Shelly Naud

Relapse to smoking after 1 year of abstinence: A meta-analysis

Most clinical trials use 6 months or 1 year follow-ups as proxies for life-time smoking cessation. Retrospective studies have estimated 2-15% of smokers relapse each year after the first year of abstinence, but these have methodological problems such as memory bias. We searched for prospective studies of adult quitters that reported the number of participants abstinent at 1 yr follow-up and who remained abstinent at >or=2 year follow-ups. We included studies that reported the percent which remained lapse-free, did not continue treatment after 1 year, and had <or=10% lost-to-follow-up. We did not locate any population-based studies but did locate eight randomized, controlled trials, all testing nicotine medications. After deleting one trial with outlier results, a meta-analysis estimated the annual incidence of relapse after 1 year to be 10%; however, the small sample sizes resulted in a wide 95% confidence interval (5-17%) suggesting this estimate is not very accurate. We conclude a non-significant amount of relapse occurs after 1 year. Better quantification of this relapse rate is important to improve estimates of life-long abstinence and reductions in morbidity and mortality from smoking cessation.

Geographic mapping of meniscus and cartilage lesions associated with anterior cruciate ligament injuries.

BACKGROUND Detailed descriptions of meniscus and articular cartilage lesions associated with anterior cruciate ligament injury have not been presented in the literature. Our goal was to determine the associations between patient sex, age, and surgical delay and the frequency and location of meniscus and articular cartilage lesions seen at the time of the anterior cruciate ligament reconstruction. METHODS Data were obtained retrospectively from a database of 1209 consecutive patients undergoing anterior cruciate ligament reconstruction between 1988 and 2002. All knee cartilage, meniscus, and ligament injuries were documented on anatomic maps at the time of surgery, and the data were analyzed. RESULTS Meniscus injuries were identified in 722 (65%) of the 1104 patients who met the criteria for inclusion in the study. Female patients were less likely to have a meniscus injury than male patients were (56% compared with 71%), and male patients were more likely to have combined medial and lateral meniscus injuries than female patients were (20% compared with 11%). Patients with a surgical delay of less than three months were less likely to have a medial meniscus injury (8% compared with 19%). Femoral articular cartilage injuries were identified in 472 patients (43%). Patients who were twenty-five years of age or older were more likely to have multiple cartilage lesions throughout the knee (7.7% compared with 1.3%) and to have more isolated medial femoral condyle lesions (24.2% compared with 13.3%). Patients with a surgical delay of more than one year were more likely to have a lesion (60% compared with 47% for all others), and a surgical delay of more than one year resulted in a greater proportion of large and grade-3 lesions of the lateral femoral condyle. Female patients had a greater proportion of grade-1 lesions of the medial femoral condyle (29% compared with 16%), whereas male patients had a greater proportion of grade-3 and 4 lesions of the medial femoral condyle (49% compared with 35%). In patients who were thirty-five years of age or older, meniscus injuries were more frequent and were located more frequently on the medial side; femoral articular cartilage lesions were also located more frequently on the medial side. CONCLUSIONS Increased age, male sex, and increased surgical delay all increase the frequency and severity of injuries of the meniscus and/or articular cartilage after an anterior cruciate ligament tear.

Therapeutic Interactive Voice Response for chronic pain reduction and relapse prevention

&NA; We developed Therapeutic Interactive Voice Response (TIVR) as an automated, telephone‐based tool for maintenance enhancement following group cognitive–behavioral therapy (CBT) for chronic pain. TIVR has four components: a daily self‐monitoring questionnaire, a didactic review of coping skills, pre‐recorded behavioral rehearsals of coping skills, and monthly personalized feedback messages from the CBT therapist based on a review of the patient’s daily reports. The first three components are pre‐recorded and all four can be accessed remotely by patients via touch‐tone telephone on demand. Following 11 weeks of group CBT, 51 subjects with chronic musculoskeletal pain were randomized to one of two study groups. Twenty‐six subjects participated in 4 months of TIVR, while a control group of 25 subjects received standard care only. The TIVR group showed maximum improvement over baseline at the 8‐month follow‐up for seven of the eight outcome measures; improvement was found to be significant for all outcomes (p ⩽ .001). Between‐group analysis of covariance (ANCOVA) revealed significantly greater improvement for the experimental group at both 4‐ and 8‐month follow‐ups for most of the outcomes. Results demonstrate that TIVR can be used to decrease pain, improve coping and decrease likelihood of relapse into pain behavior. Preliminary analysis of medication usage suggests that the superior outcome of the TIVR group was unlikely to be a consequence of differential medication use.

