The Effect of Tobacco Smoking on Musculoskeletal Health: A Systematic Review

A regression model on work-related musculoskeletal disorders and associated risk factors among radiographers

Objectives. This study aimed to develop a predictive model for work-related musculoskeletal disorders (WRMSDs) among radiographers. Methods. A survey was conducted in seven hospitals in two cities with radiographers using the ergonomic assessment for radiographers questionnaire. Logistic regression, confirmatory factor analysis and structural equation modelling (SEM) were utilized to establish statistical relationships between independent factors and musculoskeletal complaints. Results. Of 165 respondents, 75.2% reported musculoskeletal pain in the past 12 months, with lower back pain the most prevalent (58.8%). Adjusting for covariates, musculoskeletal pain significantly correlated with body mass index < 23 (odds ratio [OR] 0.06, 95% confidence interval [CI] [0.005, 0.914]), smoking status (OR 0.274, 95% CI [0.751, 6.195]), fixed work break schedule (OR 2.839, 95% CI [1.123, 7.176]), sustained posture (OR 4.854, 95% CI [1.203,19.594]) and prolonged standing or walking (OR 7.499, 95% CI [1.086, 51.753]). The fit measures indicate a moderately good fit of the proposed model to the observed data. However, latent variables did not exhibit significant associations with WRMSD in SEM. Conclusions. The model suggests that WRMSDs among radiographers moderately correlate with underweight, smoking status, fixed work breaks, sustained posture and extended periods of standing or walking. The absence of significant associations between latent variables and WRMSDs suggests the presence of unexplored factors influencing the outcome.Trial registration: Clinical Trials Registry India identifier: CTRI/2021/09/036992.

Cigarette smoke extract exacerbates progression of osteoarthritic-like changes in cartilage explant cultures

Established risk factors for osteoarthritis (OA) include obesity, joint injury, age, race, and genetics. However, the relationship between cigarette smoking and OA has yet to be established. In the present study, we have employed the use of cigarette smoke extract (CSE), the water-soluble vapor phase of cigarette smoke, with porcine cartilage explants to investigate the effects of cigarette smoking on cartilage catabolism at the tissue level. Articular cartilage explants were first exposed to 2.5%, 5%, and 10% CSE to assess its effects on cartilage homeostasis. Following, the effects of CSE on OA-like inflammation was observed by culturing explants with a combined treatment of IL-1β and TNF-α and 10% CSE (CSE + OA). Cartilage explants were assessed for changes in viability, biochemical composition, extracellular matrix (ECM) integrity, and equilibrium mechanical properties (aggregate modulus and hydraulic permeability). CSE alone leads to both a time- and dose-dependent decrease in chondrocyte viability but does not significantly affect sGAG content, percent sGAG loss, or the ECM integrity of cartilage explants. When IL-1β and TNF-α were combined with 10% CSE, this led to a synergistic effect with more significant losses in viability, significantly more sGAG loss, and significantly higher production of ROS than OA-like inflammation only. Cartilage explant equilibrium mechanical properties were unaffected. Within the timeframe of this study, CSE alone does not cause OA but when combined with OA-like inflammation leads to worsened articular cartilage degeneration as measured by chondrocyte viability, sGAG loss, proteoglycan staining, and ROS production.

Addictive behavior and mental health of adolescents aged 11-17 years in Bangladesh in 2014: A cross-sectional study

Background and Aims

This study aimed to evaluate the factors associated with addictive behavior and mental health in adolescents aged 11-17 years in Bangladesh.

Methods

This study analyzed data from the Bangladesh Global School-based Health Survey (GSHS) conducted in 2014. Adolescents aged 11-17 years studying government schools were considered as respondents for this survey. A two-phase group sample design was utilized to deliver illustrative information of all understudies in grades (classes) 7-10 in Bangladesh. Bivariate analyses followed by a weight-adjusted multiple logistic regression was fitted to a sample of size 2989 adolescents.

