Assessment of the safety of nivolumab in people living with HIV with advanced cancer on antiretroviral therapy: the AIDS Malignancy Consortium 095 Study

BACKGROUND

Although immunotherapy has emerged as a therapeutic strategy for many cancers, there are limited studies establishing the safety and efficacy in people living with HIV (PLWH) and cancer.

METHODS

PLWH and solid tumors or Kaposi sarcoma (KS) receiving antiretroviral therapy and a suppressed HIV viral load received nivolumab at 3 mg/kg every 2 weeks, in two dose deescalation cohorts stratified by CD4 count (stratum 1: CD4 count > 200/µL and stratum 2: CD4 count 100-199/µL). An expansion cohort of 24 participants with a CD4 count > 200/µL was then enrolled.

RESULTS

A total of 36 PLWH received nivolumab, including 15 with KS and 21 with a variety of other solid tumors. None of the first 12 participants had dose-limiting toxicity in both CD4 strata, and five patients (14%) overall had grade 3 or higher immune related adverse events. Objective partial response occurred in nine PLWH and cancer (25%), including in six of 15 with KS (40%; 95% CI, 16.3-64.7). The median duration of response was 9.0 months overall and 12.5 months in KS. Responses were observed regardless of PDL1 expression. There were no significant changes in CD4 count or HIV viral load.

CONCLUSIONS

Nivolumab has a safety profile in PLWH similar to HIV-negative subjects with cancer, and also efficacy in KS. Plasma HIV remained suppressed and CD4 counts remained stable during treatment and antiretroviral therapy, indicating no adverse impact on immune function.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02408861.

Construct validity and responsiveness of a health-related symptom index for persons either treated or monitored for anal high-grade squamous intraepithelial lesions (HSIL): AMC-A01/-A03

PURPOSE

To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI).

METHODS

The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization.

RESULTS

Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness.

CONCLUSION

A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making.

EVALUATING THE STAFFING METHODOLOGY MODEL IN THE VETERANS HEALTH ADMINISTRATION’S COMMUNITY LIVING CENTERS

The project purpose was to describe nursing hours per patient day (NHPPD) within the Veterans Health Administration (VHA) and to evaluate Staffing Methodology in the VHA Community Living Centers (CLCs) by comparing Staffing Methodology targeted NHPPD with actual NHPPD. Data were compiled retrospectively for each CLC unit over a one-year timeframe for calendar year 2019. VHA had 134 CLCs including 390 nursing units. Nursing units without 6 months of actual NHPPD data were excluded from the data set. For descriptive analyses, actual NHPPD were averaged across months for each unit. The percent of target was calculated as this average divided by the NHPPD target times 100. The percentage of months each unit met the targeted NHPPD was calculated. After data exclusions, the final data set included 322 nursing units from 133 CLCs. The mean for actual hours as a percent of target was 121.6% (95% CI, 118.5 to 124.7%) indicating that the units’ average hours across 2019 were 21.6% significantly higher than target. Also, half of units met their targets 91.7% of months as reflected by the median. The actual NHPPD significantly differed across months (p< 0.001) with the 2019 months of January and October having the highest NHPPD. Similar results were seen for NHPPD as a percent of target. Veteran safety is a VHA priority and appropriate nurse staffing is key to providing care that improves Veteran outcomes and reduces adverse events. Further exploration is needed on how nurse staffing in the CLCs impacts Veteran outcomes, safety, and satisfaction.

LGG-06. Selumetinib in pediatric patients with non-neurofibromatosis type 1-associated, non-optic pathway (OPG) and non-pilocytic recurrent/progressive low-grade glioma harboring BRAFV600E mutation or BRAF-KIAA1549 fusion: a multicenter prospective Pediatric Brain Tumor Consortium (PBTC) Phase 2 trial

BACKGROUND: A greater understanding of the Ras-MAP kinase pathway in pediatric low-grade glioma (LGG) paired with the availability of selective inhibitors has enhanced the ability to target this pathway with therapeutic intent. METHODS: The PBTC conducted a multi-institutional phase II study (NCT01089101) evaluating selumetinib (AZD6244, ARRY-142886), a MEK I/II inhibitor, in children with recurrent/progressive LGG assigned to 6 strata and treated at a dose of 25 mg/m2/dose PO BID for up to two years. Here we present stratum 5 which enrolled children without NF1, non-OPG and non-pilocytic LGG harboring either a BRAFV600E mutation or BRAF-KIAA1549 fusion. RESULTS: Twenty-four of 25 children enrolled were eligible; 23 were evaluable for the primary radiologic response endpoint. Enrollment stopped early due to slow accrual and initiation of COG ACNS1931. The most common histologies were ganglioglioma (42%) and astrocytoma NOS (33%). Thirteen tumors (54%) had BRAF-KIAA1549 fusion; 11 (46%) had the BRAFV600E mutation. Five of 23 (22%) evaluable patients achieved a centrally confirmed partial response (PR), 12 (52%) had stable disease and 6 (26%) had progression with a 2-year progression-free survival of 75 + 9%. Four of 11 (36%) patients with a BRAFV600E mutation and 1/12 (8%) with a BRAF-KIAA1549 fusion achieved a PR. The 2-year PFS did not significantly differ between tumors with BRAFV600E mutation (82 + 12%) versus BRAF-KIAA1549 fusion (68 + 13%) (n=24, p=0.548). No patient remains on therapy. The most common attributable toxicities were grade 1/2 ALT/AST elevation, dry skin and leukopenia. Rare grade 3/4 toxicities included elevated CPK, rash, paronychia, fever, weight gain and sinus tachycardia. CONCLUSIONS: Despite lower than planned accrual, selumetinib met the design threshold for success in treating children with recurrent/progressive non-pilocytic, non-OPG LGG without NF1 that harbored the common BRAF aberrations. Ongoing phase 3 prospective studies will better determine the role of this agent in this population.

