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How to blow your defense [5]
... Of the 516 titles and abstracts, 45 qualified for the full text review after duplicate independent review ( Figure 1). Of these, 24 studies were excluded: 7 were reviews, commen-taries, or editorials 21,22,23,24,25,26,27 ; 8 did not contain outcomes of interest or did not have smoking as a predictor 28,29,30,31,32,33,34,35 ; 1 was related to economic outcome 36 ; 1 was a qualitative study related to a patient survey 37 ; 1 thesis was not available for review 38 ; 4 were related to smoking cessation 39,40,41,42 ; 1 was a duplicate article 43 ; and 1 was related to arthroscopy 44 . A total of 21 studies from the original search met the inclusion and exclusion criteria and data were extracted from these. ...
Studies have suggested higher rates of perioperative and postoperative complications in smokers compared to nonsmokers. The objective of this systematic review was to assess the association of smoking and postoperative outcomes following total hip arthroplasty (THA) or total knee arthroplasty (TKA).
A search of 6 databases (The Cochrane Library, Scopus, Proquest Dissertation abstracts, CINAHL, Ovid Medline, and Embase) was performed by a Cochrane librarian. All titles and abstracts were screened by 2 independent reviewers with expertise in performing systematic reviews. Studies were included if they were fully published reports that included smoking and any perioperative or postoperative clinical outcome in patients with TKA or THA.
A total of 21 studies were included for the review, of which 6 provided multivariable-adjusted analyses, 14 univariate analyses, and one statistical modeling. For most outcomes, results from 1-2 studies could be pooled. Current smokers were significantly more likely to have any postoperative complication (risk ratio 1.24, 95% CI 1.01 to 1.54) and death (risk ratio 1.63, 95% CI 1.06 to 2.51) compared to nonsmokers. Former smokers were significantly more likely to have any post-operative complication (risk ratio 1.32, 95% CI 1.05 to 1.66) and death (risk ratio 1.69, 95% CI 1.08 to 2.64) compared to nonsmokers.
This systematic review found that smoking is associated with significantly higher risk of postoperative complication and mortality following TKA or THA. Studies examining longterm consequences of smoking on implant survival and complications are needed. Smoking cessation may improve outcomes after THA or TKA.
Three recent advances in assessment of routine lung function are reviewed. In both normal subjects and patients with obstructive lung disease, the flows during the forced vital capacity (FVC) manoeuvre depend significantly on the pattern of the preceding inspiratory manoeuvre. Accordingly, the latter should be standardized in clinical and epidemiological studies. Although the nature of this phenomenon is not fully understood, stress relaxation of lung tissues probably plays the primary role. The negative expiratory pressure technique provides a simple and reliable tool for detecting expiratory flow limitation both at rest and during exercise. The method does not require body plethysmography or the patient’s cooperation and coordination, and can be applied in any desired body posture. A simple method for monitoring FVC performance has been developed. It allows detection of flow limitation during the FVC manoeuvre.
Chronic obstructive pulmonary disease (COPD) is easily detected in its preclinical phase using spirometry, and successful smoking cessation (a cost-effective intervention) prevents further disease progression. This consensus statement recommends the widespread use of office spirometry by primary-care providers for patients > or = 45 years old who smoke cigarettes. Discussion of the spirometry results with current smokers should be accompanied by strong advice to quit smoking and referral to local smoking cessation resources. Spirometry also is recommended for patients with respiratory symptoms such as chronic cough, episodic wheezing, and exertional dyspnea in order to detect airways obstruction due to asthma or COPD. Although diagnostic-quality spirometry may be used to detect COPD, we recommend the development, validation, and implementation of a new type of spirometry-office spirometry--for this purpose in the primary-care setting. In order to encourage the widespread use of office spirometers, their specifications differ somewhat from those for diagnostic spirometers, allowing lower instrument cost, smaller size, less effort to perform the test, improved ease of calibration checks, and an improved quality-assurance program.
During a ten-year period, aseptic necrosis of the femoral head developed in six patients with pulmonary disease treated with corticosteroids. Five of the six patients had severe bronchial asthma. The sixth patient had desquamative interstitial pneumonia. The literature provides some insight into the possible pathogenesis of corticosteroid-related aseptic necrosis of the femoral head and factors that may prevent this complication.
Osteonecrosis, or nontraumatic (aseptic, avascular) bone necrosis, is a relatively common disorder estimated to account for more than 10 percent of all joint replacements1. Although a number of clinical entities have been associated with osteonecrosis (e.g., Gaucher's disease, systemic lupus erythematosus, rheumatoid arthritis, hemoglobinopathies, air embolism, pancreatitis, and chronic alcoholism), the incidence and pathogenesis of osteonecrosis in each condition are not well defined. Some patients with osteonecrosis have also been treated with corticosteroids. It is not clear, however, if osteonecrosis in patients treated with corticosteroids represents a drug complication, a complication of the disease process, or both1–5. . . .
One of the challenging issues faced by allergists is a risk-benefit analysis on the use of corticosteroids. An uncommon, but serious complication of corticosteroids is the development of avascular necrosis (osteonecrosis). In this review we present the differential diagnosis and pathophysiology of osteonecrosis, with particular emphasis on steroids. Osteonecrosis of the femoral head is a common disorder that may be either naturally occurring or iatrogenic. With the exception of those cases labeled as idiopathic, the majority are the result of some insult to the vascular integrity of the affected hip. The reason for this disruption is manifold and can range from direct trauma to the more subtle or indirect compromise associated with fatty emboli or often an intravascular event such as that seen in sickle cell anemia. Although they are not totally understood, corticosteroids present a special problem because of susceptibility factors that may make some patients more likely to get osteonecrosis than others. The problem may be more complex, in that the association between corticosteroid use and osteonecrosis may be disease-dependent. In any case, any patient receiving long-term corticosteroids should be warned of this potentially debilitating complication.