Acute Hypercapnic Respiratory Failure in Patients with Sleep Apneas

IntroductionAcute hypercapnic respiratory failure (AHRF) is a serious condition observed in some patients with sleep apnea-hypopnea syndrome (SAHS). The objective of the present study was to study the clinical characteristics of SAHS patients who develop AHRF and their prognosis.Patients and methodA total of 70 consecutive SAHS patients who survived an AHRF episode and 70 SAHS patients paired by age with no previous history of AHRF were prospectively studied and followed up for 3 years.ResultsThe deterioration of lung function due to obesity or concomitant chronic obstructive pulmonary diseases (COPD) was common in SAHS patients with AHRF. In the multivariate analysis, the risk factors associated with AHRF were baseline PaO₂, the theoretical percentage value of the forced vital capacity, alcohol consumption, and benzodiazepines. The mortality during follow up was higher among patients who had AHRF than in the control group. The main cause of death was respiratory, and the coexistence of COPD was identified as a mortality risk factor.ConclusionsThe development of AHRF in SAHS patients is associated with a deterioration in lung function and with alcohol and benzodiazepine consumption. The patients had a higher mortality after the AHRF episode, mainly a respiratory cause. New studies are required that evaluate the different available therapeutic options in these patients.     

Predicting early term complications of ORIF distal radius fracture in outpatient settings using NSQIP data

PurposeThere is no consensus on which risk factors are most predictive for complications following open reduction internal fixation of distal radius fractures (ORIF-DRF) in an outpatient setting. This study is a complication risk analysis for ORIF-DRF in outpatient settings based on data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).MethodsA nested, case-control study, was conducted in ORIF-DRF cases performed in outpatient settings from 2013 to 2019 obtained from the ACS-NSQIP database. Cases with documented local or systemic complications were age and gender-matched in a 1:3 ratio. The association between patient and procedure-dependent risk factors for systemic and local complications in general and for different subpopulations was examined. Bivariate and multivariable analyses were performed to evaluate the association between risk factors and complications.ResultsFrom a total of 18,324 ORIF-DRF, 349 cases with complications were identified and matched to 1047 Controls. Independent patient-related risk factors included a history of smoking, the American Society of Anesthesiologists (ASA) Physical Status Classification 3 and 4, and bleeding disorder. The intra-articular fracture with three or more fragments was found to be an independent risk factor of all procedure-related risk factors. History of smoking was found to be an independent risk factor for all gender populations, as well as for patients younger the 65 years old. For older patients (age ≥65) bleeding disorder was found to be an independent risk factor.ConclusionComplications of ORIF-DRF in outpatient settings have many risk factors. This study provides surgeons with specific risk factors for possible complications following ORIF-DRF.     

Recent results regarding the clinical impact of smoking history on postoperative complications in lung cancer patients

Cigarette smoking is a well-known risk factor for perioperative surgery-related complications; however, steady progress in perioperative management has been made year by year. This study investigated the influence of cigarette smoking on postoperative complications in patients with lung cancer over the last three years in our institution. Clinical records of 194 patients who had undergone a pulmonary resection for lung cancer were retrospectively reviewed. The clinico-pathological findings and postoperative complications were compared among patients with smoking history. Smokers, including a higher number of men, had more preoperative respiratory complications, a lower FEV(1)/FVC, larger tumors, and included more squamous cell carcinoma in comparison to non-smokers. A univariate analysis revealed that sex, age and smoking history were independent risk factors in the postoperative complications; however, a multivariate analysis revealed that those factors including smoking history were not independent. In a subgroup of smokers subclassified by their smoking status or smoking index, there were no significant differences in postoperative complications. Over the recent three years of this study, smoking history was not a significant risk factor in postoperative complications. Especially in smokers, smoking status or smoking index was not a significant risk factor in postoperative complications, too.     

Official Positions for FRAX Clinical Regarding Smoking: From Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX

The worldwide prevalence of smoking has been estimated at about 50% in men, and 10% in women, with larger variations among different populations studied. Smoking has been shown to affect many organ systems resulting in severe morbidity and increased mortality. In addition, smoking has been identified as a predictor of ten-year fracture risk in men and women, largely independent of an individual's bone mineral density. This finding has eventually lead to incorporation of this risk factor into FRAX^®, an algorithm that has been developed to calculate an individual's ten-year fracture risk. However, only little, or conflicting data is available on a possible association between smoking dose, duration, length of time after cessation, type of tobacco and fracture risk, limiting this risk factor's applicability in the context of FRAX^®.     