Accelerated Versus Nonaccelerated Rehabilitation After Anterior Cruciate Ligament Reconstruction A Prospective, Randomized, Double-Blind Investigation Evaluating Knee Joint Laxity Using Roentgen Stereophotogrammetric Analysis

Background: The relationship between the biomechanical dose of rehabilitation exercises administered after anterior cruciate ligament (ACL) reconstruction and the healing response of the graft and knee is not well understood. Hypothesis: After ACL reconstruction, rehabilitation administered with either accelerated or nonaccelerated programs produces the same change in the knees’ 6 degrees of freedom, or envelope, laxity values. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients who underwent ACL reconstruction with a bone–patellar tendon–bone autograft were randomized to rehabilitation with either accelerated (19 week) or nonaccelerated (32 week) programs. At the time of surgery, and then 3, 6, 12, and 24 months later, the 6 degrees of freedom knee laxity values were measured using roentgen stereophotogrammetric analysis and clinical, functional, and patient-oriented outcome measures. Results: Eighty-five percent of those enrolled were followed through 2 years. Laxity of the reconstructed knee was restored to within the limits of the contralateral, normal side at the time of surgery (baseline) in all participants. Patients in both programs underwent a similar increase in the envelope of knee laxity over the 2-year follow-up interval (anterior-posterior translation 3.2 vs 4.5 mm, and coupled internal-external rotations 2.6° vs 1.9° for participants in the accelerated and nonaccelerated programs, respectively). Those who underwent accelerated rehabilitation experienced a significant improvement in thigh muscle strength at the 3-month follow-up (P < .05) compared with those who participated in nonaccelerated rehabilitation, but no differences between the programs were seen after this time interval. At the 2-year follow-up, the groups were similar in terms of clinical assessment, patient satisfaction, function, proprioception, and isokinetic thigh muscle strength. Conclusion: Rehabilitation with the accelerated and nonaccelerated programs administered in this study produced the same increase in the envelope of knee laxity. A majority of the increase in the envelope of knee laxity occurred during healing when exercises were advanced and activity level increased. Patients in both programs had the same clinical assessment, functional performance, proprioception, and thigh muscle strength, which returned to normal levels after healing was complete. For participants in both treatment programs, the Knee Injury and Osteoarthritis Outcome Score (KOOS) assessment of quality of life did not return to preinjury levels.

Evaluating chronic venous disease with a new venous severity scoring system

BACKGROUND The Venous Clinical Severity Score (VCSS) has been proposed by the American Venous Forum as an objective means to clinically assess venous disease more completely than with the clinical CEAP classification. However, validation of the VCSS against an objective test is lacking. The purpose of this study was to test the VCSS against abnormalities found on venous ultrasound (US) scans. METHODS As part of a screening project in a large kindred population with protein C deficiency, VCSS and venous US scanning were performed in 210 patients (420 limbs). A single examiner scored the VCSS (0-3) clinically for pain, varicose veins, edema, skin pigmentation, inflammation, induration, ulcer duration and size, and compressive therapy. Another experienced examiner, blinded to the subjects medical history, performed a US examination of the deep and superficial venous system, with a hand-carried US system. The relationship between US and VCSS scores was analyzed by calculating an odds ratio (OR) and its 95% confidence interval (CI). RESULTS Of the 420 limbs screened, VCSS was 0 in 283 limbs, and VCSS was 1 or greater in the following categories: pain, 63 limbs; varicose veins, 70 limbs; edema, 51 limbs; skin pigmentation, 17 limbs; inflammation, 2 limbs; induration, 8 limbs; and compressive therapy, 9 limbs. The highest total score in any limb was 8. A clear association was seen with the VCSS and abnormalities found on US scans. When the score was dichotomized (0 = normal, 1 = any abnormality), it was a strong predictor of US scan abnormalities; limbs with VCSS greater than 0 had a 26-fold greater chance of US scan abnormalities than did limbs with VCSS = 0 (OR, 26.5; 95% CI, 11-64). With ultrasonography as the standard, sensitivity of VCSS compared with US scans was 89.3%, and specificity was 76.1%. Negative predictive value of VCSS = 0 was 97.9%, and positive predictive value for any positive score was 36.5% CONCLUSIONS The results of this study are based on a large kindred population with a higher risk for venous disease than found in the general population. Though the VCSS was devised to quantify the severity of chronic venous disease, this study found it a useful screening tool. The VCSS showed good association with abnormalities on US scans, and when VCSS = 0 there is a high likelihood that the patient does not have venous disease. This simple test may prove valuable in clinical practice.

