The effect of pre-operative counselling on smoking patterns in patients undergoing forefoot surgery

BackgroundSmoking contributes to higher surgical complication rates. Previous studies assessing smoking cessation interventions examined the provision of comprehensive packages. The use of surgery as an incentive to complement brief advice has not been fully evaluated.MethodsSmokers were counselled and referred to their general practitioners for specific cessation strategies. Smoking status was recorded prior to surgery, on admission and in post-operative clinics. A telephone survey at a mean of 12 months post-operation ascertained long-term behavioural changes.ResultsNinety-seven patients underwent surgery with twenty-five recorded as smokers. Sixteen stopped smoking pre-operatively; a further four reduced their intake, as a direct consequence of counselling. No patients were previously aware of the detrimental effects of smoking associated with foot surgery.ConclusionsSurgery provides an incentive for smoking cessation, maintained post-operatively. Although forefoot fusions and arthrodeses were used in our study, the results are transferable to other branches of orthopaedic surgery.     

Orthopaedic trauma patients and smoking: Knowledge deficits and interest in quitting

BackgroundSmoking is associated with increased complications in fracture care. Smoking cessation has a positive impact on outcomes. It is unknown whether orthopaedic trauma patients understand the ill effects of smoking on fracture care and whether knowledge can improve cessation interest. We hypothesized that (1) smokers less fully understand the negative effects of smoking than do nonsmokers, (2) an increased proportion of orthopaedic trauma patients are further in the process of change to quit smoking, (3) increased knowledge predicts increased readiness to quit, and (4) minimal education through a survey can improve interest in smoking cessation.MethodsSingle-centre cross-sectional cohort survey study. Patients were approached consecutively for participation. Patients 18 years or older with a new fracture in our clinic for follow-up were eligible. Smokers and nonsmokers were included and surveyed regarding demographics. Smokers were asked questions about fractures and general knowledge questions regarding the effects of smoking on health. Smokers’ interest in smoking cessation was assessed with direct questions, and transtheoretical model stage of change was queried before and after survey administration.ResultsOne hundred twelve patients participated (44 smokers, 68 nonsmokers; 75 male patients, 37 female patients). Forty-eight percent of smokers stated that the fracture made them more likely to quit. Smokers answered more questions incorrectly than did nonsmokers (p = 0.003). An increased percentage of smokers were in favourable stages of change compared with a population-based tobacco survey (68% versus 54%, p = 0.008). Survey administration increased interest in quitting in 48%, and 11% modified their stage of change towards quitting. Smokers scoring higher on knowledge questions had more than 2-fold increased odds of being in a favourable stage of change (p = 0.013; odds ratio, 2.13; 95% confidence interval, 1.744–3.855).ConclusionsCompared with nonsmokers, smokers less fully understand the negative effects of smoking on fracture care and general health. A large proportion of orthopaedic trauma patients who smoke are interested in smoking cessation and are possibly further along the pathway to change than expected. Brief education through a survey can increase interest in quitting. Formal education intervention may improve cessation rates and fracture outcomes.     

Cultured and immediately procured endothelial cells: Current and future clinical applications

Great progress has been made in the last several years in our ability to culture human endothelial cells. In addition, techniques to immediately procure and utilize these cells have also been developed. The purpose of this paper is to present an overview of the current and potential uses of these cells in both vascular and nonvascular conditions. It is likely that endothelial cells will be used in a variety of applications in the near future. Immediately procured and cultured cells will be used to resurface vascular prosthetic grafts. They may also be used on the surface of vessels following procedures such as balloon angioplasty or atherectomy. In addition, they may be placed upon the surface of implantable devices such as expandable stents. Through the mechanism of genetic engineering, these cells may be modified to produce proteins, which may modify thrombogenicity and perhaps decrease the rate of recurrent stenosis by influencing cellular hyperplasia. Genetically modified endothelial cells also have great potential in nonvascular disease. Their contact with circulating blood makes them an ideal cell for production of proteins to correct systemic conditions such as the insulin deficiency found in diabetes mellitus. The application of endothelial cell biology in both vascular and nonvascular science represents one of the most exciting fields of research active today.     