Tobacco smoking and pulmonary tuberculosis

BACKGROUND: The prevalence of tuberculosis in adult men in India is 2-4 times higher than in women. Tobacco smoking is prevalent almost exclusively among men, so it is possible that tobacco smoking may be a risk factor for developing pulmonary tuberculosis. A nested case control study was carried out to study the association between tobacco smoking and pulmonary tuberculosis. METHODS: A tuberculosis disease survey was carried out in two Panchayat unions in the Tiruvallur district of Tamil Nadu in India. Eighty five men aged 20-50 years with bacteriological tuberculosis (smear and/or culture positive) were selected as cases and 459 age matched men without tuberculosis were selected randomly as controls. Information on smoking status, type of tobacco smoked, quantity of tobacco smoked, and duration of tobacco smoking was collected from cases and controls using a questionnaire. RESULTS: The estimated crude odds ratio (OR) of the association between tobacco smoking and bacillary tuberculosis was 2.48 (95% confidence interval (CI) 1.42 to 4.37), p<0.001.The age adjusted OR (Mantel-Hanszel estimate) was 2.24.(95% CI 1.27 to 3.94), p<0.05. The ORs for mild (1-10 cigarettes/day), moderate (11-20/day), and heavy (>20/day) smokers were 1.75, 3.17, and 3.68, respectively (p<0.0001 test for linear trend). The ORs for smokers with <10 years, 11-20 years, and >20 years of smoking were 1.72, 2.45, and 3.23, respectively (p<0.0001 test for linear trend). CONCLUSION: There is a positive association between tobacco smoking and pulmonary (bacillary) tuberculosis (OR 2.5). The association also shows a strong dose-response relationship.     

Urinary cadmium, osteopenia, and osteoporosis in the US population

Summary  

The association between cadmium and osteoporosis in a multiethnic population is unclear. We found that urinary cadmium is consistently associated with osteopenia and osteoporosis in the Third National Health and Nutrition Examination Survey, regardless of age, sex, race, and smoking status. Cadmium exposure may be an independent risk factor for osteoporosis.     

Smoking--a renal risk factor

One of the most important tasks of clinical and experimental nephrology is to identify the risk factors of progression of renal failure. A major renal risk factor which has not been sufficiently acknowledged despite increasing evidence is cigarette smoking. Diabetologists were the first to recognize the adverse effects of smoking on the kidney: both in type 1 and in type 2 diabetes smoking (i) increases the risk of development of nephropathy and (ii) nearly doubles the rate of progression to end-stage renal failure. Until recently it was not known whether smoking also increases the risk to progress to end-stage renal failure in patients with primary renal disease. A retrospective multicenter European case-control study showed that smoking is an independent risk factor for end-stage renal failure in patients with inflammatory and noninflammatory renal disease, i.e. IgA glomerulonephritis and polycystic kidney disease. The pathogenesis of the smoking-related renal damage is largely unknown. The intermittent increase in blood pressure during smoking seems to play a major role in causing renal damage, but further potential pathomechanisms are presumably also operative. Smoking as a renal risk factor is of great interest to diabetologists as well as nephrologists, but unfortunately so far this information has had little impact on patient management. The present article reviews the current knowledge about the renal risks of smoking and discusses the potential mechanisms of smoking-mediated renal injury.     

Lung function at one month of age as a risk factor for infant respiratory symptoms in a high risk population

BACKGROUND: Abnormal premorbid lung function is a risk factor for subsequent wheezing in children with one or no atopic parent. This study was undertaken to establish whether early lung function in high risk infants (both parents atopic) was a risk factor for respiratory symptoms in infancy and to examine the influence of maternal asthma, smoking, and allergen exposure during pregnancy on any association. METHODS: Infants were recruited from the NAC Manchester Asthma and Allergy Study cohort at birth. Partial forced expiratory flow volume technique under sedation was carried out to determine maximal flow at FRC (V'maxFRC). Children were followed prospectively and parents completed a standard respiratory questionnaire at one year of age. RESULTS: Sixty nine term infants (34 boys; 88% mothers non-smokers; no household pets) underwent respiratory function testing. Size adjusted V'maxFRC was significantly lower in infants who had recurrent wheeze during the first year of life (mean 1.3 ml/s/cm, 95% CI 0.99 to 1.60) than in those who did not (mean 2.03 ml/s/cm, 95% CI 1.71 to 2.36; p=0.01). V'maxFRC was also significantly lower in infants who had recurrent cough symptoms. In multivariate regression analysis, when adjusted for age at test, sex, maternal asthma, smoking and maternal mattress Der 1 levels, a lower size adjusted V'maxFRC score remained strongly associated with wheezing (OR 0.37, 95% CI 0.18 to 0.77, p=0.007). Maternal smoking also remained an independent risk factor (OR 29.85, 95% CI 2.46 to 362.5, p=0.008). CONCLUSION: Significantly diminished lung function was present in high risk infants who subsequently wheezed and coughed. This was independent of maternal exposure to mite allergen, asthma, and smoking during pregnancy.     