Results

One in ten and one in four adolescents had different substance addictions and some forms of mental health conditions, respectively. Sex of participants (adjusted odds ratio [AOR]: 4.49; confidence interval [CI]:2.28-8.84), being bullied (AOR: 3.08; CI:1.46-6.49), use of tobacco among parents (AOR: 5.82; CI:3.16-10.75), parental understanding of adolescents' problems (AOR: 0.45; CI:0.23-0.82), and food affordability (AOR: 1.24; CI:1.09-1.42) were associated with addictive behaviors of adolescents. Bullied males with nonempathetic parents were found to be more vulnerable to addictive behaviors and bullied females showed higher tendencies to mental health issues.

Conclusion

Considering the elevated prevalence of reported mental health concerns, identifying vulnerable groups and formulating intervention-oriented policies engaging youths can pave the way towards achieving robust health and well-being for them in Bangladesh.

Effect of chronic heavy tobacco smoking on ankle fracture healing

INTRODUCTION

Tobacco smoking is linked to an elevated risk of osteomyelitis and delayed healing in long bone fractures. However, the impact of smoking on bone union and soft tissue recovery following ankle fractures remains unclear. This study presents a retrospective comparative analysis evaluating the effects of chronic heavy tobacco smoking on the healing process and outcomes of ankle fractures after surgical interventions.

MATERIALS AND METHODS

We examined 220 consecutive cases of chronic heavy smokers (CHS) with closed ankle fractures who were referred to our unit for further treatment. A control group, consisting of 220 age- and sex-matched individuals (non-smokers with closed ankle fractures), was identified for comparative analysis. We collected clinical data, including pre-existing comorbidities, Lauge-Hansen fracture classification, necessity for surgery, and the surgical procedures performed. The primary outcomes investigated were the time required for fracture union and wound healing. Secondary outcomes included postoperative complications such as prolonged pain, bleeding, swelling, infection, compartment syndrome, and neurovascular impairment, as well as the incidence of delayed union, non-union, and the need for further intervention. Both cohorts were monitored for a minimum of 24 months.

RESULTS

Our analysis revealed that the surgical cohort of chronic heavy smokers exhibited a statistically significant delay in fracture union compared to both the conservatively managed smokers and the control group. Further scrutiny of the surgical cohort of chronic smokers indicated a significant correlation between smoking and extended postoperative pain duration, persistent swelling at the fracture site, and both superficial and deep wound infections. Additionally, these patients experienced delays in both fracture union and wound healing when compared to the control group. Similarly, the conservatively managed chronic smokers showed a marginal increase in the incidence of post-injury pain duration, extended swelling at the fracture site, and delayed union compared to the control group.

CONCLUSION

Patients who are chronic heavy smokers and require surgical intervention for ankle fractures should be made aware of their increased risk for delayed fracture union and poor wound healing. Orthopedic surgeons should proactively encourage these patients to participate in smoking cessation programs.

Effect of COVID-19 pandemic on lifestyle and bone mineral density in young adults

OBJECTIVES

This study investigates the relationships between the COVID-19 pandemic, lifestyle factors, and their impact on bone mineral density in the radius forearm bone and the total bone mineral content in young adults from Slovakia.

METHODS

We assessed 773 Slovak young adults aged 18 to 30 years, divided into subgroups on their pandemic status. Bone mineral density (BMD) was analyzed by the QUS device (Sunlight MiniOmni™), and bone mineral content (BMC) and fat mass (FM) were measured by InBody 770 bioimpedance analyzer. Finally, linear regression analysis tested the associations.