Plasma extracellular vesicles bearing PD-L1, CD40, CD40L or TNF-RII are significantly reduced after treatment of AIDS-NHL

Emerging evidence shows that tumor cells secrete extracellular vesicles (EVs) that carry bioactive cell surface markers, such as programmed death-ligand 1 (PD-L1), which can modulate immune responses and inhibit anti-tumor responses, potentially playing a role in lymphomagenesis and in promoting the growth of these cancers. In this study, we investigated the role of EVs expressing cell surface molecules associated with B cell activation and immune regulation. We measured levels of EVs derived from plasma from 57 subjects with AIDS-related non-Hodgkin lymphoma (AIDS-NHL) enrolled in the AIDS Malignancies Consortium (AMC) 034 clinical trial at baseline and post-treatment with rituximab plus concurrent infusional EPOCH chemotherapy. We found that plasma levels of EVs expressing PD-L1, CD40, CD40L or TNF-RII were significantly reduced after cancer treatment. AIDS-NHL patients with the diffuse large B cell lymphoma (DLBCL) tumor subtype had decreased plasma levels of EVs bearing PD-L1, compared to those with Burkitt's lymphoma. CD40, CD40L and TNF-RII-expressing EVs showed a significant positive correlation with plasma levels of IL-10, CXCL13, sCD25, sTNF-RII and IL-18. Our results suggest that patients with AIDS-NHL have higher levels of EVs expressing PD-L1, CD40, CD40L or TNF-RII in circulation before cancer treatment and that levels of these EVs are associated with levels of biomarkers of microbial translocation and inflammation.

Compression Therapy for HIV-Associated Kaposi Sarcoma Leg Lymphedema: Results of the Kenyan Improvised Compression for Kaposi Sarcoma Randomized Controlled Trial

PURPOSE

Evaluate the effectiveness of compression while receiving chemotherapy compared with chemotherapy alone in the treatment of HIV-associated Kaposi sarcoma (KS) lymphedema.

METHODS

A randomized controlled trial was conducted in a single oncology clinic in western Kenya (NCT03404297). A computer-generated randomization schedule was used to allocate treatment arms. Randomized block design was used for stratification by lymphedema stage. Participants were HIV positive adults age ≥ 18 years on antiretroviral therapy with biopsy-proven KS associated with leg lymphedema and being initiated on chemotherapy. The intervention was 10 weeks of weekly clinic-based application of two-component paste compression bandages. The primary outcome was change in the Lower Extremity Lymphedema Index (LELI) score from week 0 to week 14. The secondary outcomes were change in the Lymphedema Quality of Life measure (LYMQOL) and change in the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 score from week 0 to week 14. Blinded outcome assessments were conducted.

RESULTS

Of 30 participants randomly assigned, 25 eligible patients (chemotherapy [control], n = 13; compression plus chemotherapy [intervention], n = 12) returned at week 14. Change in LELI, LYMQOL, and EORTC QLQ-C30 scores between week 14 and week 0 did not significantly differ by arm. The mean (standard deviation) change in LELI score was -25.9 (34.6) for the control arm compared with -13.3 (29.5) for the intervention arm, P = .340. The difference (95% CI) in the change in LELI score was -12.6 (-39.3 to 14.1).

CONCLUSION

Future studies evaluating a 14-week change in LELI for KS lymphedema should assume a standard deviation of approximately 30. Lessons learned from this pilot trial should inform the development of a larger, multicenter trial to evaluate the effectiveness of compression for KS lymphedema.

Immune Activation and Microbial Translocation as Prognostic Biomarkers for AIDS-Related Non-Hodgkin Lymphoma in the AMC-034 Study

PURPOSE

AIDS-related non-Hodgkin lymphoma (ARL) is the most common cancer in HIV-infected individuals in the United States and other countries in which HIV-positive persons have access to effective combination antiretroviral therapy (cART). Our prior work showed that pretreatment/postdiagnosis plasma levels of some cytokines, such as IL6, IL10, and CXCL13, have the potential to serve as indicators of clinical response to treatment and survival in ARL. The aims of this study were to identify novel prognostic biomarkers for response to treatment and/or survival in persons with ARL, including biomarkers of microbial translocation and inflammation.

EXPERIMENTAL DESIGN

We quantified plasma levels of several biomarkers (sCD14, LBP, FABP2, EndoCab IgM, IL18, CCL2/MCP-1, sCD163, IP-10/CXCL10, TARC/CCL17, TNFα, BAFF/BLyS, sTNFRII, sCD44, and sIL2Rα/sCD25) by multiplexed immunometric assays (Luminex) or ELISA in plasma specimens obtained from ARL patients enrolled in the AMC-034 trial, which compared infusional combination chemotherapy (EPOCH: etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone) with concurrent or sequential rituximab. Plasma was collected prior to the initiation of therapy (n = 57) and after treatment initiation (n = 55).

RESULTS

We found that several biomarkers decreased significantly after treatment, including TNFα, sCD25, LBP, and TARC (CCL17). Moreover, pretreatment plasma levels of BAFF, sCD14, sTNFRII, and CCL2/MCP-1 were univariately associated with overall survival, and pretreatment levels of BAFF, sTNFRII, and CCL2/MCP-1 were also associated with progression-free survival.

CONCLUSIONS

Our results suggest that patients with ARL who responded to therapy had lower pretreatment levels of inflammation and microbial translocation as compared with those who did not respond optimally.

Prevalence of oral human papillomavirus infection among Indian HIV-positive men who have sex with men: a cross-sectional study

BACKGROUND

Oral human papillomavirus (HPV) infection has been causally linked to a subset of oropharyngeal cancers in Western populations, and both oropharyngeal cancer and oral HPV infection are increased among HIV-positive individuals. India has high incidences of oral and oropharyngeal cancers, and Indian HIV-positive men who have sex with men (MSM) may be at increased risk of developing oropharyngeal cancers. However, there is little information available on the prevalence of oral HPV in this population.

METHODS

We tested 302 HIV-positive Indian MSM for oral HPV infection using L1 HPV DNA PCR with probes specific for 29 types and a mixture of 10 additional types. CD4+ level and plasma HIV viral load (VL) were measured. Participants completed an interviewer-administered questionnaire including a sexual history.