Adverse Effects of Smoking on Peak Bone Mass May Be Attenuated by Higher Body Mass Index in Young Female Smokers

Smoking is associated with postmenopausal bone loss and fracture, but the effect of smoking on bone in younger women is unclear. Peak bone mass is an important determinant for fracture risk; therefore, our aim was to evaluate the association between smoking and bone mass in 25-year-old women, specifically the influence of daily cigarette consumption and total exposure, duration, age at starting smoking, and time since smoking cessation on bone density and fracture risk. Smoking and bone mineral density (BMD) data were available for 1,054 women from the PEAK-25 cohort. Analyses comparing current smokers with women who never smoked were performed using number of cigarettes per day, pack-years, smoking duration, age smoking started, and, for former smokers, age at quitting. BMD did not differ between never, former, and current smokers; and the relative fracture risk in smokers was not significant (relative risk [RR] = 1.2, 95 % confidence interval 0.8–1.9). Among current smokers, BMD decreased with a dose response as cigarette consumption increased (femoral neck p = 0.037). BMD was not significantly lower in young women who had smoked for long duration or started smoking early (p = 0.07–0.64); long duration and early start were associated with higher body mass index (BMI; p = 0.038). Lower BMD persisted up to 24 months after smoking cessation (p = 0.027–0.050), becoming comparable to never-smokers after 24 months. Hip BMD was negatively associated with smoking and dose-dependent on cigarette consumption. Smoking duration was not associated with BMD, although young women with a long smoking history had higher BMI, which might attenuate the adverse effects from smoking.     

Arterial-ureteral fistula: Case study with review of published reports

Arterial-ureteral fistula, a rare cause of gross hematuria, may be associated with life-threatening hemorrhage if not rapidly diagnosed and treated. Recently, a patient at the Hunter H. McGuire Veterans Administration Medical Center developed an arterial-ureteral fistula at the site of the confluence of the external iliac artery and a superior mesenteric artery bypass graft. Review of the world's literature revealed 31 additional reported cases of arterial-ureteral fistulas [1—31]. This current case is only the second one reported in which the diagnosis was made with arteriography. Several common features of arterial-ureteral fistulas were present in this case: a history of ureteral obstruction and urinary tract infections, upper urinary tract disease, and previous vascular surgery. The condition is usually associated with either prior upper urinary tract instrumentation or vascular surgery, and an antecedent period of intermittent hematuria, followed by life-threatening hematuria, is common. A high index of suspicion and early surgical intervention are required for successful management. The major surgical challenges are to establish unobstructed urinary drainage and restore vascular continuity. Exclusion of prosthetic material from potentially infected areas is mandatory.     

Smoking and adverse outcomes at radical prostatectomy

BackgroundMultiple large epidemiologic studies have examined the relationship between smoking and prostate cancer incidence and mortality only to arrive at contradictory results. In this series, we studied the effect of smoking on pathologic outcomes and biochemical recurrence in a cohort of men undergoing radical prostatectomy.MethodsWe identified 630 men who underwent radical prostatectomy between 1989 and 2005 who had detailed smoking histories. There were 321 smokers and 309 nonsmokers. Pathologic outcomes included prostate weight, volume of cancer, volume of high grade cancer, margin status, seminal vesicle involvement, extraprostatic extension, perineural invasion, angiolymphatic invasion, and the presence of nodal metastasis. Biochemical recurrence was defined as a postoperative PSA ≥ 0.1 ng/ml. Univariate analysis and multivariate linear and Cox regression were used to study the impact of smoking on these outcomes.ResultsThe volume of cancer (2.54 vs. 2.16 ml, P = 0.016) and the volume of high grade cancer (0.58 vs. 0.28 ml, P = 0.004) were greater in smokers compared with nonsmokers. Smoking independently predicted greater volumes of cancer and high grade cancer in multivariate analysis. Heavy smokers (≥20 pack-year history) had a greater risk of biochemical recurrence on univariate survival analysis. Smoking also predicted a greater risk of biochemical recurrence on Cox regression, the magnitude of which was approximately 1% per pack-year smoked.ConclusionsSmoking is associated with adverse pathologic features and a higher risk of biochemical recurrence in men undergoing radical prostatectomy. If confirmed by additional studies, smoking history may need to be included into risk assessment models.     

