2 Mar
2021

smoking group had a comparable BMI

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Alvarez
Bartsch et al 2007
Chang et al 2006
Sorensen 2010
Sorensen 2002
Moler 2003
90 patients, of whom 51 were nonsmokers and 39 smokersThe phenolization group comprised 44 patients (88 nail folds) curettage group comprised 46 patients (85 nail folds).Primary outcome parameter analyzed was the wound healing time after segmental phenolization in smoker and nonsmoker patients as described in methods.Secondary outcome parameter analyzed was the influence of curettage of the cauterized tissue on healing time in the 2 groups of patients.In both treatment groups, the healing time was significantly longer (P < .0001) in the smokers than in the nonsmokers.It was also significantly longer in patients who underwent phenolization alone than in those who also underwent curettage. This latter difference was also found to be statistically significant (P <.0001) when comparing only the smokers of the 2 treatment groups phenolization vs curettage).
Ten smoking patients showed impaired wound healing compared to only four patients of the non-smokers.We monitored the following wound healing problems: minor haematoma, minor wound dehiscence and partial infections.In the nonsmokers group two patients operated by the Hall-Findlay technique showed wound-healing complications, compared to two patient operated by the Eren-technique.The group of smokers showed equal number of wound-healing complications five in each group – in both groups of surgical techniques.
The smoking group had a comparable BMI to the nonsmoking group (26.6 versus 26.8) but was on the whole younger (32.8 versus 38.3 years) and had less tissue resected (1278 versus 1521 g), Comparison of smokers and nonsmokers showed a higher rate of wound healing problems among smokers. Thirty-six of those in the smoking group (55.4%) developed problems compared with 35 of the nonsmokers (33.7%). As smokers differed in mean age from nonsmokers ,a multifactorial analysis (logistic regression) was carried out to assess the effect of smoking and age on the rate of wound-healing problems. This showed that smokers had a higher rate (odds ratio, 2.80; 95% confidence interval, 1.43!194$5.48) when adjusting for the effect of age. The average number of visits to the dressings clinic for wound reviews was also higher for the smoking group (5.2 versus 4.6 times), although the difference subtle. smoker and nonsmoker was similar, notwithstanding the small number of cases of vertical mammaplasty. It was thus reasonable to scrutinize the wound-healing problems of all the breast reductions collectively, comparing smokers and nonsmokers. Different types of problems for each group were subdivided into broader groups of dehiscence, fat necrosis, antibiotic- treated, and procedure-requiring (Table 4). Out of the 9 patients in the last category, 2 had resultant nipple necrosis; 1 was a smoker but not the other. Using the !2 test and Fisher exact test, these subgroups were found not to differ significantly, although there were more fat necrosis cases among the smokers (7.7% versus 1.0%, P # 0.06). Despite having a higher rate of wound-healing problems for smokers, no particular problem was found to be the main cause of the difference. The group of smokers (n#65) was divided into 3 groups: those who stopped for more than 4 weeks (n#15, 23.1%), those who stopped for less than 4 weeks (n # 19, 29.2%) and those who still persisted in smoking (n # 31, 47.7%). Among smokers, a !2 test for trend was carried out according to when smokers had ceased to smoke (Table 5). This showed a significant association (P # 0.028). This stepwise association can be visualized in Figure 3, where the subgroups are compared with the nonsmokers.
One week after wounding, smokers’ wounds were 3.1 ± 0.1 mm (mean, standard error of the mean) wide and were 1.3 ± 0.1 mm deep compared with the never smokers’ wounds, measuring 3.7 ± 0.1 mm wide and 1.5 ± 0.1 mm deep (P < .01, respectively). Abstinent smokers’ wounds were 3.3 ± 0.1 mm wide (NS) and were 1.4 ± 0.1 mm deep (P = .02 compared with smokers). In smokers, vitamin C and PINP were 50.5 ± 9.0 mmol/L and were 52.7 ± 6.6 ng/mL, respectively, compared with 68.8 ± 14.5 mmolL and 64.7 ± 4.7 ng/mL in never smokers (P < .001 and P = .07). Both increased significantly after smoking cessation. Plasma MMP-8 and MMP-9 were correlated with neutrophil blood count, which significantly was affected by smoking status. No effect of TNP was found.