RESULTS

The prevalence of oral HPV was 23.7% (95% CI: 19-29%) and 2.4% of participants had oncogenic HPV types. No participants had oral HPV type 16 (HPV-16) and the prevalence of other anogenital HPV types was low. Participants with higher CD4+ levels had reduced odds of having any oral HPV infection (OR: 3.1 [1.4-6.9]) in multivariable analyses.

CONCLUSIONS

This is the first report of oral HPV among Indian HIV-positive MSM. Our results show a high prevalence of oral HPV infection consistent with studies from Western populations. However, oncogenic anogenital HPV types were relatively uncommon in our study population. It is unknown what the impact of this distribution of oral HPV will be on oropharyngeal cancers. HIV-positive MSM in India should be monitored closely for oral and oropharyngeal pre-cancer and cancer.

AIDS Malignancy Consortium 054: Safety and Immunogenicity of the Quadrivalent Vaccine in Indian Women Living With HIV

BACKGROUND

Human papillomavirus (HPV)-associated cervical cancer is a leading cause of death among Indian women. Indian women living with HIV (WLWH) may be at especially high risk. The quadrivalent HPV (qHPV) vaccine is effective in prevention of initial infection with HPV-6/11/16/18 in HIV-negative women. Little is known about previous exposure to HPV-6/11/16/18, safety, and immunogenicity of qHPV in Indian WLWH.

METHODOLOGY

One hundred fifty WLWH with different CD4 levels and HIV viral load (VL) were vaccinated at 0/2/6 months at CART-CRS-IDMC, Chennai, India. Serology was performed at weeks 0, 28, and 52 for HPV-6/11/16/18 using a competitive Luminex immunoassay and for HPV-16/18 using a pseudovirion-based neutralization assay.

RESULTS

Mean age was 30.8 years (range, 19-44 years). 71/87/73/81% of women were naive (sero-negative and DNA-negative) to HPV-6/11/16/18 at baseline, respectively. Among per-protocol women naive to HPV-6/11/16/18 at baseline, 100/99/99/90%, respectively, seroconverted at week 28 and 95/96/98/71% were sero-positive at week 52, respectively. Pseudovirion-based neutralization assay identified more seroconversion to HPV-18 than competitive Luminex immunoassay. There were no significant differences in the proportion seroconverting by baseline or nadir CD4 or HIV VL; however, there was a trend for increased proportion seroconverting to HPV-18 among women with higher baseline CD4 level (P = 0.052). There were no qHPV-related serious adverse events and no change in CD4 level or HIV VL among women on ART.

CONCLUSIONS

qHPV vaccine was safe and immunogenic in Indian WLWH. A high proportion were naive to HPV-6/11/16/18 and may benefit from vaccination although many were married and several years post-initiation of sexual activity.

Impact of anti-PD-1 and anti-CTLA-4 on the HIV reservoir in people living with HIV with cancer on antiretroviral therapy: The AIDS Malignancy Consortium-095 study

BACKGROUND

Antibodies to PD-1 and CTLA-4 may perturb HIV persistence during antiretroviral therapy (ART) by reversing HIV-latency and/or boosting HIV-specific immunity leading to clearance of infected cells. We tested this hypothesis in a clinical trial of anti-PD-1 alone or in combination with anti-CTLA-4 in people living with HIV (PLWH) and cancer.

METHODS

This was a substudy of the AIDS Malignancy Consortium-095 Study. ART-suppressed PLWH with advanced malignancies were assigned to nivolumab (anti-PD-1) with or without ipilimumab (anti-CTLA-4). In samples obtained pre-infusion and one and seven days after the first and fourth dose of immune checkpoint blockade (ICB), we quantified cell-associated unspliced (CA-US) HIV-RNA and HIV-DNA. Plasma HIV-RNA was quantified during the first treatment cycle. Quantitative viral outgrowth assay (QVOA) to estimate the frequency of replication-competent HIV was performed before and after ICB for participants with samples available.

RESULTS

Of forty participants, 33 received nivolumab and seven nivolumab plus ipilimumab. Whereas CA-US HIV RNA did not change with nivolumab monotherapy, we detected a median 1.44 fold-increase (IQR 1.16-1.89) after the first dose of nivolumab and ipilimumab combination therapy (P=0.031). There was no decrease in the frequency of cells containing replication-competent HIV, but in the two individuals on combination ICB for whom we had longitudinal QVOA, we detected decreases of 97% and 64% compared to baseline.

CONCLUSION

Anti-PD-1 alone showed no effect on HIV-latency or the latent HIV-reservoir, but the combination of anti-PD-1 and anti-CTL-4 induced a modest increase in CA-US HIV RNA and may potentially eliminate cells containing replication-competent HIV.

Translating Exercise Benefits Over Telehealth

Background: Gerofit-Geriatric walking clinic is a home-based program that helps older veterans engage in regular walking via different platforms to improve access. The objective was to compare the outcomes of face-to-face visits to telehealth visits. Methods: Older Veterans (N=646) and walking-buddies (N=154) were seen either face-to-face or via telehealth at baseline, 2-, and 6-months. The primary intervention, pedometer feedback and motivational phone calls were delivered remotely. Results: Demographic data were similar in both Veteran groups and 47% were seen via telehealth. Compared to face-to-face, a higher proportion in the telehealth group had walking buddies (10% vs. 27%; p<0.001), received exercise counseling (75% vs. 95%; p=0.001), and reported perceived barriers (40% vs. 67%; p=0.004). There were statistically significant improvements in step-counts at 2- and 6-months compared to baseline (57% and 99% improvement; p<0.01) with no significant between-group differences. Conclusion: Tailored activity promotion programs via telehealth are effective in reaching older veterans.

Medical Student’s Perception of Dementia Assessment and Management Among Rural Veterans

Background: Rural Veterans rely on their caregivers, case managers and primary care providers for dementia management. Providers of such patients need to work closely with caregivers, know the local dementia resources and be comfortable with the multiple facets of dementia assessment and management. Unfortunately, medical students are not particularly well trained in these aspects and huge knowledge gaps exist. The goal was to study the impact of a multi-component, experiential, brief curriculum on attitudes of dementia care. Methods: 108 medical students participated in a curriculum including didactics, clinical, and team-based learning followed by pre-post assessments. Results: Student’s perception of their ability to assess multiple facets of dementia such as behaviors, caregiver burden, and cognition improved significantly (p<0.001). Students’ perception of the role of social worker improved significantly (p=0.002). Conclusion: An interdisciplinary curriculum, improved medical students’ perception of their ability to assess for dementia in a cohort of predominantly rural Veterans.