Inhibition of neutrophil superoxide production by adenosine released from vascular endothelial cells

To investigate the inhibitory effect of adenosine released by endothelium on neutrophil Superoxide (O ₂ ^–) production, we treated confluent monolayers of cultured human umbilical vein endothelial cells with the enzyme adenosine deaminase, and then added human neutrophils. Superoxide (O₂ ^–) production by human neutrophils stimulated with 10^–6 M formyl-methionyl-leucyl-phenylalanine was inhibited by 49% in the presence of a confluent monolayer of human umbilical vein endothelial cells (5.1 ± 0.1 versus 2.6 ± 0.3 nmols O₂ ^–/10⁶ neutrophils). Addition of 0.25 U/ml adenosine deaminase to neutrophils plus endothelial cells restored formyl-methionyl-leucyl-phenylalanine-stimulated neutrophil Superoxide production to the level seen with neutrophils alone. Deoxycoformycin (10^–4 M), an inhibitor of adenosine deaminase activity, prevented the increase in Superoxide production associated with adenosine deaminase addition. The adenosine analogue 5-(N-ethylcarboxamido)-adenosine (3 × 10^–4 M) caused increased inhibition of formyl-methionyl-leucylphenylalanine-stimulated superoxide release by neutrophils in the presence of endothelial cells and prevented neutrophil-mediated endothelial cell damage, as measured by release of³H-2-deoxy-D-glucose. Pairing 2-chloroadenosine (10^–5 M) or 5-(N-ethylcarboxamido)-adenosine (3 × 10^–4 M) with a cyclic adenosine monophosphate phosphodiesterase inhibitor, 3-isobutyl-l-methyl-xanthine (10^–4 M), produced greater inhibition of neutrophil superoxide production than occurred with either compound alone. The results support the hypothesis that vascular endothelial cells protect themselves from neutrophil attack by releasing adenosine to inhibit superoxide production.     

Marginal ulcers after laparoscopic Roux-en-Y gastric bypass: analysis of the amount of daily and lifetime smoking on postoperative risk

BackgroundA common postoperative complication after laparoscopic Roux-en-Y gastric bypass (LRYGB) is the development of marginal ulcers (MUs) at the gastrojejunal anastomosis. Several risk factors, such as smoking, seem to have an impact on the development of MUs.ObjectiveVery little is known about how much smoking increases the risk. We therefore reviewed our patients regarding their smoking behavior and the development of MUs after LRYGB.SettingPrimary care hospital and a university hospital.MethodsThis study included 249 patients who underwent LRYGB surgery between 2010 and 2015 with at least 2 years of follow-up at a single institution. This retrospective analysis focused on the development of marginal ulcers after LRYGB, the time of appearance, and possible risk factors.ResultsA total of 27 (10.8%) patients in this study developed MUs. The majority of MUs (66.7%) occurred within the first postoperative year. Smoking is an independent and statistically significant predictor of the development of MUs with a 4.6-fold greater risk (P = .003). Light, moderate, and heavy daily smokers have the same rate of MUs (17.4% versus 17.1% versus 17.9%, respectively). Light smokers with <10 cigarettes per day are at significantly increased risk for MUs compared with nonsmokers (17.4 versus 4.2%, respectively; P = .027). Former and current smokers are at comparable risks for MUs (13.3% versus 17.5%, respectively; P = .685).ConclusionThe described incidence of 10.8% shows that marginal ulcers are one of the most important and frequent complications after LRYGB. Smoking at every intensity is associated with an extraordinary risk of MU formation after LRYGB and therefore, smoking cessation before bariatric surgery must be strongly recommended.     