In the pooled cohort, the complication rates were as follows: wound infection 10.2% [95% confidence interval .(7.5±13.5%)], skin flap necrosis 6.1% (4.0±8.8%) and epidermolysis 8.9% (6.4±12.1%). Baseline characteristics for the patients are displayed in Table 1. With postoperative wound infection as dependent variable, the multivariate logistic regression analysis disclosed that both light and heavy smoking compared to non-smoking were significantly and independently associated with wound infection (Table 2). Furthermore, alcohol consumption over 14 drinks per week compared with abstaining was also associated with wound infection. Diabetic patients compared to non-diabetic patients and patients with increasing body mass index had a higher risk of wound infection. Finally, patients operated by trainees had a higher risk of wound infection compared with patients operated by specialist surgeons. With skin flap necrosis and epidermolysis as dependent variables, each multivariate logistic regression analysis disclosed that both light and heavy smoking compared to non-smoking was significantly and independently associated with either variable (Tables 3 and 4). Furthermore, increasing duration of surgery was associated with both skin flap necrosis and epidermolysis, whereas daily intake of NSAIDs was associated with epidermolysis (Table 4). A non-significant dose-response relation between smoking and either outcome variable was observed. No significant interaction between variables in either logistic regression model was found.
Table X Included studies, with their characteristics and JCI score
Author
Country
Sample size
Primary Outcome Measured
Secondary Outcome Measured
Study Type
JBI Score
Álvarez-Jiménez and Córdoba-Fernández 2014
Spain
90
Burn wounds of smokers take longer time to get healed than the non-smokers
Curettage reduces wound healing time in both smokers and non-smokers
Prospective Randomized Clinical Study. 
9
Sørensen et al. 2010
Denmark
78
Smoking attenuates inflammatory and proliferative phase of wound healing.
Smoking cessation induces the markers of these two phases of wound healing
Prospective study
8
Bartsch et al. 2007
Austria
50
Smoking has negative effect on wound healing
Cessation of smoking can improve wound healing
Prospective study
8
Chan, Withey and Butler 2006
United Kingdom
173
After the reduction mammoplasty, smoking has negative impact on wound healing
Smoking cessation can improve occurrence of wound healing problems
Case control study
7
Møller et al. 2003
Denmark
811
Smoking increases postoperative wound complications
Smoking is also linked with cardiopulmonary conditions
Prospective study
8
Sørensen et al. 2002
Denmark
425
Smoking induces wound healing complications
The complication of wound healing is not related to the rate of smoking
Prospective study
6
Table X. Data Extraction Table
Author and Date
Álvarez-Jiménez and Córdoba-Fernández 2014
Sørensen et al. 2010
Title
Influence of Smoking on Wound Healing in Patients Undergoing Nail Matrix Phenolization: A Prospective Randomized Clinical Study
Smoking attenuates wound inflammation and proliferation while smoking cessation restores inflammation but not proliferation
Country
Spain
Denmark
Aims and Objectives
Investigated the difference in the wound healing time after segmental phenolization among smokers and non-smokers
Examined the wound cell sample and tested them histologically to assess the markers of wound healing stage in smokers and non-smokers.
Design
Prospective Randomized Clinical Study
Case control study
Care Setting
Multicemter Participants were admitted from two different clinical settingSubjects recruited from community but accepted a three-night stay at the research center
Multicenter Participants hospitalised for the first 3 days of each study period. Then set home when comfortable with machine and readmitted for final set of measurements.
Population/Size
90 participants 53 smokers 37 non-smokers
78 participants 48 smokers 30 non-smokers
Inclusion/ Exclusion criteria
Inclusion: patients with stage I, II or III ingrown toenails, according to the proposed classification Exclusion: Patients who were exposed to second-hand smokers. infected ingrown toenails with partial onycholysis of one or both nail borders clotting problems, uncontrolled diabetes, bone pathology, alergy or immune problems.
Inclusion: Age 20-40 years in smokers and non-smokers Exclusion: Chronic medical diseases, skin diseases, allergy, pregnancy, menopause, Participants taking corticosteroids.
Duration
October 2009 – January 2012
13 weeks
Intervention(s)
Phenolization treatmentsCurettage on the wounded tissues.