Overweight and Obesity Among School Bus Drivers in Rural Arkansas

Introduction

Obesity is a major public health concern. Compared with other occupational groups, transportation workers, such as school bus drivers, have higher rates of obesity. However, little is known about the body weight and related health behaviors of these drivers, and opportunities for intervention are undetermined.

Methods

We collected multilevel data from school bus drivers working from 4 school bus garages in Little Rock, Arkansas, and their work environment from January through July of 2017. Data on weight, height, sociodemographic characteristics, work factors, weight-related behaviors, and psychosocial variables were collected from 45 drivers. Analyses explored associations between body mass index (BMI; weight in kg/ height in m²) and sociodemographic characteristics, work factors, weight-related behaviors, and psychosocial variables. Two focus groups with a total of 20 drivers explored drivers’ perspectives about healthy weight. Observational data at the bus and garage levels were collected through 2 “ride-alongs” and an environmental scan.

Results

Drivers in our sample were predominately overweight or obese (91.1%), and most did not meet dietary or physical activity guidelines. Drivers who were currently dieting had higher BMIs (36.4; standard deviation [SD], 8.2) than drivers who were not dieting (28.5; SD, 7.7); drivers who reported eating less to lose weight had higher BMIs (38.1; SD, 8.5) than those who did not report eating less (29.5; SD, 6.0). Drivers who did not meet physical activity recommendations had higher BMIs (36.5; SD, 9.8) than those who met recommendations (30.9; SD, 4.8). Structural barriers and work stress were significant barriers to achieving a healthy weight. Resources for healthful eating and physical activity were limited in the garage.

Conclusion

Our study provides preliminary data on the prevalence, risk factors, and perceptions of overweight and obesity among school bus drivers. Study data on drivers’ body weight, health-related behaviors, and psychosocial characteristics could serve as a basis for worksite interventions to improve drivers’ health.

AIDS malignancy consortium (AMC) 095: A phase I study of ipilimumab (IPI) and nivolumab (NIVO) in advanced HIV-associated solid tumors (ST) with expansion cohorts in HIV-associated solid tumors and classical Hodgkin lymphoma (cHL)

TPS44

Background: Immune checkpoint blockade (ICB) using agents that target the priming phase (i.e. CTLA-4) and effector phase (e.g. PD-1) of host immunity, used individually or in combination, has emerged as a therapeutic strategy for cancers. However, little is known about the safety, tolerability and efficacy of ICB in patients (pts) with HIV infection and cancer. Methods: AMC 095 (NCT02408861) is a multicenter, international phase I study of the PD-1 inhibitor, nivo alone or in combination with a CTLA-4 inhibitor, ipi, in 2 cohorts stratified by CD4 counts (Stratum 1: CD4 counts≥200/uL and Stratum 2: CD4 count 100-200/uL) with additional expansion cohorts at the recommended phase II dose in pts with ST and cHL. The primary study objective is to determine the safety and feasibility of nivo alone and the nivo+ipi combination. Secondary objectives are to evaluate the effects of single agent nivo, and ipi+ nivo, on HIV replication and immune function (HIV viral load in plasma using conventional assay, CD4+, and CD8+ cells), and to obtain preliminary information regarding response. The trial was initiated in 8/15, as of 9/30/17, the study is ongoing, and 14 pts have been enrolled. Updated information on the safety and responses will be presented. Clinical trial information: NCT02408861. Funded by the NCI Grant #UM1CA121947.[Table: see text]

Concordance Between Veterans' Self-Report and Documentation of Surrogate Decision Makers: Implications for Quality Measurement

CONTEXT

The Measuring What Matters initiative of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association identified documentation of a surrogate decision maker as one of the top 10 quality indicators in the acute hospital and hospice settings.

OBJECTIVES

To better understand the potential implementation of this Measuring What Matters quality measure #8, Documentation of Surrogate in outpatient primary care settings by describing primary care patients' self-reported identification and documentation of a surrogate decision maker.

METHODS

Examination of patient responses to self-assessment questions from advance health care planning educational groups conducted in one medical center primary care clinic and seven community-based outpatient primary care clinics. We assessed the concordance between patient reports of identifying and naming a surrogate decision maker and having completed an advance directive (AD) with presence of an AD in the electronic medical record.

RESULTS

Of veterans without a documented AD on file, more than half (66%) reported that they had talked with someone they trusted and nearly half (52%) reported that they had named someone to communicate their preferences.

CONCLUSIONS

Our clinical project data suggest that many more veterans may have initiated communications with surrogate decision makers than is evident in the electronic medical record. System changes are needed to close the gap between veterans' plans for a surrogate decision maker and the documentation available to acute care health care providers.

Evaluation of Myocardial Strain in Patients With Amyloidosis Using Cardiac Magnetic Resonance Feature Tracking

PURPOSE

To study the use of cardiac magnetic resonance (CMR) feature tracking technique in evaluation of myocardial amyloidosis.

MATERIALS AND METHODS

CMR scans of 28 patients with biopsy proven myocardial amyloidosis and 35 controls were reviewed. Conventional short axis, vertical long axis, and 4-chamber cine steady-state free precession images from CMR scans were used to generate radial, circumferential, and longitudinal myocardial strain maps using feature tracking software. Global and regional peak radial, circumferential, and longitudinal strain values were computed.

RESULTS

There were significant decreases in radial, circumferential, and longitudinal strains in patients with myocardial amyloidosis globally and across layers (all P < 0.001). Strain was relatively preserved for the apex and most affected for the basal level. The area under the receiver operating characteristic curve for base peak radial, circumferential, and longitudinal strain 0.899, 0.884, and 0.866 and cut offs of 22.9, -13.3, and -10.9, respectively, were determined by receiver operating characteristic analysis. CMR feature tracking strain analysis of base-level strain parameters was able to differentiate patients with myocardial amyloidosis from those without myocardial amyloid with high sensitivity (82.5%) and specificity (82.9%) particularly for radial strain. The maximum sensitivity (89.3%) was achieved if any of the 3 parameters were abnormal, and the maximum specificity (88.6%) when all 3 parameters were abnormal.

