Active Tobacco Use Research Articles

Comparative results of open lower extremity revascularization in nonagenarians

The average lifespan in the United States continues to lengthen. We have observed a similar trend in our patients, with an increased number of nonagenarians presenting for evaluation of vascular disease. This study evaluated outcomes of lower extremity revascularization in patients aged >or=90 years. The vascular registry at Albany Medical College was retrospectively reviewed for all lower extremity bypasses performed between 1996 and 2006. We evaluated patient demographics, indications, procedure, patency rates, and complications. Patients were divided into groups based on age >or=90 years (>or=90 group) and <90 years (<90 group). Variables were evaluated by chi(2) analysis. Outcomes were prepared using life-table methods and compared with log-rank analysis. During the last 10 years, 5443 lower extremity bypasses were performed on patients aged <90 years and 150 on patients aged >or=90 years. The <90 group had significantly more men (61.4% vs 29.3%) and was obviously younger, at 68 years (range 7-89 years) vs 92 years (range, 90-101 years). The <90 group had more comorbidities in terms of diabetes, active tobacco use, and hypercholesterolemia. No significant difference was noted in coronary artery disease or chronic renal insufficiency between the groups. Critical limb ischemia as an indication was significantly higher in the >or=90 group (149 [99%] vs 4472 [82%]; P < .0.5). Strikingly, the primary patency was significantly higher in the >or=90 group at 4 years (77% vs 62%; P < .05). Complication and amputation rates did not differ between the groups. Perioperative (15% vs 3%; P < .05) and 1-year (45% vs 11%; P < .05) mortality rates were significantly higher in the >or=90 group. Lower extremity bypass for nonagenarians offers acceptable patency and limb salvage but at a significantly higher mortality rate.

Prevalencia de enfermedad arterial periférica estimada mediante el índice tobillo-brazo en pacientes con síndrome metabólico. Estudio MERITO I

Patients with Metabolic Syndrome have high cardiovascular morbidity and mortality rate above that expected when using accepted scales for risk stratification. Ankle brachial index (ABI) is an available, straightforward and reproducible method for the detection of peripheral vascular disease and for improving risk stratification in this population. Our study aimed to evaluate the prevalence of low ABI in patients with metabolic syndrome older than 50 years and to study the risk factors associated with its development. 1519 subjects between 50 and 85 years, 935 of them with metabolic syndrome (Adult Treatment Panel III [ATP III] criteria), in primary prevention, without symptoms of intermittent claudication and who gave their consent to have an ABI measurement in internal medicine offices were included in the study. Cardiovascular risk factors were evaluated in all participants. An ABI < 0.9 was considered low. The prevalence of a low ABI in subjects with metabolic syndrome was 27.7 (95% CI: 24.8-30.5). Factors associated with low and a pathological ABI were age, higher serum creatinine levels and presence of proteinuria. After multivariate adjustment, only age (OR: 1.07; 95% CI: 1.04-1.09) and active tobacco use (OR: 1.45; 95% CI: 1.10-1.92) continued to be significant. Prevalence of a low ABI is elevated in subjects with metabolic syndrome without known cardiovascular disease and related with age and active tobacco use.

163: The feasibility of diaphragmatic transplantation in a canine model: Novel potential therapy for treatment of Duchenne muscular dystrophy-associated respiratory failure

etiologies of respiratory failure. Charts of patients with emphysema were reviewed for NETT criteria that suggest favorable prognosis with LVRS including PFTs, CT scan, and comorbid conditions. Active tobacco use resulted in exclusion. Results: 162 patients were referred for lung transplant evaluation, 69 patients were listed. 93 patients deferred or denied, 56 carried the diagnosis of emphysema. 16 (29%) met NETT criteria for LVRS. 4 patients had ongoing tobacco use. 9 patients had cardiac contraindications, 6 other comorbid conditions. 17 patients had PFTs outside the strict NETT criteria. One patient had a previous talc pleurodesis. One patient had prior LVRS. Conclusions: LVRS has been shown to be beneficial in select patients with emphysema yet appears underutilized in the VA population. Almost 30% of deferred patients were potential candidates for volume reduction. LVRS as a bridge to transplant has been used minimally in the VA. This unique population with referral from throughout the United States gives insight into national trends in medical care . Our data suggests that changes in reimbursment coverage after NETT recommendations have not increased numbers of LVRS or its acceptance as alternative to transplantation in select patients.