Persistence of urothelial carcinoma of the bladder risk among former smokers: Results from a contemporary,prospective cohort study

ObjectivesCigarette smoking is a known risk factor for urothelial carcinoma (UC) of the bladder. However, the persistence of an increased risk for UC following smoking cessation is not well established. We assessed the risk of UC among former smokers using a recent, prospective cohort with a high proportion of former smokers.Materials and methodsStudy participants were members of the VITamins And Lifestyle cohort (VITAL), a group of 77,719 men and women between the ages of 50 and 76 years from western Washington State. Smoking history and other risk factors were obtained at the time of recruitment. The primary outcome was a new diagnosis of UC (n =385), as determined through linkage to a population-based cancer registry.Results and limitationsThe cohort included 8% current and 44% former smokers, and among the UC cases, 15% were current and 60% former smokers. Both the current and former smoker had an increased risk of UC compared with never smokers (hazard ratio [HRs]: 3.81; 95% confidence intervals [CI] 2.71–5.35 and 2.0; 95% CI 1.55–2.58, respectively). Among former smokers, the risk of UC increased with the pack-years smoked and decreased with the years since quitting. When both the measures of smoking were considered together, the risk of UC was similar for long-term quitters and recent quitters for a given level of pack-years. For example, for those with pack-years of 22.5–37.5, the HR of UC was 1.91 (95% CI 1.17–3.11) for the distant quitters (≥23.5 y before baseline) and HR = 1.92 (95% CI 1.26–2.94) among the recent quitters. Limitations include the small number of cases at the extremes of smoking history and errors in self-reported smoking history.ConclusionsThe risk of bladder cancer in former smokers remains elevated>32 years after quitting, even among those with moderate smoking histories. This argues that a history of smoking confers a lifelong increased risk of UC.     

Smoking Cessation has no Influence on Quality of Life in Patients with Peripheral Arterial Disease 5 Years Post-vascular Surgery

ObjectivesSmoking is an important modifiable risk factor in patients with peripheral arterial disease (PAD). We investigated differences in quality of life (QoL) between patients who quitted smoking during follow-up and persistent smokers.DesignCohort study.MethodsData of 711 consecutively enrolled patients undergoing vascular surgery were collected in 11 hospitals in the Netherlands. Smoking status was obtained at baseline and at 3-year follow-up. A 5-year follow-up to measure QoL was performed with the EuroQol-5D (EQ-5D) and Peripheral Arterial Questionnaire (PAQ).ResultsAfter adjusting for clinical risk factors, patients, who quit smoking within 3 years after vascular surgery, did not report an impaired QoL (EQ-5D: odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.28–1.43; PAQ: OR = 0.76, 95% CI = 0.35–1.65; visual analogue scale (VAS): OR = 0.88, 95% CI = 0.42–1.84) compared with patients, who continued smoking. Current smokers were significantly more likely to have an impaired QoL (EQ-5D: OR = 1.86, 95% CI = 1.09–3.17; PAQ: OR = 1.63, 95% CI = 1.00–2.65), although no differences in VAS scores were found (OR = 1.17, 95% CI = 0.72–1.90).ConclusionsThere was no effect of smoking cessation on QoL in PAD patients undergoing vascular surgery. Nevertheless, given the link between smoking, complications and mortality in this patient group, smoking cessation should be a primary target in secondary prevention.     