Full thickness (5mm) punch biopsy wounds were created artificially.Wounds were covered with transparent semi-permeable dressing
Primary Outcomes
Burn wounds of smokers take longer time to get healed than the non-smokers.
Smoking attenuates inflammatory and proliferative phase of wound healing.
Secondary Outcomes
Curettage reduces wound healing time in both smokers and non-smokers.
Smoking cessation induces the markers of the two phases of wound healing
Measurements
Wound healing stages were monitored. Wound closure was documented with digital photographs Healing time were measured
Wound cell histology was measures histologically.
Technical Notes
the Ethics and Experiment Committee of the University of Seville (CEE 875/US) approved the Declaration of Helsinkian and the European Guidelines for Good Clinical Practice on Ethical Conduct in Research Involving HumansInformed consent was obtained from all patients, including consent to the publication of photographs.
Ethical consents were taken from each subjectUsed HFNC (Airvo )device All on optimal medication as per GOLD Ethical approval obtained. Informed consent obtained. Participants trained by doctors and nurses Exacerbation defined as a worsening of baseline respiratory symptoms that required treatment with oral corticosteroids and/or antibiotics. An estimate of 30 study participants were needed to obtain 80% power at a two-sided 5% level of significance, to detect a change in SGRQ-C of 11points between the treatment, considering a correlation between two measurements of 0.5 and a between-patient standard deviation (SD) of 20. A change in SGRQ was calculated as the sum of difference in treatment effects (value at the end of each treatment period (either period 1 or 2) minus a value at baseline). The baseline characteristics of study participants in Group A and Group B were tested for homogeneity by t-test and Fisher’s exact test for continuous and categorical variables, respectively. Linear mixed-effects models were used to evaluate effect of treatment, controlling for the fixed effects of time and a random effect to account for repeated measurements. These models were used for the primary and secondary outcomes, except for 6MWT, physical activity, exacerbation rates, changes in medication, and oxygen flow volume. All models examined the differences of the measurements between baseline and week 6 or 12. These differences are shown by the mean±standard error.
Results
The healing time in the curettage group was (8.80 T 1.51 days in smokers vs 6.72 T 1.26 days in nonsmokers;P < .0001) and (13.24 T 1.8 days in the smoker group vs 10.67 T 1.78 days in the nonsmoker group; P < .0001) in the phenolization alone group. Significant differences were found in respect to time to healing among smokers in both groups (13.24 T 1.8 days in the phenolization group vs 8.80 T 1.51 days in the curettage group; P < .0001). Similarly, significant differences were found with respect to time to healing among nonsmokers in both groups (10.46 T 2.04 days in the phenolization group vs 6.71 T 1.11 days in the curettage group; P = .0001).Three patients in the phenolisation group with a clinical pattern of postoperative infection were excluded from the study. The final study included 90 patients, 51 non-smokers and 39 smokersThe phenolization group consisted of 44 patients (88 nail folds) and the curettage group of 46 patients (85 nail folds).Patients’ general characteristics in terms of gender, treatment, number of operated nail folds and smokers or non-smokers.As a secondary parameter, the influence of curettage of cauterized tissue on healing time was analysed in both patient groups.In both treatment groups, healing time is significantly longer in smokers (P < .0001) than in non-smokers. In patients who underwent phenolization alone, it was considerably longer than in patients who underwent curettage. This latter difference was statistically significant (P < .0001) when only smokers in the two treatment groups were compared (phenolization versus curettage).
One week after wounding, smokers’ wounds were 3.1 ± 0.1 mm (mean, standard error of the mean) wide and were 1.3 ± 0.1 mm deep compared with the never smokers’ wounds, measuring 3.7 ± 0.1 mm wide and 1.5 ± 0.1 mm deep (P < .01, respectively). Abstinent smokers’ wounds were 3.3 ± 0.1 mm wide (NS) and were 1.4 ± 0.1 mm deep (P = .02 compared with smokers). In smokers, vitamin C and PINP were 50.5 ± 9.0 mmol/L and were 52.7 ± 6.6 ng/mL, respectively, compared with 68.8 ± 14.5 mmolL and 64.7 ± 4.7 ng/mL in never smokers (P < .001 and P = .07). Both increased Significantly after smoking cessation. Plasma MMP-8 and MMP-9 were correlated with neutrophil blood count, which ignificantly was affected by smoking status. No effect of TNP was found.The inflammation markers were less in concentration in smokers than the non-smokers.