RESULTS

Statistically significant lower speed of sound (SOS) along the length of the forearm radius bone and Z-score values was determined in participants during the COVID-19 pandemic than before it, and statistically significant lower BMC values were observed in the male group during COVID-19 than beforehand. Regression analysis confirmed the negative pandemic effect in the following indices: SOS (p < .001 for women and p = .035 for men), Z-score (p < .001 for women and p = .003 for men), and BMC (p = .024 for men). Vitamin D was a further significant SOS predictor in women at p = .029, but this association was not detected in men. In contrast, the significant male BMC predictors were pandemic presence (p = .028), physical activity (p = .028), and fat mass percentage (p = .001).

CONCLUSIONS

Significant COVID-19 pandemic effects on bone tissue were determined on bone mass density in the radius forearm bone and the total bone mineral content. These effects establish that the pandemic had a negative impact on both their bone quality and health.

Interaction between depressive symptoms and obesity-related anthropometric measures on multimorbidity among community-dwelling older adults: evidence from India

BACKGROUND

This study aimed to examine the associations between depressive symptoms, body mass index (BMI), waist circumference, waist-hip ratio and multimorbidity among community-dwelling older adults. We also examine the interaction effects between depressive symptoms, BMI, waist circumference and waist-hip ratio on multimorbidity among older adults in India.

METHODS

A cross-sectional study was conducted, and the data were obtained from the Longitudinal Ageing Study in India (LASI) wave-1, with a sample of 31,464 older adults aged 60 years and above (men-15,098 and women-16,366). We used multinomial logistic regression to explore the independent associations between depressive symptoms, obesity-measures, and single and multimorbidity. We also estimated the interaction effects of depressive symptoms and obesity-measures on multimorbidity.

RESULTS

The prevalence of multimorbidity was higher among individuals with depressive symptoms (39.22%) than individuals with no depressive symptoms (29.94%). Adjusted models indicated that older adults with depressive symptoms had higher odds of single and multimorbidity [(AOR = 1.40, 95% CI: 1.17-1.68) and (AOR = 1.85, 95% CI: 1.58-2.16), respectively]. Similarly, in comparison to the normal BMI category, overweight and obese older adults were more likely to report single morbidity [(AOR = 1.62, 95% CI: 1.37-1.92 and (AOR = 2.14, 95% CI: 1.67-2.75), respectively] and multimorbidity [(AOR = 2.00, 95% CI: 1.72-2.33) and (AOR = 3.77, 95% CI: 2.94-4.82), respectively].

CONCLUSION

The findings revealed that the presence of depressive symptoms, overweight or obesity, and high-risk anthropometric measures such as high-risk waist circumference and high-risk waist to hip ratio significantly increased the risk of morbidity among older adults in India. Thus, it is suggested to adopt an integrated public health policy approach to control depressive symptoms and high-risk body composition to strategically prepare against the elevated risk of multimorbidity among ageing populations.

Smoking-Related Disease Impact in the Eastern Mediterranean Region: A Comprehensive Assessment Using Global Burden of Disease Data

BACKGROUND

Smoking remains a significant risk factor for numerous health issues, including lung cancer, chronic obstructive pulmonary disease, ischemic heart disease, stroke, and respiratory infections. This study investigates the burden of tobacco-related diseases in the Middle East and North Africa (MENA) region.

METHODS

Utilizing the GBD data, we examined the risk of smoking and second-hand smoke exposure and their related causes of death and disability in the 22 MENA countries. Smoking prevalence and disease burden data were analyzed with estimates reported as age-standardized rates.

RESULTS

Tobacco abuse accounted for 14.5% of all deaths and 23.2% of deaths tied to known risk factors, with an age-standardized death rate of 110.8 per 100,000. Cardiovascular diseases were the primary cause of smoking-related deaths and DALYs, representing 53.4% of all deaths and 50.3% of all DALYs. This was followed by neoplasms (24.6% of all deaths and 20.3% of all DALYs), chronic respiratory diseases(12.4% of all deaths and 11.9% of all DALYs), and respiratory infections and tuberculosis(4% of all deaths and 3.4% of all DALYs). Second-hand smoking caused 20.5% of tobacco-related deaths and 21.5% of tobacco-related DALYs, disproportionately affecting younger individuals. An increasing disease burden was observed in Lebanon, Turkey, Syria, Tunisia, UAE, and Libya, and declining rates were most evident in Oman and Qatar.