2302: Greater Than 6 Months of Androgen Deprivation Therapy Does Not Improve Overall Survival for High-Risk Prostate Cancer Patients Treated With Radiotherapy or Prostatectomy

To analyze the effect of the duration of androgen deprivation (AD) in the definitive treatment of high-risk prostate cancer. A total of 579 patients with high-risk prostate cancer were treated definitively at the Cleveland Clinic from 1998 to 2003 with either external beam radiation (RT, n=390), radical prostatectomy (RP, n=165), or permanent prostate implant (PI, n=24). High-risk disease was defined as: initial PSA (iPSA)> 20, Gleason score (GS) 8–10, clinical stage T3, or iPSA 10–20 and GS 7. The study endpoints were: biochemical failure [(bF), using the ASTRO consensus definition for RT and PI patients and two consecutive PSA’s ≥0.2ng/ml for RP patients], clinical failure [(cF), defined as the detection of biopsy proven local recurrence, or evidence of definite metastases to bone, lymph nodes, or elsewhere] and overall survival (OS). Cox proportional hazards regression was used to determine what factors, including iPSA, GS, stage, AD, age, race, income, BMI, and smoking history correlated with bF, cF, and OS. Median follow up was 60 months (range: 24–114). Median age for all patients was 67 years (range: 41–85). AD was given to 426 (73.6%) patients, with 82.6% of those patients receiving 1–6 months (median 6 months) and 17.4% receiving >6 months (median 15 months) of AD. Univariate analysis revealed that > 6 months of AD had no statistically significant impact on bF or cF, but did result in a statistically significant worse OS, (p=0.0003). Other factors found to result in worse OS on univariate analysis included GS ≥ 8 (p=0.0424), active tobacco use (p=0.0467), and increasing number of pack-years smoked (p=0.0139). Kaplan-Meier estimates of OS for patients receiving no AD vs. 1–6 months of AD vs. > 6 months of AD were 92%, 92%, and 76% at 5-years and 78%, 84%, and 67% at 7-years, respectively (p=0.0007). The use of >6 months of AD remained an independent predictor of death on multivariate analysis (RR 2.158, p=0.0329), as did Gleason score and increasing number of pack-years smoked. While smoking and use of >6 months of AD both had a detrimental effect on OS, no synergistic effect between the two factors was detected. In high-risk patients treated with radiotherapy or prostatectomy, longer duration of androgen deprivation (> 6 months) does not improve biochemical or clinical failure rates, and appears to result in worse overall survival. The cause of this lower overall survival is unknown and warrants further investigation.

Validity of self reports in a cohort of Swedish adolescent smokers and smokeless tobacco (snus) users

Objective: To validate self reports of cigarette and smokeless tobacco (snus) use in a prospective cohort of adolescents. Design: A cross sectional analysis of a cohort sub-sample. Setting: County of...

Aberrant p16 methylation is a biomarker for tobacco exposure in cervical squamous cell carcinogenesis

Objective The purpose of this study was to determine the association between active tobacco exposure and aberrant p16 promoter methylation in primary cervical squamous cell cancer and high-grade squamous cervical dysplasia. Study design p16 methylation–specific polymerase chain reaction was performed on DNA that was extracted from 60 cervical cancers, 30 high-grade dysplasia specimens, and 78 normal cervical cytologic specimens. Patient data were obtained by medical record review or were collected prospectively. Results Aberrant p16 methylation was significantly higher in squamous cell cervical cancers (61%) than in squamous high-grade dysplasia (20%) or normal cytologic specimens (7.5%). Approximately one half the women with squamous cancer and one half of the women with high-grade dysplasia were active smokers. Aberrant p16 methylation was associated with active tobacco use in patients with squamous carcinoma (odds ratio, 20.6; 95% CI, 3.6-118; P<.001) and high-grade dysplasia (odds ratio, 4.57; 95% CI, 1.63-12.78; P = .002). Conclusion Aberrant p16 methylation is associated strongly with active tobacco use in squamous cell cervical cancers and high-grade dysplasia.