Limitations
The authors did not use any reliable test to validate the reliability of the participants’ smoking statusThree participants of the phenolization group were excluded from completion of the study because they presented a clinical pattern of postoperative infectionDouble blinded studyOne clinician performed all the proceduresA single observer has to evaluate the clinical efficacy and adverse effects (who was blind to which procedure was applied)Wound healing was monitored spontaneously, wound closure over a month using clinical assessments and digital photographs.Participants were seen every 48 hours and from the fourth day on, both groups were treated with an antiseptic solution.Checks were carried out daily until the criteria for the healing time were fully met.Clinical criteria for early healing were the absence of drainage (no visible exudate), granulation tissue covered with a scab (no indication of hypergranulation tissue) and no signs of infection (i.e. no pain or clinical evidence of discharge associated with local spreading redness).The sample size for the study was calculated using the computer program CTM-1.1 (Glaxo Wellcome SA, Madrid, Spain).The result of the calculation was that a clinically relevant difference of 5 days in the mean healing time between the experimental and control groups was detected for a significance level of! = .05 and an error ” = .15, a minimum of 19 patients would be necessary in each group.Statistical analysis was performed using SPSS 17.0 (SPSS Science, Chicago, Illinois).Limited number of patients and controls Reduced sample size increases the risk of a type 2 error particularly in the control group Treatment limited to 1 night in a group of mild to moderate COPD, which limits conclusions that can be drawn on the overall significance. Limited number of subjects did not allow to strengthen the correlation by doing some multivariate regression models.
The authors did not specify the inclusion criteria properlyNot blinded 2 drop outs and 1 death related to suicide Small study and limited to Japanese patients 3 participants from group A were excluded from final analysis potentially influencing findings. Did not screen for co-existing sleep disorders. Did not have washout period between treatments suggested by previous studies although it is probable that HFNC does not accumulate affect. To minimize carry over effect and bias they used linear mixed models adjusted for time and effect. Tomi K reports honoraria from Teijin Pharma Limited. All the other authors have no conflict of interest
Conclusion/ Recommendations
Nicotine affects induce -operative complications that include wound dehiscence, graft necrosis, infectionSmoking prolongs healing timeThe segmental phenolization burn wounds of smokers take longer to heal than those of non-smokers.Curettage of the cauterized tissue after segmental phenolization shortens healing time in both smokers and nonsmokers.Curettage after phenolization should be systematically considered in patients who smoke to reduce the healing time after the procedure.Data suggests HFNC may not only have beneficial effects on respiratory stability during sleep but also reduces sympathetic activity during REM sleep in COPD patients. The observed association between reduction in sympathetic activity with NHF and the degree of impaired lung function suggests that worsening COPD disease severity in associated with increased sympathetic activity during sleep and that NHF may be used to mitigate cardiovascular burden in COPD patients. Supports the initiation of clinical trials addressing long term effects of HFNC in patients with the entire disease spectrum of COPD. Improved breathing mechanics with single night treatment of HFNC but not elevated oxygenation through supplementary O2 reduces vascular sympathetic activity in COPD patients during REM sleep. Sympathetic off loading by HFNC showed a strong association with the degree of COPD severity. Encourages further research on the long-term efficacy of NHF in patients with different COPD diseases severities
Smoking affects wound healing Smoking stops inflammatory and proliferative stages of wound healing.Addition of HFNC to LTOT improves quality of life and improve hypercapnia in patients with chronic hypercapnia respiratory failure due to COPD. Further studies needed on the effect on progressioni and cost effectiveness. Not known if longer study durations would have led to further improvements therefore Longer trial period
JBI Score
9
8
Author and Date
Bartsch et al. 2007
Chan, Withey and Butler 2006
Title
Crucial aspects of smoking in wound healing after breast reduction surgery
Smoking and Wound Healing Problems in Reduction Mammaplasty
Country
Austria
United Kingdom
Aims and Objectives
Investigated the influence of smoking on the patients who are undergoing breast reduction surgery.