CONCLUSION

Myocardial amyloidosis produces significant changes in regional and global strain parameters, and the peak radial and circumferential strain are the most affected at the basal layer.

Home Screening for Bacterial Vaginosis to Prevent Sexually Transmitted Diseases

BACKGROUND

Longitudinal studies have consistently found a significant association between bacterial vaginosis (BV) and acquisition of sexually transmitted diseases. However, there are limited prospective data to confirm these findings.

METHODS

We conducted a prospective, randomized, open-label trial of home screening and treatment of young women with asymptomatic BV who were also at high risk for sexually transmitted diseases. These women were screened every 2 months for 12 months and randomized to treatment with oral metronidazole 500 mg twice daily for 7 days or observation alone. The primary outcome was the incidence of gonorrhea and/or chlamydia.

RESULTS

A total of 1365 subjects were enrolled in the study across 10 sites. Adherence with mailing specimens obtained at home was excellent in both groups (84%-88%). The incidence of gonorrhea and/or chlamydia was 19.1 per 100 person-years (95% confidence interval, 15.1-22.1) for the treatment group and 18.5 per 100 person-years (15.1-22.8) for the observation arm, a difference that was not statistically significant.

CONCLUSIONS

Young women were very amenable to home screening for BV, gonorrhea, and chlamydia. Treatment of asymptomatic BV with 1 week of oral metronidazole did not decrease the incidence of gonorrhea and/or chlamydia.

CLINICAL TRIALS REGISTRATION

NCT00667368.

Women's Perceptions of Provider Empathy in the Context of Healthcare Disparities

An issue in addressing racial healthcare disparities is the need to reduce, often unconscious, provider bias. Provider empathy can overcome such bias. Patient perceptions of provider empathy were explored to identify which provider behaviors patients perceived as conveying empathy and how perceived provider empathy influenced patient-provider interactions. In this qualitative study utilizing in-depth interviews and medical records, interviewers conducted in-depth interviews with 23 patients from three clinics. Patients reported that the following influenced perceptions of provider empathy: Taking time, patient engagement, valuing the patient, clear communication, and the healthcare system. Subtle racial differences existed. This information contributes to research on empathy and patient-provider interaction and provides preliminary evidence for racial differences.

Randomized Trial of Periodic Presumptive Treatment With High-Dose Intravaginal Metronidazole and Miconazole to Prevent Vaginal Infections in HIV-negative Women

BACKGROUND

Vaginal infections are common, frequently recur, and may increase women's risk for sexually transmitted infections (STIs). We tested the efficacy of a novel regimen to prevent recurrent vaginal infections.

METHODS

Human immunodeficiency virus (HIV)-negative women 18-45 years old with 1 or more vaginal infections, including bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), or Trichomonas vaginalis (TV), were randomly assigned to receive vaginal suppositories containing metronidazole 750 mg plus miconazole 200 mg or matching placebo for 5 consecutive nights each month for 12 months. Primary endpoints, evaluated every 2 months, were BV (Gram stain) and VVC (positive wet mount and culture).

RESULTS

Participants (N = 234) were randomly assigned to the intervention (N = 118) or placebo (N = 116) arm. Two hundred seventeen (93%) women completed an end-of-study evaluation. The intervention reduced the proportion of visits with BV compared to placebo (21.2% vs 32.5%; relative risk [RR] 0.65, 95% confidence interval [CI] .48-.87). In contrast, the proportion of visits with VVC was similar in the intervention (10.4%) versus placebo (11.3%) arms (RR 0.92, 95% CI .62-1.37).

CONCLUSIONS

Monthly treatment with intravaginal metronidazole plus miconazole reduced the proportion of visits with BV during 12 months of follow-up. Further study will be important to determine whether this intervention can reduce women's risk of STIs.

Fully integrated e-services for prevention, diagnosis, and treatment of sexually transmitted infections: results of a 4-county study in California

OBJECTIVES

We examined the acceptability, feasibility, and cost of a fully integrated online system (eSTI) for sexually transmitted infection (STI) testing, treatment, and linkage to care with 4 Northern California health departments.

METHODS

In April 2012, we implemented the eSTI system, which provided education; testing of self-collected vaginal swabs for chlamydia, gonorrhea, and trichomoniasis; e-prescriptions; e-partner notification; and data integration with clinic electronic health records. We analyzed feasibility, acceptability, and cost measures.

RESULTS

During a 3-month period, 217 women aged 18 to 30 years enrolled; 67% returned the kit. Of these, 92% viewed their results online. STI prevalence was 5.6% (chlamydia and trichomoniasis). All participants with STIs received treatment either the same day at a pharmacy (62%) or within 7 days at a clinic (38%). Among participants completing follow-up surveys, 99% would recommend the online eSTI system to a friend, and 95% preferred it over clinic-based testing within a study.

CONCLUSIONS

The fully integrated eSTI system has the potential to increase diagnosis and treatment of STIs with higher patient satisfaction at a potentially lower cost.

Examination of costs for a lay health educator-delivered translation of the Diabetes Prevention Program in senior centers

OBJECTIVE

Older adults in the U.S. have high rates of obesity. Despite the demonstrated efficacy of lifestyle interventions among older adults, lifestyle interventions are not widely implemented in community settings. Program delivery by lay health educators (LHEs) might support greater dissemination because of lower delivery cost and greater accessibility. We examined the costs of a LHE-delivered translation of the Diabetes Prevention Program (DPP) evidence-based lifestyle intervention for older adults in Arkansas senior centers.

METHODS

This examination of costs used data from a cluster randomized control trial (conducted 2008-2010) in which 7 senior centers (116 participants) were randomized to implement a LHE-delivered 12-session translation of the DPP lifestyle intervention. We compiled direct lifestyle intervention implementation costs, including training, recruitment, materials, and ongoing intervention implementation support. Weight loss data (at 4-month follow-up) were collected from participants.