CONCLUSION

Our study emphasizes the impact of smoking on cardiovascular disease, the primary cause of smoking-related mortality and morbidity in the MENA region. Our findings highlight the urgent need for effective tobacco control policies and interventions.

The association between cultural and social occasions and smoking cessation: The case of Saudi Arabia

INTRODUCTION

Tobacco use remains high in Saudi Arabia, necessitating an understanding of the influence of cultural and social events on smoking cessation. This study examined whether cultural and social events like Ramadan, Eids, and birthdays, motivate Saudi adults to quit smoking.

METHODS

Convenience sampling of 742 Saudi tobacco users was conducted between July 2021 and May 2022. A cross-sectional survey was used to assess self-reported desire to quit (1 = 'least desire' to 10 = 'highest desire') and behaviors in relation to special occasions. Multiple linear regression was performed to examine the association between cultural and social occasions and the desire to quit, while logistic regression was used to assess the relationship between cultural and social occasions and historical quit attempts, medicinal nicotine product use, visiting smoking cessation clinics, and calling the national Quitline. Demographic variables and tobacco types were controlled for in the analyses.

RESULTS

Considering quitting during Ramadan, Eids, and birthdays was associated with a higher desire to quit (Ramadan: B=2.99; 95% CI: 2.51-3.47, Eids: B=2.83; 95% CI: 2.12-3.54, and birthdays: B=2.76; 95% CI: 1.93-3.60, p<0.01) and a greater likelihood of past quit attempts (Ramadan: AOR=8.2; 95% CI: 5.5-12.1, Eids: AOR=5.8; 95% CI: 3.2-10.5, and birthdays: AOR=4.8; 95% CI: 2.4-9.4). Only considering quitting during Ramadan was associated with calling the national Quitline (AOR=2.9; 95% CI: 1.8-4.9).

CONCLUSIONS

Cultural and social events like Ramadan and Eids motivate adults in Saudi Arabia to attempt tobacco cessation. Targeting interventions around meaningful cultural occasions may promote successful quitting. These findings highlight the importance of understanding cultural and religious influences on cessation behaviors in Saudi Arabia and in other countries.

A comprehensive review on environmental pollutants and osteoporosis: Insights into molecular pathways

A significant problem that has an impact on community wellbeing is environmental pollution. Environmental pollution due to air, water, or soil pollutants might pose a severe risk to global health, necessitating intense scientific effort. Osteoporosis is a common chronic condition with substantial clinical implications on mortality, morbidity, and quality of life. It is closely linked to bone fractures. Worldwide, osteoporosis affects around 200 million people, and every year, there are almost 9 million fractures. There is evidence that certain environmental factors may increase the risk of osteoporosis in addition to traditional risk factors. It is crucial to understand the molecular mechanisms at play because there is a connection between osteoporosis and exposure to environmental pollutants such as heavy metals, air pollutants, endocrine disruptors, metal ions and trace elements. Hence, in this scoping review, we explore potential explanations for the link between pollutants and bone deterioration through deep insights into molecular pathways. Understanding and recognizing these pollutants as modifiable risk factors for osteoporosis would possibly help to enhance environmental policy thereby aiding in the improvement of bone health and improving patient quality of life.

The burden of neck pain among adults aged 70 years and older in Iran, 1990-2019

Background

Neck pain is a complex musculoskeletal disorder that can result in substantial morbidity. The present article presents the neck pain burden in Iranians who were at least 70 years old, from 1990 to 2019, by sex, age group, and province.