Patients undergoing infrainguinal bypass to treat atherosclerotic vascular disease are underprescribed cardioprotective medications: effect on graft patency, limb salvage, and mortality

IntroductionEstablished American Heart Association guidelines recommend the use of statin drugs, angiotensin converting enzyme (ACE) inhibitors, and antiplatelet agents in patients with systemic atherosclerosis, such as those undergoing operative intervention to treat peripheral atherosclerotic disease. Many of these patients have not received treatment of coronary heart disease and have not been prescribed these medications. Whether statin drugs and ACE inhibitors confer an improvement in graft patency, limb salvage, and operative mortality is unknown. MethodsConsecutive patients who underwent infrainguinal bypass between 1997 and 2002 were evaluated for demographic data, comorbid disease, medication use, as well as cumulative graft patency, limb salvage, and mortality. Univariate, multivariate logistical regression, and Kaplan-Meier analyses were performed. P < .05 was considered significant. ResultsTwo hundred ninety-three patients (mean age, 64 years; 67% men) underwent 338 infrainguinal bypass procedures with autologous vein (n = 218), prosthetic grafts (n = 88), or composite prosthetic-vein grafts (n = 32). Limb salvage was the operative indication in 75% of procedures. Coexisting diseases included hypertension (70%), diabetes (52%), hyperlipidemia (37%), coronary heart disease (51%), congestive heart failure (14%), and active tobacco use (30%). Statin drugs were taken by 56% of patients, ACE inhibitors by 54% of patients, and antiplatelet agents or warfarin sodium (Coumadin) by 93% of patients. Postoperative graft surveillance was done in 39% of patients. Cumulative graft patency was 73%, limb salvage was 85%, and mortality was 9%, with a mean follow-up of 17 months.Factors independently associated with increased graft patency included statin drug use (odds ratio [OR], 3.7; 95% confidence interval [CI], 2.1-6.4), male sex (OR, 2.8; 95% CI, 1.6-5.0), and graft surveillance (OR, 2.4; 95% CI, 1.3-4.5). Factors associated with decreased amputation rate were statin drug use (OR, 0.34; 95% CI, 6.15-0.77) and graft surveillance (OR, 0.23; 95% CI, 6.1-0.63). Factors associated with decreased mortality included graft surveillance (OR, 0.18; 95% CI, 0.1-0.56), whereas congestive heart failure (OR, 6.5; 95% CI, 2.5-17) and hemodialysis-dependent renal failure (OR, 29; 95% CI, 6.1-140) were associated with increased mortality. Kaplan-Meier analysis showed that only ACE inhibitors were associated with lower mortality (P = .05) ConclusionsPatients undergoing infrainguinal bypass are undertreated with respect to cardioprotective medications. ACE inhibitor use is associated with lower mortality, and statin drug use is associated with improved graft patency and limb salvage. Institution of consensus guidelines concerning these medications should be considered by all vascular specialists, including vascular surgeons.

Hepatic steatosis on ultrasound: Associated factors and relationship with steatosis on liver biopsy

80%. Results: Alcoholic liver disease (ALD) alone occurred in 31%, ALD + HCV: 13.7%, HC%' alone: 21.7% and other liver diseases: 33.5%. The median age was 48 years in all groups. 88% were Caucasian and 55% were males. Liver transplantation was performed in 292 (18%). Hepamma was diagnosed in 37 (2.3%). Universal risk factors for mortality were, male gender: Hazard ratio (HR) 1.7, 95% C.L 1.3-2.2, age: HR 1.04, 95% C.I. 1.02-1.05, MELD score: HR 1.8, 95% C.I. 1.6-2.1, and active tobacco use: HR 1.4, 95% C.I. 1.1-1.9. Continued alcohol abuse after diagnosis predicted mortality in ALD patients (HR 1.9, 9% C.1. 1.1-3.1). Etiology, of liver disease was not a significant predictor of mortality after adjusting tot liver disease severity at presentation. The median MELD score was 8 (range 10 to 55), MELD scores at presentation were ALD: 13, ALD+ HCV: 8, HCV: 4, all others: 7. In all there were 102 deaths at 3 months and 167 at 1 year. Tbe concordance between actual and predicted 3-month mortality using MELD was 0.89 tor all bver patients and for 1-year mortality 0.79. In the non-alcoholic cohorL 61 deaths were observed by I year and the concordance was 0.83. Conclusion: MELD predicts lx, th 3and 12-month mortality, in a large hospital-based cohort of liver patients, irrespective of disease etiology. It is a good predictor of 1-year mortality in a less severe chronic liver disease group. ALD is a prevalent cause of severe liver disease, with excess mortality attributable to more advanced liver disease at first presentation