Investigated the wound healing problem associated with smoking in patients with reduction mammaplasty.
Design
Prospective study
Case control study
Care Setting
Population/Size
50 25 smokers 25 non-smokers
173 67 smokers 106 non-smokers
Inclusion/ Exclusion criteria
Inclusion: patients had breast reduction surgery within the year 2000-2003. The age range 19.9-63.8Exclusion: Patients with systemic, metabolic, immunogenic or histologic diseases.
Inclusion: minimum 3 cigarettes per day were smoked by the smokersExclusion: Patients with small volume reduction were excluded.
Duration
4 days
1st January 2002 – 25th February 2004
Intervention(s)
After surgery, the wounds were left undressed. No antibiotics were provided to observe the natural healing.
-Smokers were told to stop smoking 1 month prior to the surgery. -Basic wound dressing.
Primary Outcomes
Smoking has negative effect on wound healing
After the reduction mammaplasty, smoking has negative impact on wound healing.
Secondary Outcomes
Cessation of smoking can improve wound healing
Smoking cessation can improve occurrence of wound healing problems.
Measurements
-Classified wounds in 4 differential groups. -Wound healing stages were analyzed after 4 days.
Wound healing stages were monitored in clinic.
Technical Notes
Ethical approvals were taken.
-SPSS statistical tool was used. -Ethical consents were taken.
Results
-10 out of 25 smokers were found with impaired wound healing. -4 out of non-smokers were found with the same wound condition. -Smokers had higher cotinine level than the non-smokers.
55.6% of the smokers and 33.7% of the non-smokers faced wound healing problems of different categories
Limitations
-The study duration was really short. -The study included a wide range of age among the subjects.
The smoking status detector kit had limitations.
Conclusion/ Recommendations
Nicotine impairs wound healing
Smoking has significant role in enhancing the wound healing problems.
JBI Score
8
7
Author and Date
Møller et al. 2003
Sørensen et al. 2002
Title
Effect of smoking on early complications after elective orthopaedic surgery
Smoking as a risk factor for wound healing and infection in breast cancer surgery
Country
Denmark
Denmark
Aims and Objectives
Determined the association between smoking and postoperative complications after orthopedic surgery
Investigates the effect of smoking on wound healing and wound necrosis after the breast cancer surgery.
Design
Prospective study
Prospective study
Care Setting
Population/Size
811 Participants 232 Smokers 454 never smokers 125 smokers who stopped smoking
425 smokers
Inclusion/ Exclusion criteria
Inclusion: Patients who had undergone knee or hip arthroplasty between 1999-2000 at Frederiksberg or Bispebjerg UniversityExclusion: not mentioned specifically
Inclusion: patients who undergone simple mastectomy and modified radial mastectomy.Exclusion: Patients who undergone breast conserving surgery
Duration
January1999 – December 2000
June 1994 – August 1996
Intervention(s)
In recovery stage after the surgery patients were provided with oxygenation.
Primary Outcomes
Smoking increases postoperative wound complications
Smoking induces wound healing complications
Secondary Outcomes
1. Smoking is also linked with cardiopulmonary conditions. 2. Smoking increases the hospital stay time.
The complication of wound healing is not related to the rate of smoking.
Measurements
Pre- and post-operative factors were measured, which included wound related complication, ICU admission and any complication related to cardiopulmonary conditions and knee arthroplasty.
-Wound healing progression was measured. -Postoperative wound infection, epidermolysis and skin flap necrosis were documented.
Technical Notes
SPSS software (version 10.0) was used. Ethical permission was taken from the local ethical committee
SPSS for Windows 8 was used
Results
– Smokers have significantly higher chances of developing wound complications after the surgery (p<0.001). -Smokers had longer hospital days than the non-smokers.
10.2% of the pooled cohort have wound necrosis, 6.1% faced skin flap necrosis and 8.9% faced epidermolysis.
Limitations
No specific exclusion criteria are mentioned in the article.
The authors did not include a criterion for the age group, which is a factor affecting wound healing. Patients with other medical conditions also were not excluded.
Conclusion/ Recommendations
Smoking is directly linked with wound complications during wound healing, after elective arthroplasty in knees or hips
Smoking causes decreased oxygenation in the wounds that disrupts wound healing.
JBI Score
8
6

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