Combining smoking information and molecular markers improves prognostication in patients with urothelial carcinoma of the bladder

ObjectivesTissue-based markers improve the accuracy of prediction models in urothelial carcinoma of the bladder (UCB). Current smoking status and cumulative exposure also affect outcomes. To evaluate whether the combination of molecular markers and smoking features further improved the prognostication of patients who underwent radical cystectomy (RC) for UCB.Materials and methodsA total of 588 patients underwent RC and bilateral lymphadenectomy for UCB from 1995 to 2005. Immunohistochemistry for p53, p21, pRB, p27, Ki-67, and survivin was performed on tissue microarrays from the RC specimen. Smoking features were routinely assessed at diagnosis. Multivariable Cox regression models assessed time to disease recurrence and cancer-specific mortality.ResultsOf the 588 patients, 128 were never (22%), 283 former (48%), and 177 current smokers (30%). In total, 227 patients experienced disease recurrence, whereas 190 died of UCB. Smoking status was independently associated with both outcomes (hazard ratio [HR] = 1.48 and 2.62, for former and current vs. never smokers, respectively, P<0.001). All markers were significantly associated with both outcomes (P<0.05) except for survivin. The combination of the 4 cell cycle markers p53, p21, pRB, and p27 increased the discrimination of clinicopathologic model for former and current vs. never smokers with c-indices 0.779 and 0.780, respectively (base model c-indices of 0.741 and 0.740 for former and current vs. never smokers, respectively). The further addition of smoking features and biomarker status improved the discrimination of the model (c-indices of 0.783 and 0.786 for former and current vs. never smokers, respectively).ConclusionsWe confirmed that smoking information and tissue markers status improve prognostication of UCB outcomes after RC; the combination of both reaching the highest level of discrimination.     

111Indium is an unreliable in vivo label for vascular endothelial cells

We studied the retention of ¹¹¹Indium-labeled canine endothelial cells on 32 grafts (16 dogs). Canine endothelial cells were harvested from the external jugular veins, grown in culture, and labeled with¹¹¹Indium oxine; 10⁶ factor VIII positive cells were inoculated on fibronectin-coated, 4 mmlD Hytrel grafts and cultured 18 hours to reach confluence. An autologous seeded graft was interposed in each of the common carotid arteries and exposed to flow for six hours.¹¹¹Indium label was measured pre- and postperfusion and corrected for decay. Twenty-five grafts from 13 dogs were available for study. Scanning electron microscopic planimetry was used to determine percent surface coverage by six mutually exclusive surface characteristics: endothelial cells, bare graft, white blood cells on graft, white blood cellson endothelium, white blood cells under endothelium, and thrombus. ¹¹¹Indium retention was compared with percent coverage by scanning electron microscopy using regression analysis.¹¹¹Indium labeling projected an erroneous retention of 41% at zero percent coverage (r=0.67; p<0.01). Multiple regression analysis revealed an equivalent distribution of¹¹¹Indium label over nonendothelial portions of the flow surface and indicated a leak rate into the circulation of 25.6% of the initial¹¹¹Indium label over six hours. We conclude that: 1)¹¹¹Indium labeling data usually overestimates endothelial cell retention; 2) an average of 4.67%/hour is lost into the general circulation; 3)¹¹¹Indium label can be found equally on surfaces of thrombus, white blood cells, and hydrophilic Hytrel graft; and 4)¹¹¹Indium labeling is not a reliable method forin vivo studies of endothelial cell retention.     

Intraaortic balloon pump entrapment

Catheter entrapment is a rare complication of intraaortic balloon counterpulsation caused by the formation of hard blood clot within the balloon itself. We present two cases of intraaortic balloon pump entrapment seen at the University Hospital, Boston. This phenomenon usually presents as a limb threatening vascular emergency. The entrapped catheter becomes stuck fast within the iliac system during withdrawal of the device, occluding arterial flow at that level. The etiology of this phenomenon, and a proposed management scheme is discussed. Preoperative radiographic determination of the level of entrapment may be necessary. We feel it is necessary to control the abdominal aorta prior to removal of an entrapped intraaortic balloon.     