Methods

Publicly available information on the prevalence, incidence, and years lived with disability (YLD) caused by neck pain was extracted from the Global Burden of Disease study 2019. The estimates were all provided as counts and age-standardized rates (per 100,000), and included 95% uncertainty intervals.

Results

The point prevalence of neck pain in 2019 was 8710.6, while the incidence rate was 1334.7 per 100,000 population. That same year, there were number of 27.8 thousand YLDs and an YLD rate of 801.7 per 100,000. The prevalence, incidence, and YLD rates did not change substantially over the measurement period (1990-2019). The highest YLD rate was found in Tehran (960.9 per 100,000), while Kohgiluyeh and Boyer-Ahmad had the lowest (730.5 per 100,000). Females had slightly higher prevalent cases, incident cases, and YLDs, as well as their corresponding rates in 2019. In 2019, the number of prevalent cases, incident cases, and YLDs peaked in the 70-74 age group, for both sexes, and in all cases they reduced with age. In both 1990 and 2019, Iran had a higher YLD rate than that found among elderly adults in the Middle East and North Africa region.

Conclusions

The burden of neck pain in Iran has decreased slightly over the last three decades, but it still imposes a substantial burden and is higher than that found in the rest of the region. Therefore, preventive programs should be initiated at a young age to reduce the attributable burden later in life.

Public health interventions to prevent adolescent vaping: a scoping review protocol

OBJECTIVE

The objective of the review is to systematically examine the emerging literature related to public health interventions aimed at preventing adolescent vaping.

INTRODUCTION

The prevalence of vaping among adolescents is a rising concern worldwide. A thorough investigation of existing public health interventions to prevent vaping among adolescents is imperative to reduce serious and avoidable vaping-related health risks for this cohort. Many vaping-prevention interventions have been described in the literature, but their key components and outcomes have not been summarized.

INCLUSION CRITERIA

All English literature related to public health interventions preventing adolescent (aged 10 to 18 years) vaping from all countries will be included.

METHODS

This review will follow the JBI methodology for scoping reviews. A comprehensive search of academic and gray literature using MEDLINE (Ovid), CINAHL (EBSCOhost), Embase (Ovid), PubMed, PsycINFO (Ovid), ProQuest (Health and Medicine and Sociology Collections), and Web of Science Core Collection will be performed. Articles will be screened for inclusion by 2 independent reviewers. Results will be extracted using customized tools and summarized in a final report using narrative synthesis and presented in table format.

Effect of smoking on the redox status of knee osteoarthritis: A preliminary study

Even though smoking has been scarcely studied in osteoarthritis (OA) etiology, it is considered a controversial risk factor for the disease. Exposure to tobacco smoke has been reported to promote oxidative stress (OS) as part of the damage mechanism. The aim of this study was to assess whether smoking increases cartilage damage through the generation of OS. Peripheral blood (PB) and synovial fluid (SF) samples from patients with OA were analyzed. The samples were stratified according to smoking habit, Kellgren-Lawrence score, pain, and cotinine concentrations in PB. Malondialdehyde (MDA), methylglyoxal (MGO), advanced protein oxidation products (APOPs), and myeloperoxidase (MPO) were assessed; the activity of antioxidant enzymes such as gamma-glutamyl transferase (GGT), glutathione S-transferase (GST) and catalase (CAT), as well as the activity of arginase, which favors the destruction of cartilage, was determined. When stratified by age, for individuals <60 years, the levels of MDA and APOPs and the activity of MPO and GST were higher, as well as antioxidant system activity in the smoking group (OA-S). A greater degree of pain in the OA-S group increased the concentrations of APOPs and arginase activity (P < 0.01 and P < 0.05, respectively). Arginase activity increased significantly with a higher degree of pain (P < 0.01). Active smoking can be an important risk factor for the development of OA by inducing systemic OS in young adults, in addition to reducing antioxidant enzymes in older adults and enhancing the degree of pain and loss of cartilage.