Do point prevalence and prolonged abstinence measures produce similar results in smoking cessation studies? A systematic review

INTRODUCTION Many smoking cessation trials report either prolonged abstinence (PA) rates (i.e., not smoking since a quit date, with or without a grace period) or point prevalence (PP) abstinence rates (i.e., no smoking one or more days prior to the follow-up), but how these two relate is unclear. METHODS We located 28 pharmacotherapy trials that provided 76 within-study comparisons of PA versus PP. The first two authors independently coded all trials. RESULTS The two measures were highly correlated (r = .88) and PA averaged 0.74 that of PP. Equations for converting PP to PA and vice versa produced estimations that, in 90% of cases, were within 4%-5% of actual PP or PA values. The odds ratio and the relative risk for active versus control were identical when PA and PP were used; however, the difference in proportion abstinent for active versus control was somewhat less when PA was used than when PP was used (8% vs. 10%). DISCUSSION We conclude that PA and PP are closely related and can be interconverted with moderate accuracy. They also produce similar effect sizes when odds ratio and relative risk are used as effect sizes. When absolute difference in percent abstinent is used as an effect size, PA produces a smaller effect size than PP. We believe trials should continue to report both PA and PP outcomes to enhance comparisons across studies.

Relationship Between Isokinetic Strength and Tibiofemoral Joint Space Width Changes After Anterior Cruciate Ligament Reconstruction

Background: It has been hypothesized that quadriceps muscle weakness is directly associated with the onset and progression of posttraumatic osteoarthritis after anterior cruciate ligament (ACL) injury and reconstruction (ACLR). This relationship, however, has not been studied with a prospective approach that includes the use of tibiofemoral joint space width difference (JSW-D) measurements to characterize the onset of posttraumatic osteoarthritis before the clinical manifestation of the disease. Purpose: To assess the relationship between thigh muscle strength and JSW-D at presurgery baseline and at 1- and 4-year follow-up after ACLR compared with healthy, noninjured participants of similar sex, age, body mass index, and activity level. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 39 unilateral ACL-injured patients and 32 healthy controls were followed prospectively. During each follow-up, JSW, isokinetic knee strength, single-legged hop, and clinical- and patient-oriented outcomes were assessed. At final follow-up, ACL-injured participants who had JSW-D values (considered as the injured minus normal knee) that were less than the 95% confidence interval of controls were considered to be in the ACLR-narrow group, while those with JSW-D values that fell within the confidence intervals were in the ACLR-normal group. Relationships were evaluated between ACLR groups and controls via multilevel regression, as well as Kruskal-Wallis tests for between-group comparisons at 4-year follow-up. Results: At 4-year follow-up, 30 participants (79%) were in the ACLR-normal group and 8 (21%) were in the ACLR-narrow group. At baseline, the extension, flexion, and extension/flexion ratio strength values for both ACLR groups were significantly lower than those of controls (P ≤ .05), while the ACLR-narrow group had significantly lower extension strength at 60 and 180 deg/s (P = .04 and .03, respectively), as well as extension/flexion ratio at 60 deg/s (P = .04) in comparison with the ACL-normal group. At 4-year follow-up, 60 deg/s extension strength deficits persisted in the ACLR-narrow group compared with controls and ACLR-normal participants (P = .01 and .04, respectively). Flexion strength at 180 and 300 deg/s was also significantly lower in the ACLR-narrow group compared with ACLR-normal (P = .02 and .04, respectively), as was single-legged hop distance (P = .04). Conclusion: Strength deficits present within months after ACL injury and persist through 4 years after ACLR in participants with significantly narrowed JSW-D, compared with ACLR participants with normal JSW-D and controls. This study revealed a significant relationship between quadriceps strength loss that occurred soon after injury and JSW narrowing.