Cigarette smoking: an independent risk factor for atherosclerosis in the hypogastric-cavernous arterial bed of men with arteriogenic impotence

We investigated the relationship between cigarette smoking and atherosclerosis of the hypogastric-cavernous arterial bed by evaluating arteriograms of young impotent men referred for selective pudendal angiography. Those patients with hemodynamically significant atherosclerosis had smoked more pack-years than had patients without arterial disease. These differences were statistically significant (p less than 0.05) for the common penile artery (32.8 pack-years, 40 patients versus 22.3 pack-years 57 patients) and the dorsal artery (31.3 pack-years, 48 patients versus 22.0 pack-years, 49 patients). The effect of cigarette smoking as an independent risk factor for atherosclerotic disease in the hypogastric-cavernous arterial bed was evaluated as well. When controlled for age, trauma history, hypertension and diabetes, cigarette smoking was independently associated with atherosclerosis in the internal pudendal artery (p less than 0.05). The relative risk (and 95% confidence interval) of developing internal pudendal artery atherosclerosis for each 10 pack-years smoked was 1.31 (1.05 to 1.64). A third analysis investigated the potential interactive effects of cigarette smoking and pelvic or perineal trauma. A significantly higher incidence (p less than 0.05) of cavernous artery atherosclerosis was found among smokers with a history of chronic perineal trauma (33 patients) compared to nonsmokers with a similar history (25 patients). The findings of this study indicate that cigarette smoking is an independent risk factor in the development of atherosclerotic lesions in the internal pudendal and common penile arteries of young impotent men. Cigarette smoking appears to predispose these patients to early atherosclerotic lesions in the cavernous artery following chronic perineal trauma.     

Correlations between C-reactive protein and metabolic syndrome or other associated diseases

The aim of the paper is to present few aspects about the implication of the C-reactive protein (CRP) in the metabolic syndrome. High-sensitivity (hs) CRP is a marker of subclinical inflammation and it is a mediator of atherosclerotic disease. A recent study indicates a possible dose-effect relationship between waist circumference and hs-CRP levels. Elevated level of hs-CRP was associated with risk of developing metabolic syndrome (MS). However, cross-sectional studies have reported increased concentration of these inflammatory markers in both MS and over type 2 diabetes mellitus (DM) and prospective studies have found strong, graded relations between hs-CRP and incident diabetes. A growing number of large-scale studies are finding positive correlations of CRP with cardiovascular disease and these correlations are independent of smoking. The studies show that it is an association between chronic inflammation and depressive symptoms.     

Peyronie's disease: prevalence and association with cigarette smoking. A multicenter population-based study in men aged 50-69 years.

OBJECTIVES: We present a multicenter, population-based epidemiological survey aimed at assessing the prevalence of Peyronie's disease (PD) and its potential risk factors in the general population. METHODS: In each of the ten centers throughout Italy, a uroandrologist contacted all the men in the age range 50-69 years registered with a general practitioner (GP). The subjects recruited were evaluated on the basis of their medical history, including alcohol consumption and cigarette smoking. The following questionnaires were administered: IIEF, IIPSS symptom score, premature ejaculation and PD. RESULTS: All the subjects registered with a GP were invited to participate in the study. Of the 1,180 subjects, 647 (53%) entered over survey. In this population, 46 cases of PD were identified, accounting for a prevalence of 7.1%. The prevalence rate increased with age even if the trend is not statistically significant. The multivariate analysis showed a significant correlation between cigarette smoking and PD, with an odds ratio (OR) of 4.6 (CL 95%) confidence limit 1.506- 14.287). Smoking as single variable had an OR of 7.2 (95% CL 2.34-24.93). No significant association was observed between PD and the other variables such as cardiovascular diseases, diabetes, hypertension and alcohol consumption. CONCLUSIONS: PD is a much more frequent condition in the general population than previously reported. According to our results, cigarette smoking may be considered a risk factor for developing PD. If further and more targeted studies confirm that giving up smoking may reduce the risk of developing PD, then there will be new prospects for primary and secondary prevention and for curbing the progression of the disease.     