RESULTS

Participant weight loss averaged 3.7kg at 4-months. The total estimated cost to implement the lifestyle intervention is $2731 per senior center, or $165 per participant. The implementation cost per kilogram lost is $45.

CONCLUSIONS

A LHE-delivered DPP translation in senior centers is effective in achieving weight loss at low cost and offers promise for the dissemination of this evidence-based intervention.

Smoking restrictions in the homes of children with cancer

OBJECTIVES

To examine smoking restrictions in households of children with cancer and their effect on biological measures of children's secondhand smoke exposure (SHSe).

METHODS

A sample of 135 parents of nonsmoking children with cancer who lived with a smoker completed structured interviews.

RESULTS

Approximately 43% of families prohibited smoking in the home. Children living in homes that prohibited smoking had median cotinine levels that were 71% and 52% lower than did those from homes with no and partial restrictions.

CONCLUSIONS

Parents should be directed to completely ban all smoking from the home and car to best protect their children from SHSe.

A randomized trial of a community-based cognitive intervention for obese senior adults

OBJECTIVE

To determine whether a cognitive intervention delivered by lay health educators (LHEs) in senior centers was effective in improving cognition in obese older adults.

METHODS

This cluster randomized trial was conducted in 16 senior centers from which 228 senior adults were recruited. The centers were randomized to either the cognitive intervention or a control, weight-loss intervention. The primary outcome variable, cognitive function, was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

Analyses of RBANS indices as continuous variables did not indicate significant differences between arms. However, after adjusting for baseline delayed memory, gender, and baseline body mass index, seniors in the cognitive intervention arm had a 2.7 times higher odds of a reliable improvement (clinically significant) in delayed memory from baseline as compared to those in the control intervention (95% CI, 1.3-5.6, p = .011). The intervention effect was not significant for the proportion showing reliable improvement in immediate memory or in attention. Attendance at the 12-session program was high with an average of 83% (67%-92%) sessions attended and 87% of participants in the cognitive arm indicating they would recommend the program.

DISCUSSION

Cognitive interventions can be effectively delivered in the community by LHEs.

Parental psychosocial predictors of secondhand smoke exposure (SHSe) for children with cancer

Children with cancer are at greater risk for the negative consequences of secondhand smoke exposure, making the identification of predictors of exposure critical. The current study investigated the impact of parents' psychosocial variables (perceived stress and vulnerability, self-efficacy), as well as health-related and demographic variables, on children's current exposure levels. Data were from 135 families whose children (M = 8.6 years old) lived with a smoker and were being treated for cancer. Self-efficacy was the consistent significant psychosocial predictor of exposure and the time since a child's diagnosis was indicative of lower exposure when limiting the sample to only smoking parents (n = 95). Both predictors of exposure have implications on motivation for behavioral change and may be suggestive of a teachable moment. Interventions may profit from tailoring programs to families based on these predictors of exposure, in particular for tobacco-based interventions for parents of medically compromised children, such as children with cancer.

Training of lay health educators to implement an evidence-based behavioral weight loss intervention in rural senior centers

PURPOSE OF THE STUDY

Lay health educators (LHEs) offer great promise for facilitating the translation of evidence-based health promotion programs to underserved areas; yet, there is little guidance on how to train LHEs to implement these programs, particularly in the crucial area of empirically validated obesity interventions.

DESIGN AND METHODS

This article describes experiences in recruiting, training, and retaining 20 LHEs who delivered a 12-month evidence-based behavioral lifestyle intervention (based on the Diabetes Prevention Program) in senior centers across a rural state. A mixed method approach was used which incorporated collecting the folllowing: quantitative data on sociodemographic characteristics of LHEs; process data related to training, recruitment, intervention implementation, and retention of LHEs; and a quantitative program evaluation questionnaire, which was supplemented by a qualitative program evaluation questionnaire. Descriptive statistics were calculated for quantitative data, and qualitative data were analyzed using content analysis.

RESULTS

The training program was well received, and the LHEs effectively recruited participants and implemented the lifestyle intervention in senior centers following a structured protocol.

IMPLICATIONS

The methods used in this study produced excellent long-term retention of LHEs and good adherence to intervention protocol, and as such may provide a model that could be effective for others seeking to implement LHE-delivered health promotion programs.

Outcome of patients with relapsed/refractory acquired immune deficiency syndrome-related lymphoma diagnosed 1999-2008 and treated with curative intent in the AIDS Malignancy Consortium

No comparative studies exist for relapsed/refractory (rel/rfr) acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL). To determine practices over the last decade and to assess the outcomes of salvage chemotherapy with curative intent and autologous stem cell transplant (ASCT), we retrospectively evaluated treatment outcomes in patients with rel/rfr ARL who were treated in 13 national AIDS Malignancy Consortium (AMC) sites between 1999 and 2008 (n = 88). The most commonly used second-line therapies were ICE (ifosfamide/carboplatin/etoposide, n = 34), dose adjusted EPOCH (etoposide/prednisone/vincristine/cyclophosphamide/doxorubicin, n = 17) and ESHAP (etoposide/methylprednisolone/cytarabine/cisplatin, n = 11). The odds of achieving a response were lower for those with non-Hodgkin lymphoma (NHL) than for those with HL and for those with primary refractory disease than for those with relapse. Overall survival (OS) was significantly longer for those with relapsed disease compared to those with refractory disease and for those with non-Burkitt NHL compared to those with Burkitt. OS was longer in patients who underwent ASCT compared to those who did not (1-year OS: 63.2% vs. 37.2%). However, among 32 patients (36%) who achieved a complete or partial response (CR/PR) after second-line therapy, 1-year OS was not different between the two groups (87.5% for ASCT vs. 81.8% for non-ASCT). Long-term survival in some patients with rel/rfr ARL may be possible without transplant, although transplant remains the standard of care for chemotherapy sensitive disease.