Sarcomatoid renal cell carcinoma is an example of epithelial–mesenchymal transition

Background Sarcomatoid renal cell carcinomas (SRCC) are composed of two cell populations, a sarcomatous component (SC) and a carcinomatous component (CC). SRCC are particularly aggressive and often present at an advanced stage at diagnosis. Epithelial–mesenchymal transition (EMT) has been proposed as a mechanism for the development of SC from CC. Aims and methods E- to N-cadherin switching, localisation of β-catenin, and expression of Snail and secreted protein acidic and rich in cysteine (SPARC) (markers of EMT) were studied to determine whether SRCC is an example of EMT. Expression of these markers was analysed by immunohistochemistry on 21 cases of SRCC that had both SC and CC and scored according to intensity and extent. Results E-cadherin expression was decreased in SC (Wilcoxon signed-rank test, p=0.0004) while N-cadherin expression was high in both components (p=0.46). Membranous β-catenin expression was decreased in SC (p<0.0001) while cytoplasmic expression was increased (p=0.0002). Snail and SPARC had higher expression in SC (p=0.002 and p<0.0001, respectively). When the scores were dichotomised into low and high expression levels, the results using McNemars test substantiated the above results. Conclusions E- to N-cadherin switching, dissociation of β-catenin from the membrane, and increased expression of Snail and SPARC in SC indicate that SRCC is an example of EMT. High expression of N-cadherin and Snail in CC suggest early involvement in initiating EMT. Once EMT is established, loss of E-cadherin, release of β-catenin into the cytoplasm, and expression of SPARC correspond with mesenchymal phenotypic expression.

Results of an Intervention for Individuals and Families with BRCA Mutations: A Model for Providing Medical Updates and Psychosocial Support Following Genetic Testing

Providing medical management updates and long-term support to families with hereditary cancer syndromes in rural areas is a challenge. To address this, we designed a one-day retreat for BRCA1/2 carriers in our region. The retreat included educational updates about medical management, genetic privacy and discrimination, and addressed psychological and family issues. Evaluations completed at the conclusion of the retreat were overwhelmingly positive with requests for a similar event in the future. The impact of this retreat on a variety of health behaviors was assessed. Eligible participants completed questionnaires before and 6 months after the retreat. Questionnaires focused on lifestyle, cancer screening and prevention practices, psychological history and distress, decision-making regarding genetic testing, and family communication issues. For individuals who completed both the pre and post retreat questionnaires, one-half made lifestyle changes and nearly two-thirds increased cancer screening, initiated chemoprevention, completed or planned to complete preventative surgery in the future. We conclude that this type of forum provides a valuable opportunity for BRCA carriers and their families to receive updated medical information, share personal experiences, provide and receive support, as well as change health behaviors.

Carcinoma and atypical hyperplasia in reduction mammaplasty: increased sampling leads to increased detection. A prospective study.

Background: Reduction mammaplasty for symptomatic macromastia or correction of asymmetry is performed more than 100,000 times per year in the United States. The reported incidence of occult breast cancer in reduction mammaplasty ranges from 0.06 to 4.6 percent. No standard pathology assessment for reduction mammaplasty exists. The authors evaluated the incidence of occult carcinoma and atypical hyperplasia in reduction mammaplasty specimens and identified clinical risk factors. Systematic sampling of additional tissue sections was instituted to evaluate the hypothesis that increased sampling would identify more significant pathologic findings. Methods: All reduction mammaplasty specimens over a 20-month period at a single institution were prospectively examined. All specimens had baseline gross and microscopic evaluations, and then each was subjected to systematic additional sampling. The incidence of significant pathologic findings (carcinoma and atypical hyperplasia) was tabulated. Variables such as age and preoperative mammogram were examined. Results: A total of 202 cases were evaluated. Significant pathologic findings (carcinoma and atypical hyperplasia) were present in 12.4 percent. The rate of carcinoma was 4 percent in all patients (6.2 percent in patients ≥40 years and 7.9 percent in patients ≥50 years). Conclusions: A significantly higher rate (12.4 percent) of significant pathologic findings was identified in this prospective study compared with published literature. None of the lesions was identified on preoperative mammogram. Age was significantly associated with significant pathologic findings. Increased sampling was associated with significant pathologic findings only in patients 40 years or older, indicating the need for thorough sampling of reduction mammaplasty specimens in patients older than 40.