Predictors of early disease in the lower limbs

Increasing age and male gender are unavoidable risk factors for peripheral arterial occlusive disease (PAOD). A number of studies have looked at classical risk factors for atherosclerosis, such as diabetes, hypertension, lipid abnormalities, and smoking, as well as some more recently identified associations, such as plasma fibrinogen levels, impaired glucose tolerance, and hyperhomocysteinemia. However, most "risk factors" are really associations. A causal relationship may only reasonably be firmly established if a prospective controlled study shows that removing the risk factor significantly alters the course of the disease, as with smoking. Smoking is probably the strongest risk factor for intermittent claudication (IC), but hyperhomocysteinemia also appears to be strongly associated with the development of PAOD. Moderate alcohol intake and regular physical exercise appear to have a protective effect. A genetic risk factor is suggested but not as yet confirmed. The magnitude of the association varies from odds ratios of 2 to 3 for smoking and diabetes. There is insufficient evidence for hyperhomocysteinemia, but the effect may be even greater. The association with hypertension and lipid abnormalities is surprisingly inconclusive.     

Sleep Apnea-Hypopnea Syndrome Without Excessive Daytime Sleepiness

Nowadays, sleepiness in patients with sleep apnea-hypopnea syndrome (SAHS) is understandable. It is somewhat more difficult to explain why most patients with SAHS enrolled in epidemiologic studies, even those with a high apnea-hypopnea index, do not experience excessive daytime sleepiness. The reasons for this discrepancy lie beyond mere polysomnographic events.This review examines data from the literature that may help us understand why these patients do not experience daytime sleepiness. It also analyzes studies that support and refute sleepiness as a marker of cardiovascular risk in patients with SAHS, and discusses the mechanisms that might increase this risk.     

Respiratory Complications of Obesity

Obesity, well known as a cardiovascular risk factor, can also lead to significant respiratory complications. The respiratory changes associated with obesity extend from a simple change in respiratory function, with no effect on gas exchange, to the more serious condition of hypercapnic respiratory failure, characteristic of obesity hypoventilation syndrome. More recently, it has been reported that there is an increased prevalence of asthma which is probably multifactorial in origin, but in which inflammation may play an important role. Hypoventilation in the obese subject is the result of complex interactions that involve changes in the ventilatory mechanics and anomalies in breathing control. Two other conditions (COPD and sleep apneahypopnea syndrome [SAHS], often present in obese patients, can trigger or aggravate it. The prevalence of hypoventilation in the obese is under-estimated and the diagnosis is usually established during an exacerbation, or when the patient is studied due to suspicion of SAHS. Ventilatory management of these patients, ventilatory management of these patients includes either CPAP or NIV. The choice of one or another will depend on the underlying clinical condition and whether or not there is another comorbidity. Both NIV and CPAP have demonstrated their effectiveness, not only in the control of gas exchange, but also in improving the quality of life and survival of these patients     

Risk factors for development of posttransplant diabetes mellitus in renal transplant recipients

Diabetes mellitus appearing after kidney transplantation--posttransplant diabetes mellitus (PTDM)--is a common complication associated with poor graft and patient survival. The purpose of the current study was to determine the risk factors for developing PTDM in 204 renal transplant recipients who had been followed for at least 30 months. Posttransplant diabetes mellitus was diagnosed according to the American Diabetic Association/WHO criteria, or a requirement for insulin, an oral hypoglycemic agent, or both. Analyses of possible risk factors for PTDM included demographic features, dialysis and posttransplantation duration, smoking, body mass index, medications, co-morbid diseases, HLA mismatches, as well as laboratory metrics of serum creatinine, albumin, calcium, phosphorus, C-reactive protein, parathyroid hormone, and lipid profiles. Twenty-six patients displayed PTDM. Univariate analysis showed that older age, greater body mass index, presence of hepatitis C virus (HCV) infection, and smoking at the time of renal transplantation were associated with PTDM development. In a multivariate analysis, HCV infection, smoking, and patient age at the time of transplantation were independent risk factors for PTDM. In conclusion, the presence of HCV infection or a smoking habit in addition to older age at the time of transplantation were the main predictors for developing PTDM. Patients should be closely followed regarding their smoking habit and weight gain as modifiable risk factors for PTDM.     