Intervention to reduce secondhand smoke exposure among children with cancer: a controlled trial

OBJECTIVE

This randomized controlled trial tested the efficacy of parent-based behavioral counseling for reducing secondhand smoke exposure (SHSe) among children with cancer. It also examined predictors of smoking and SHSe outcomes.

METHODS

Participants were 135 parents or guardians of nonsmoking children with cancer, <18 years, at least 30 days postdiagnosis, and living with at least one adult smoker. Parents were randomized to either a standard care control group or an intervention consisting of six counseling sessions delivered over 3 months. Parent-reported smoking and child SHSe levels were obtained at baseline, 3, 6, 9, and 12 months. Children provided urine samples for cotinine analyses.

RESULTS

Reductions in parent-reported smoking and exposure were observed in both the intervention and control conditions. There was a significantly greater reduction in parent-reported smoking and child SHSe at 3 months for the intervention group compared with the control group. Child SHSe was significantly lower at 12 months relative to baseline in both groups. Children's cotinine levels did not show significant change over time in either group. Exposure outcomes were influenced by the number of smokers at home, smoking status of the parent participating in the trial, and the child's environment (home versus hospital) the day before the assessment.

CONCLUSIONS

Children's SHSe can be reduced by advising parents to protect their child from SHSe, combined with routine reporting of their child's exposure and cotinine testing, when delivered in the context of the pediatric cancer setting. More intensive interventions may be required to achieve greater reductions in SHSe.

Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections in men with nongonococcal urethritis: predictors and persistence after therapy

BACKGROUND

Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), and Trichomonas vaginalis (TV) are sexually transmitted infections (STIs) associated with nongonococcal urethritis (NGU). We assessed their predictors and persistence after treatment.

METHODS

We analyzed data from an NGU treatment trial among symptomatic heterosexual men aged 16-45 years from STI clinics. Nucleic acid amplification tests detected CT, MG, and TV at baseline and at 1 and 4 weeks after therapy. Associations between variables and STI detection were investigated.

RESULTS

Among 293 participants, 44% had CT, 31% had MG, and 13% had TV at baseline. In multivariate analysis, CT infection was associated with young age and STI contact. Young age was also associated with MG, and having ≥ 1 new partner was negatively associated with TV. We detected persistent CT in 12% and MG in 44% of participants at 4 weeks after therapy, which were associated with signs and symptoms of NGU. Persistent CT was detected in 23% of participants after azithromycin treatment vs 5% after doxycycline treatment (P = .011); persistent MG was detected in 68% of participants after doxycycline vs 33% after azithromycin (P = .001). All but 1 TV infection cleared after tinidazole.

CONCLUSIONS

Persistent CT and MG after treatment of NGU are common, and were associated with clinical findings and drug regimen.

Down-regulation of the serotonin transporter in hyperreactive platelets counteracts the pro-thrombotic effect of serotonin

An elevated plasma concentration of serotonin ([5-HT]) is a common feature of cardiovascular disease often associated with enhanced platelet activation and thrombosis. Whether elevated in vivo plasma 5-HT per se represents an independent risk factor for platelet hyperreactivity or only is an epiphenomenon of cardiovascular disease is poorly understood. We examined in vitro and in vivo platelet function following a 24h elevation of plasma [5-HT] in mice. In vivo administration of 5-HT using osmotic minipumps increased plasma [5-HT] in treated mice compared to control mice instrumented with saline loaded pumps. 5-HT infusion did not increase systolic blood pressure, but markers of platelet activation including P-selectin and (PE)Jon/A staining were increased and these findings coincided with the enhanced aggregation of isolated platelets in response to type I fibrillar collagen. Tail bleeding times and the time to occlusion following chemical damage to the carotid artery were shortened in 5-HT-infused mice. 5-HT-infused mice were treated with paroxetine (Prx) to block 5-HT uptake via the serotonin transporter (SERT). Prx lowered platelet [5-HT] and attenuated platelet activation and aggregation. These results and our biochemical indices of enhanced 5-HT intracellular signaling in the platelets of 5-HT-infused mice reveal a mechanistic link between elevated plasma [5-HT], abnormal intracellular 5-HT signaling and accentuated platelet aggregation. Although a down-regulation of the serotonin transporter (SERT) on the platelet surface may counteract the pro-thrombotic influence of elevated plasma [5HT], this compensatory mechanism may fail to prevent the increased thrombotic risk caused by elevated plasma [5-HT].

Lay health educators translate a weight-loss intervention in senior centers: a randomized controlled trial

BACKGROUND

Older adults have high obesity rates and respond well to evidence-based weight-loss programs, such as the Diabetes Prevention Program (DPP) Lifestyle intervention. The goal of this study was to determine whether a translation of the DPP Lifestyle program delivered by lay health educators and conducted in senior centers is effective in promoting weight loss among older adults.

DESIGN

An RCT with older adults nested within senior centers. Senior centers identified lay health educators to receive training and deliver the intervention program at the senior center. Senior centers were randomized to DPP Lifestyle program or an attention control intervention (cognitive training).

SETTING/PARTICIPANTS

Senior centers (N=15) located throughout Arkansas. Participants (N=228) were obese (BMI=34.5±4.9) older (aged 71.2±6.6 years) adults able to engage in moderate exercise. Follow-up data were collected at 4 months on 93% of the original cohort between February 2009 and July 2010.

INTERVENTIONS

A 12-session translation of the Diabetes Prevention Program Lifestyle behavioral weight-control program delivered in group sessions by trained lay health educators.

MAIN OUTCOME MEASURES

Body weight was assessed by digital scale. Percentage weight loss from baseline and proportion achieving ≥5% and ≥7% weight loss were examined. Analyses were completed in March 2011.

RESULTS

Participants attending senior centers randomized to Lifestyle lost a significantly greater percentage of baseline weight (3.8%, 95% CI=2.9%, 4.6%) than those in the control senior centers (0.2%, 95% CI= -0.6%, -0.9%) after adjusting for baseline BMI and gender (p<0.001). Among participants attending senior centers offering the Lifestyle program, 38% lost ≥5% of baseline weight compared with 5% in the control arm (p<0.001). Similarly, significantly more participants (24%) in Lifestyle senior centers lost ≥7% than did control participants (3%, p=0.001).