Long-term follow-up of coronary artery disease presenting in young adults

ObjectivesThis study evaluated long-term survival and predictors of elevated risk for young adults diagnosed with coronary artery disease (CAD). BackgroundCoronary artery disease is rarely seen in young adults. Traditional cardiac risk factors have been studied in small series; however, many questions exist. MethodsWe identified 843 patients under age 40 with CAD diagnosed by coronary angiography from 1975 to 1985. Death, hypertension, gender, family history, prior myocardial infarction (MI), diabetes, heart failure, angina class, number of diseased vessels, ejection fraction (EF), Q-wave infarction, in-hospital death, and initial therapy were studied. Patients were followed for 15 years. ResultsThe mean age was 35 for women (n = 94) and 36 for men (n = 729). The average EF was 55%. Fifty-eight percent of the subjects had single-vessel disease, and 10% were diabetic. The strongest predictors of long-term mortality were a prior MI (hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.00 to 1.73), New York Heart Association class II heart failure (HR 1.75, 95% CI 1.03 to 2.97), and active tobacco use (HR 1.59, 95% CI 1.14 to 2.21). Revascularization, rather than medical therapy, was associated with lower mortality (coronary angioplasty: HR 0.51, 95% CI 0.32 to 0.81; coronary artery bypass graft: HR 0.68, 95% CI 0.50 to 0.94). Overall mortality was 30% at 15 years. Patients with diabetes had 15-year mortality of 65%. Those with prior MI had 15-year mortality of 45%, and patients with an EF <30% a mortality of 83% at 15 years. ConclusionsCoronary disease in young adults can carry a poor long-term prognosis. A prior MI, diabetes, active tobacco abuse, and lower EF predict a significantly higher mortality.

AIR POLLUTION AND BIRTH WEIGHT IN NORTHERN NEVADA, 1991-1999

This study examined the association between particulate matter ≤ 10 µm in aerodynamic size (PM 10), carbon monoxide (CO), and ozone (O 3), and birth weight in Washoe County, NV, from 1991 through 1999. In total, 39,338 single births were included in this study. The mean birth weight was 3383 ± 460 g and prevalence of low birth weight (LBW) was 2.46% for single births with a gestational age of 37-44 wk. After controlling for cofactors including infant sex, maternal residential city, education, medical risk factors, active tobacco use, drug use, alcohol use, prenatal care, mother's age, race and ethnicity of mothers, and weight gain of mothers, we found PM 10 exposure in the third trimester of pregnancy to be a significant predictor of birth weight of newborns. A 10-µg/m 3 increase in the 24-h PM 10 level in the third trimester of pregnancy can be associated with a birth-weight reduction of 11 g (95% CI: 2.3-19.8 g) using multiple linear regression; however, PM 10 was not found to be related with the risk of LBW from logistic regression. CO and O 3 were not found to be associated with birth weight or risk of LBW of newborns by the same modeling procedure. The results suggest PM 10 could be a risk factor associated with birth-weight reduction of newborns in urban northern Nevada; however, the current level of PM 10 is not a risk factor to increase the chance of LBW newborns.

Determinants of red cell, platelet, plasma, and cryoprecipitate transfusions during coronary artery bypass graft surgery: the Collaborative Hospital Transfusion Study

Very little is known about the determinants of blood transfusions in patients undergoing coronary artery bypass graft surgery. To identify factors that influenced the transfusion of red cells, platelets, plasma, and cryoprecipitate, statistical methods were used to study 2476 consecutive diagnosis-related group 106 and 107 patients in five teaching hospitals who underwent coronary artery bypass surgery between January 1, 1992, and June 30, 1993. The likelihood of red cell transfusion was significantly associated with 10 preoperative factors: 1) admission hematocrit, 2) the patient's age, 3) the patient's gender, 4) previous coronary artery bypass surgery, 5) active tobacco use, 6) catheterization during the same admission, 7) coagulation defects, 8) insulin-dependent diabetes with renal or circulatory manifestations, 9) first treatment of new episode of transmural myocardial infarction, and 10) severe clinical complications. Platelet and/or plasma transfusions were strongly associated with the dose of red cells transfused. Transfusion requirements and other in-hospital outcomes were associated with patient characteristics, surgical procedure (reoperation vs. primary procedure), and the conduits used for revascularization (venous graft only, venous and internal mammary artery graft, or internal mammary artery graft only). Blood resource use and donor exposures were evaluated with respect to the risk to patients of contracting hepatitis C virus and human immunodeficiency virus infections. The classification of coronary artery bypass graft patients on the basis of attributes known preoperatively and by conduits used yields subsets of patients with distinctly different transfusion requirements and in-hospital outcomes.