Pronounced risk of nontraumatic osteonecrosis of the femoral head among cigarette smokers who have never used oral corticosteroids: a multicenter case–control study in Japan

BackgroundCigarette smoking has been linked to an increased risk of nontraumatic osteonecrosis of the femoral head (ONFH) in previous studies. However, the effect of smoking amount, duration and cessation, and interaction with corticosteroids remains unclear. The purpose of this study was to precisely evaluate the effects of smoking and the interaction with corticosteroid use.MethodsThis was a multicenter, matched case–control study in Japan. Cases were defined as patients who were newly diagnosed with ONFH at an initial visit or during the previous year if they were referred patients. For each case, matched controls were selected from patients without ONFH. The matching conditions were sex, age, and ethnicity. A logistic regression model was used to compute odds ratios (OR) and 95 % confidence intervals (95 % CI).ResultsWe compared 72 cases with 244 matched controls. ORs were 3.89 (95 % CI 1.46–10.4) for current smokers, 3.89 (1.22–12.4) for smokers consuming more than 20 cigarettes per day, 4.26 (1.32–13.7) for smokers with 26 pack–years or more, and 3.11 (0.92–11.5) for smokers with a history of 29 years or more, with significant or marginally significant dose–response relationships. OR for current smokers was 10.3 among those who had never used corticosteroids and 1.56 among past or current corticosteroid users (P for interaction 0.010).ConclusionsOur results revealed that heavier cigarette smoking was associated with a higher risk of ONFH. The elevated risk from cigarette smoking was markedly pronounced among those who had never used oral corticosteroids.     

Secondary Abdominal Compartment Syndrome in a Patientwith Isolated Extraperitoneal Injuries

Abstract  The abdominal compartment syndrome (ACS) is defined as increased intra-abdominal pressure (IAP) associated with adverse physiologic consequences. The ACS ismost commonly diagnosed in patients sustaining abdominal or pelvic trauma, or suffering some other intraabdominal hemorrhagic catastrophe. Recently, several groups have reported cases in which patients sustaining extra-abdominal trauma developed ACS following acute resuscitation with crystalloids or blood. This secondary ACS (SACS) appears to be related to resuscitation-induced bowel edema and ascites. SACS is a poorly understood and characterized syndrome where the increased intra-abdominal pressure occurs without abdominal injury. Timely diagnosis is difficult because of its low incidence and major trauma to other body regions. We report a fatal case of SACS, which progressed to necrotic and gangrenous large bowel.     

Segmental pulmonary vascular responses to changes in pH in rat lungs: role of nitric oxide

Background: Respiratory or renal failure is associated with changes in blood pH. Changes in pH may have profound effects on vascular tone and reactivity. Site of action of acidosis in the pulmonary vasculature and the role of nitric oxide production remain unclear. Methods: We utilized isolated rat lung preparation perfused with autologous blood (Hct=20%, flow rate=33 ml/min), and investigated the effect of acidosis and alkalosis (induced by ventilation with high and low inspired CO₂) on vascular resistance and the role of nitric oxide during resting and elevated tone conditions. Changes in resistance were described in terms of small and large arteries and veins, using the vascular occlusion technique. Results: Acidosis (P_CO2=66.7±0.7 mmHg, pH=7.17±0.01, P_O2=255±3 mmHg) caused vasoconstriction under resting and increased vascular tone conditions (U46619-induced). The changes in resistance occurred primarily in the small arteries. In contrast, alkalosis (P_CO2=20.1±0.3 mmHg, pH=7.61±0.01, P_O2=244±3 mmHg) caused vasodilation only at elevated tone conditions. Nitrow-L-arginine (LNA), an inhibitor of nitric oxide synthase, increased vascular resistance slightly but did not modulate the responses to pH, suggesting that such responses are not nitric oxide dependent. During KCl-induced contraction, the effects of pH were abolished. Conclusions: We conclude that in rat lung, acidosis causes an increase in pulmonary vascular resistance at normal and elevated tone conditions. Furthermore, the response is limited primarily to the small arteries, and is not mediated by nitric oxide. Alkalosis tends to cause the opposite effects. The effects of acidosis and alkalosis were abolished when vascular tone was elevated with a low dose of KCl, suggesting that vascular response to pH may involve changes in membrane potential.     