CONCLUSIONS

A behavioral lifestyle weight-loss intervention delivered by a lay health educator offers a promising vehicle for translation of evidence-based obesity treatment programs in underserved areas.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.govNCT01377506.

Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens--a randomized clinical trial

BACKGROUND

Nongonococcal urethritis (NGU) is a common chlamydia-associated syndrome in men; however, Trichomonas vaginalis and Mycoplasma genitalium are associated with its etiology and should be considered in approaches to therapy. We sought to determine whether the addition of tinidazole, an anti-trichomonal agent, to the treatment regimen would result in higher cure rates than those achieved with treatment with doxycycline or azithromycin alone. A secondary aim was to compare the efficacy of doxycycline therapy and with that of azithromycin therapy.

METHODS

Randomized, controlled, double-blinded phase IIB trial of men with NGU. Participants were randomized to receive doxycycline plus or minus tinidazole or azithromycin plus or minus tinidazole and were observed for up to 45 days.

RESULTS

The prevalences of Chlamydia trachomatis, M. genitalium, and T. vaginalis were 43%, 31%, and 13%, respectively. No pathogens were identified in 29% of participants. Clinical cure rates at the first follow-up visit were 74.5% (111 of 149 patients) for doxycycline-containing regimens and 68.6% (107 of 156 patients) for azithromycin-containing regimens. By the final visit, cure rates were 49% (73 of 149 patients) for doxycycline-containing regimens and 43.6% (68 of 156 patients) for azithromycin-containing regimens. There were no significant differences in clinical response rates among the treatment arms. However, the chlamydia clearance rate was 94.8% (55 of 58 patients) for the doxycycline arm and 77.4% (41 of 53 patients) for the azithromycin arm (P = .011), and the M. genitalium clearance rate was 30.8% (12 of 39 patients) for the doxycycline arm and 66.7% (30 of 45 patients) for the azithromycin arm (P = .002).

CONCLUSIONS

Addition of tinidazole to the treatment regimen did not result in higher cure rates but effectively eradicated trichomonas. Clinical cure rates were not significantly different between patients treated with doxycycline and those treated with azithromycin; however, doxycycline had significantly better efficacy against Chlamydia, whereas azithromycin was superior to doxycycline for the treatment of M. genitalium.

Establishing the predictive validity of intentions to smoke among preadolescents and adolescents surviving cancer

PURPOSE

A significant proportion of adults surviving childhood cancer are smokers. Although these estimated rates of smoking are slightly lower than those in the US population, they remain alarmingly high for this high-risk group. The purpose of this study was to examine the predictive validity of adolescent self-reported smoking intentions for later smoking among childhood cancer survivors.

PATIENTS AND METHODS

Baseline tobacco intentions were collected from 119 nonsmoking cancer survivors, age 10 to 18 years, who participated in a tobacco-based clinical trial during the late 1990s. Follow-up smoking status was systematically collected annually up to 10 years postintervention (median follow-up, 6.0 years; interquartile range, 3.0 to 6.9 years) as part of clinical survivorship care.

RESULTS

Twenty-seven participants (22.7%) subsequently initiated tobacco use within 5 years of study enrollment. The 5-year cumulative incidence was 29.8% +/- 6.0% for those who were susceptible to smoking compared with 12.8% +/- 5.4% for those who were committed never smokers (P = .022). Past use (P < .001) and having friends who smoked (P = .038) were also associated (univariate model) with tobacco initiation, and there was a trend for an association for older adolescents (P = .073). Every unit increase on the intentions scale was associated with a 17% increase in the risk for tobacco initiation (P = .002) after adjusting for age group and past tobacco use in a multivariable model.

CONCLUSION

Because early intentions to smoke are predictive of later tobacco use, survivors as young as 10 years of age who waver in their commitment to remain tobacco abstinent should be targeted for tobacco prevention interventions.

A comparison of tobacco-related risk factors between preadolescents with and without cancer

INTRODUCTION

To compare preadolescents with and without cancer on current smoking status, future intentions to smoke, and tobacco-related risk factors, as well as to explore the relationship between cancer status and tobacco-related variables with intentions.

PROCEDURE

Ninety-four preadolescents undergoing treatment for cancer and a matched comparison sample of 190 participants without cancer, ages 8 to 11 years, completed questionnaires about their smoking habits, intentions to smoke and tobacco-related psychosocial risk factors.

RESULTS

No preadolescents with cancer and only two preadolescents without cancer reported current smoking. Compared to healthy nonsmoking preadolescents, nonsmokers with cancer were approximately one-half as likely to report future intentions to smoke. Intention to smoke was better predicted by variables most proximal to smoking including older age, being male, not having cancer, having close friends who smoke, parental smoking, and lower perceived vulnerability for tobacco-related illnesses. In the model examining distal variables, preadolescents who were more rebellious, older, and without cancer were more likely to report future smoking intentions.

DISCUSSION/CONCLUSIONS

Although future intentions to smoke differed according to cancer status, the relationship between tobacco-related risk factors and future smoking intentions appeared to be similar among preadolescents with and without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Smoking prevention and tobacco-related health risk education should begin during the elementary years, a time prior to smoking initiation and the development of solidified smoking attitudes. The diagnosis and treatment of pediatric cancer may provide an excellent opportunity for health care providers to begin communicating anti-smoking messages and health risk counseling to their young patients and families.

Anti-Smoking Communication to Preadolescents with and without a Cancer Diagnosis: Parents and Healthcare Providers as Important Communicators

A cancer diagnosis does not prevent smoking among pediatric oncology patients, and anti-smoking communications among parents and health care providers have been proposed as influencing smoking outcomes in this group. Anti-smoking communications were compared among 93 preadolescents with cancer and 402 controls. After adjusting for demographics and covariates, preadolescents with cancer were less likely than control participants to report receipt of anti-smoking messages from physicians and parents, and recalled more messages >/= 4 months post-diagnosis as compared to 1-3 months. Should anti-tobacco communications prove to influence smoking outcomes, parents and physicians may be uniquely positioned to provide smoking prevention interventions to these patients.