04), and 6 month adherence was a significant predictor of weight loss at 6 months (b = -.594, SE = .049, p < .0001). The indirect effect of the WAI-Bond subscale was significant (b = -.037, p = .03, 95% confidence interval: -.074, -.002) and accounted for 54% of the total effect of participant-interventionist bond on weight loss. However, the total weight loss explained by WAI-Bond subscale was small (0.04 kg). Participant-interventionist bond between participant and interventionist is an early predictor of treatment adherence and weight loss success at 6 months; however, the degree of weight loss explained by participant-interventionist bond is small and was not maintained at 18 months.

Distal Measurements Can Produce False Negative Results: A Prospective Secondary Analysis of a Natural History Study.

INTRODUCTION: Most prospective studies of quit attempts (QAs) or abstinence measure the ability of variables to predict quitting many weeks or months later. This design ignores more proximal fluctuations in the predictor that may be more relevant. The present secondary analysis compares 6-week (distal) and daily (proximal) changes in cigarettes per day (CPD) as predictors of making a QA. METHODS: Daily smokers reported CPD and QAs nightly throughout a 12-week natural history study. We provided no treatment. In the distal analysis, we tested whether reduction in CPD between baseline and 6 weeks predicted making a QA during the following 6 weeks. In the proximal analysis, we identified episodes of one or more days of ≥10% reduction in CPD and tested whether reduction predicted making a QA on the day immediately after the reduction episode. We tested the following predictors: (1) reduction in CPD of ≥10% (yes/no), (2) percent reduction, (3) absolute magnitude of reduction, and (4) CPD at the end of reduction. RESULTS: In the distal analysis, reduction did not predict making a QA. In the proximal analysis, any reduction (OR = 3.0), greater percent reduction (OR = 1.6), greater absolute reduction (OR = 1.3), and fewer CPD on the final day of an episode (OR = 11.8) predicted making a QA the next day (all p < .001). DISCUSSION: Relying on distal measurements to identify causes of a behavior may produce false-negative results. Increased use of technological advances will make assessments of the more valid proximal measurements more feasible. IMPLICATIONS: This secondary analysis tested distal and proximal predictors of making a quit attempt among the same participants and found that distal tests did not, but proximal tests did predict quit attempts. Relying on distal measurements may result in false negatives.

Study characteristics influence the efficacy of substance abuse treatments: A meta-analysis of medications for alcohol use disorder.

BACKGROUND: Understanding study characteristics' influence on treatment efficacy could improve methodologies and interpretation of findings. We examine study characteristics as predictors of outcomes in clinical trials of medications for alcohol problems. METHODS: We obtained data on 23 trials of naltrexone and 22 trials of acamprosate from Cochrane reviews. We extracted data for 14 study characteristics and 3 dependent variables (odds ratio; percent abstinent in placebo; medication conditions). We used general linear models to determine which study characteristics explained the variability among outcomes after controlling for medication characteristics. RESULTS: Study characteristics accounted for 45% of the variance in odds ratio when trials of different medications were combined, 19% among acamprosate, and 48% among naltrexone trials above and beyond medication characteristics. When medications were combined, greater odds ratios were predicted by having more dropouts in the placebo than medication conditions, an earlier publication year, and not receiving industry funding. Whether this was due to effects on placebo or medication conditions was unclear. Among acamprosate trials, smaller sample sizes predicted greater odds ratios, which appeared to be due to more abstinence in medication conditions. Among naltrexone trials, greater odds ratios were predicted by having more dropouts in the placebo than medication conditions and a greater probability of randomizing participants to treatment. This appeared to be due to less abstinence in placebo conditions. CONCLUSION: Study characteristics influence the assessment of treatment efficacy beyond medication characteristics in alcohol treatment trials. Future studies are needed to determine which study characteristics reliably influence efficacy to help investigators design and help clinicians interpret trials.

Recommendations for Pathologic Evaluation of Reduction Mammoplasty Specimens: A Prospective Study With Systematic Tissue Sampling.

CONTEXT: - Breast reduction mammaplasty (RMP) for symptomatic macromastia or correction of asymmetry is performed in more than 100 000 patients per year in the United States. The reported incidence of significant pathologic findings (SPF), that is, carcinoma and atypical hyperplasia, ranges from 0.06% to 12.8%. No standard pathology assessment for RMP exists. OBJECTIVES: - To propose standard sampling for microscopic evaluation in RMP specimens, to evaluate the incidence of occult carcinoma and atypical hyperplasia, and to identify clinical risk factors for SPF in patients undergoing RMP. DESIGN: - All RMP specimens from 2006 to 2013 at a single institution were prospectively examined. After baseline gross and microscopic evaluations, each specimen was subjected to systematic additional sampling. The incidence of SPF was tabulated, and variables such as age, specimen weight, previous history of SPF, and results of preoperative mammogram were examined. Clinical follow-up review was also subsequently undertaken. RESULTS: - A total of 595 patients were evaluated. Significant pathologic findings were present in 9.8% (58 of 595) of patients. No cancer was identified in patients younger than 40 years; the rates of carcinoma were 2.4% (14 of 595) in all patients, 3.6% (14 of 392) in patients aged 40 years or older, and 4.3% (10 of 233) in patients aged 50 years or older. No carcinoma or atypical hyperplasia was identified on preoperative mammogram. Increased sampling was associated with a significantly greater frequency of SPF only in patients aged 40 years or older. CONCLUSIONS: - In patients younger than 35 years, gross-only evaluation is sufficient. However, increased sampling may be necessary in patients older than 40 years.