Smoking is Associated with Increased Blood Loss and Transfusion Use After Lumbar Spinal Surgery

Background

Little is known about the association between smoking and intraoperative blood loss and perioperative transfusion use in patients undergoing spinal surgery. However, we found that although many of the common complications and deleterious effects of smoking on surgical patients had been well documented, the aspect of blood loss seemingly had been overlooked despite data reported in nonorthopaedic sources to suggest a possible connection.

Questions/Purposes

We asked: (1) Is smoking associated with increased estimated blood loss during surgery in patients undergoing lumbar spine surgery? (2) Is smoking associated with increased perioperative transfusion usage?

Methods

Between 2005 and 2009, 581 lumbar decompression procedures (with or without fusion) were performed at one academic spine center. Of those, 559 (96%) had sufficient chart documentation to categorize patients by smoking status, necessary intra- and postoperative data to allow analysis with respect to bleeding and transfusion-related endpoints, and who did not meet exclusion criteria. Exclusion criteria included: patients whose smoking status did not fit in our two categories, patients with underlying coagulopathy, patients receiving anticoagulants (including aspirin and platelet inhibitors), history of hepatic disease, history of platelet disorder or other blood dyscrasias, and patient or family history of any other known bleeding disorder. Smoking history in packs per day was obtained for all subjects. We defined someone as a smoker if the patient reported smoking up until the day of their surgical procedure; nonsmokers were patients who quit smoking at least 6 weeks before surgery or had no history of smoking. We used a binomial grouping for whether patients did or did not receive a transfusion perioperatively. Age, sex, number of levels of discectomies, number of levels decompressed, number of levels fused, and use of instrumentation were recorded. The same approaches were used for transfusions in all patients regardless of smoking history; decisions were made in consultation between the surgeon and the anesthesia team. Absolute indications for transfusion postoperatively were: a hemoglobin less than 7 g/dL, continued symptoms of dizziness, tachycardia, decreased exertional tolerance, or hypotension that failed to respond to fluid resuscitation. Multiple linear regression analyses correcting for the above variables were performed to determine associations with intraoperative blood loss, while logistic regression was used to analyze perioperative transfusion use.

Results

After controlling for potentially relevant confounding variables noted earlier, we found smokers had increased estimated blood loss compared with nonsmokers (mean, 328 mL more for each pack per day smoked; 95% CI, 249–407 mL; p < 0.001). We also found that again correcting for confounders, smokers had increased perioperative transfusion use compared with nonsmokers (odds ratio, 13.8; 95% CI, 4.59–42.52).

Conclusions

Smoking is associated with increased estimated surgical blood loss and transfusion use in patients undergoing lumbar spine surgery. Patients who smoke should be counseled regarding these risks and on smoking cessation before undergoing lumbar surgery.

Level of Evidence

Level III, therapeutic study.     

The relationship between posttraumatic stress disorder and smoking outcome expectancies among U.S. military veterans who served since September 11, 2001

Posttraumatic stress disorder (PTSD) is associated with increased rates of smoking although little is known regarding the mechanisms underlying this relationship. The current study examined expectations about smoking outcomes among smokers with and without PTSD. The sample included 96 veterans (mean age of 34 years) and included 17% women and 50% racial minorities. Smoking expectancies were measured with the Smoking Consequences Questionnaire-Adult (Copeland, Brandon, & Quinn, 1995). Consistent with previous work suggesting that smokers with PTSD smoke in an effort to reduce negative affect, unadjusted analyses indicated that smokers with PTSD (n = 38) had higher expectations that smoking reduces negative affect than smokers without PTSD (d = 0.61). Smokers with PTSD also had increased expectancies associated with boredom reduction (d = 0.48), stimulation (d = 0.61), taste/sensorimotor manipulation aspects of smoking (d = 0.73), and social facilitation (d = 0.61). Results of hierarchical linear regression analyses indicated that PTSD symptom severity was uniquely associated with these expectancies beyond the effects of gender and nicotine dependence. More positive beliefs about the consequences of smoking may increase risk of continued smoking among those with PTSD who smoke. Further understanding of smoking expectancies in this group may help in developing interventions tailored for this vulnerable population.     