Respiratory symptoms and home environment in children: a national survey

BACKGROUND: Respiratory diseases are common in childhood and may lead to chronic disease in adult life; environmental factors probably play an important part in their causation. METHODS: A survey of respiratory symptoms in children aged 12-14 years was conducted throughout Great Britain as part of the International Study of Asthma and Allergies in Childhood (ISAAC). Information was obtained on certain aspects of the home environment in order to assess their importance as risk factors. RESULTS: The response rate was 79.3%, and 25,393 children in 93 schools participated. In a multiple regression analysis, wheeze was reported more often in nonmetropolitan areas and in association with active smoking, passive smoking, the presence of a furry pet, bottled gas, paraffin, and other unusual heating fuels; small regional differences persisted. Current smoking, previous smoking, and passive smoking accounted for 10.4%, 6.8%, and 6.5%, respectively, of wheezing in the past 12 months, and furry pets accounted for 5.0%. Cough and phlegm were associated with active and passive smoking and with the miscellaneous fuels; similar associations were found for rhinitis, but were less consistent for rhinitis occurring in spring and summer. Gas cooking showed little association with respiratory symptoms. CONCLUSIONS: Passive as well as active smoking is an important cause of respiratory symptoms in adolescence. Pets seem to increase the risk of wheeze and rhinitis, and fumes from certain unusual heating fuels may have adverse effects. Home environment and geographical location have independent effects on the prevalence of respiratory symptoms.     

Cigarette Smoking Increases the Risk for Rotator Cuff Tears

There is little available evidence regarding risk factors for rotator cuff tears. Cigarette smoking may be an important risk factor for rotator cuff disease. The purpose of this study was to determine if cigarette smoking correlates with an increased risk for rotator cuff tears in patients who present with shoulder pain. A questionnaire was administered to 586 consecutive patients 18 years of age or older who had a diagnostic shoulder ultrasound for unilateral, atraumatic shoulder pain with no history of shoulder surgery. Three hundred seventy-five patients had a rotator cuff tear and 211 patients did not. Data regarding cigarette smoking were obtained for 584 of 586 patients. A history of smoking (61.9% versus 48.3%), smoking within the last 10 years (35.2% versus 30.1%), mean duration of smoking (23.4 versus 20.2 years), mean packs per day of smoking (1.25 versus 1.10 packs per day), and mean pack-years of smoking (30.1 versus 22.0) correlated with an increased risk for rotator cuff tear. We observed a dose-dependent and time-dependent relationship between smoking and rotator cuff tears. We observed a strong association between smoking and rotator cuff disease. This may indicate smoking is an important risk factor for the development of rotator cuff tears.     

POSTOPERATIVE RESPIRATORY MORBIDITY: IDENTIFICATION AND RISK FACTORS

Two hundred consecutive patients admitted for general surgery were studied prospectively to evaluate the contribution of risk factors to postoperative respiratory morbidity (PORM). PORM was expressed both in terms of individual clinical features present on the second postoperative day (when the incidence was greatest), and as an aggregate score incorporating many clinical features. The importance of recognised risk factors, such as previous respiratory disease, cigarette smoking, upper abdominal procedures and the duration of surgery was confirmed, in that these factors were associated with some of the individual clinical features of PORM. The relative importance and independent contribution of these risk factors were assessed by their association with the aggregate score. A naso-gastric tube (NGT) present for 24 hours postoperatively was the factor more associated with PORM. The NGT identified patients at risk more clearly than, and independently of, the next most important factor, upper abdominal surgery. The duration of surgery did not contribute to PORM after the influence of NGT and site of surgery had been considered. Previous respiratory disease predisposed to PORM, and was best identified by, in order of importance, an observed productive cough, a reduced one second forced expiratory volume, and purulent sputum. After the influence of these factors had been considered, cigarette smoking and a history of a chronic productive cough did not contribute further to PORM.     

Choice of coronary heart disease risk factor variables in a cross-sectional study of white South Africans

This report explores the possibility of redefining risk factors so as to improve their observed associations with prevalent coronary heart disease (CHD). A large cross-sectional community study of 5,895 white males and females aged 25-64 years yielded 240 cases of confirmed angina pectoris and 361 of confirmed myocardial infarction. Odds ratios for CHD end-points by level of risk factors when risk factors were expressed in the conventional manner (e.g. total cholesterol, systolic and diastolic blood pressure or current smoking) were often low and not statistically significant. Redefinition of risk factor variables in a manner that improved their specificity or compensated to some extent for the decreased risk factor exposure as a result of a CHD event (e.g. stopping smoking after a myocardial infarct) improved the strength of association. In this study, the most useful cholesterol variable was total cholesterol minus high-density lipoprotein cholesterol; for blood pressure the most useful variable was a blood pressure of 160/95 mmHg or above and/or being on anti-hypertensive treatment; and for smoking the most useful variable was the total duration of smoking (previous and current). Strong associations with CHD end-points were also found for conventionally expressed serum uric acid, diabetes prevalence (females) and family history of CHD. The study suggests that appropriate redefinition of risk factor variables and CHD end-points in cross-sectional studies yields associations similar in strength and direction to those found in prospective studies.