Ischemia/reperfusion injury in skeletal muscle

Ischemia reperfusion injury to skeletal muscle may be explained by a cascade of cellular and systemic events initiated by an ischemic period followed by reperfusion. During the period of ischemia there is a gradual reduction of intracellular energy stores. Adenosine triphosphate is gradually depleted despite the buffering effect of creatine phosphate which is present in large stores in muscles. As well, glycogen stores are depleted with resultant production of small amounts of energy and large accumulations of lactate. Upon reperfusion there is a reactive hyperemia, resulting in an overall increase in muscle blood flow, despite the fact that areas may continue to be underperfused. Results of this blood flow are mixed with the beneficial effects of removing metabolic by-products and supplying exogenous substrates and oxygen. However, this blood flow also causes harmful effects by washing out necessary precursors for adenine nucleotide resynthesis. Production of oxygen free radicals occurs with resultant membrane lipid peroxidation, and calcium influx occurs upon reoxygenation with resultant disruption of oxidative rephosphorylation in the mitochondria. The sequestration of white blood cells in the muscle due to up regulation of both neutrophil receptors and endothelial leukocyte adhesion molecules results in a prolongation of the reperfusion injury. This subsequently results in damage to remote organs, including lung, heart, and kidneys. The future for therapeutic interventions aimed at reducing this injury lie mostly in the ability to modulate the reperfusion effect.     

Cigarette smoking and chronic allograft nephropathy.

BACKGROUND: Smoking has been demonstrated to decrease patient and graft survival after kidney transplantation. Data on histological changes associated with smoking in renal allografts are lacking. METHODS: Smoking habits before and after renal transplantation were evaluated by questionnaire in 279 patients. A transplant biopsy was performed more than 1 year after transplantation in 76 of them. Histological changes were classified according to Banff 97 criteria. Linear regression analysis and proportional odds models for histological changes including the factors age, gender, diabetes, body mass index, donor age, time since transplantation, history of acute rejection and smoking status were calculated. RESULTS: Overall 22% of patients continued smoking after transplantation, with the proportion decreasing from 38% of those transplanted before 1990 to 13% of those transplanted after 2000. Serum creatinine was non-significantly higher in smokers (2.3 +/- 2.7 mg/dl vs 1.8 +/- 1.4 mg/dl, P = 0.21). A renal biopsy was performed in 24% of non-smokers and 39% of smokers (P = 0.02), and smokers were biopsied on average 1.5 years earlier. Among biopsied patients current smokers tended to suffer more often from diabetes (25.0% vs 13.5%, P = 0.33), to develop transplant failure (33.3% vs 21.2%, P = 0.25) or experience a cardiovascular event (29.2% vs 15.4%, P = 0.16). The frequency of acute rejection was comparable between smokers and non-smokers (25.0% vs 34.6%, P = 0.40). Glomerular sclerosis was associated with diabetes (P = 0.03). Severity of vascular intimal fibrous thickening was associated with current smoking (P = 0.004), whereas the degree of arteriolar hyalinosis (P < 0.001) and chronic/sclerosing nephropathy (P = 0.05) were associated with time since transplantation. CONCLUSIONS: The number of patients who continue cigarette smoking after renal transplantation has decreased in recent years. The main allograft lesion associated with smoking is fibrous intimal thickening of small arteries.