Metastatic Squamous Cell Carcinoma of the Lung Disclosed From Constipation Workup

A palpable rectal mass associated with gastrointestinal (GI) symptoms immediately raises concern for colorectal cancer, but rarely can represent distant metastatic disease. The incidence of symptomatic colorectal metastasis from a primary lung cancer without any pulmonary symptom is extremely rare. We report a rare case of constipation as the presenting symptom in a patient ultimately found to have metastatic squamous cell carcinoma of the lung. A rectal mass was readily palpable on examination, illustrating the importance of digital rectal examination. In addition, GI clinicians should maintain a high index of suspicion when evaluating patients at risk of non-GI malignancies.

Linking metabolic syndrome with low bone mass through insights from BMI and health behaviors

The objective of this study is to investigate the relationship between metabolic syndrome (MetS), and bone density in a 30- to 50-year-old Taiwanese population, and to explore the combined effects of BMI and health behaviors on this association. A total of 52,912 individuals aged 30-50 years from the Taiwan Biobank were included in this cross-sectional study. Bone density status was assessed using quantitative ultrasound (QUS). The joint effect was assessed by including an interaction term in the multi-logistic regression models to test the association between MetS, BMI, and bone density while controlling for potential confounders. MetS was associated with reduced bone density, with the risk of severe low bone density (SLBD) higher among BMI < 24 kg/m2 individuals with MetS (adjusted odds ratio [aOR] 1.5, 95% confidence interval [CI] 1.09-2.16), while the risk was not significant among BMI ≥ 24 kg/m2 individuals with MetS. Smoking, alcohol consumption, and lack of regular exercise among individuals with a BMI < 24 kg/m2 and MetS were associated with higher risk of severe low bone density (SLBD), the aORs (95%CI) were 2.9 (1.59-5.20), 2.1 (1.06-4.22), and 1.8 (1.24-2.54) respectively. Our study suggests that metabolic syndrome could increase the risk of severe low bone density, but this risk can be minimized through higher BMI, non-smoking, no alcohol consumption, and regular exercise. Conversely, smoking, alcohol consumption or lack of regular exercise may exacerbate the risk of severe low bone density. These findings highlight the importance of a multifactorial approach in managing bone healthcare.

The impact of e-cigarette exposure on different organ systems: A review of recent evidence and future perspectives

The use of electronic cigarettes (e-cigs) is rapidly increasing worldwide and is promoted as a smoking cessation tool. The impact of traditional cigs on human health has been well-defined in both animal and human studies. In contrast, little is known about the adverse effects of e-cigs exposure on human health. This review summarizes the impact of e-cigs exposure on different organ systems based on the rapidly expanding recent evidence from experimental and human studies. A number of growing studies have shown the adverse effects of e-cigs exposure on various organ systems. The summarized data in this review indicate that while e-cigs use causes less adverse effects on different organs compared to traditional cigs, its long-term exposure may lead to serious health effects. Data on short-term organ effects are limited and there is no sufficient evidence on long-term organ effects. Moreover, the adverse effects of secondhand and third hand e-cigs vapour exposure have not been thoroughly investigated in previous studies. Although some studies demonstrated e-cigs used as a smoking cessation tool, there is a lack of strong evidence to support it. While some researchers suggested e-cigs as a safer alternative to tobacco smoking, their long-term exposure health effects remain largely unknown. Therefore, more epidemiological and prospective studies including mechanistic studies are needed to address the potential adverse health effects of e-cigs to draw a firm conclusion about their safe use. A wide variation in e-cigs products and the lack of standardized testing methods are the major barriers to evaluating the existing data. Specific regulatory guidelines for both e-cigs components and the manufacturing process may be effective to protect consumer health.

Factors associated with prehospital delay in acute myocardial infarction in Maldives

BACKGROUND

Acute myocardial infarction (AMI) is the top cause of death in Maldives. Our study aims to determine the prehospital delay and its associated factors in AMI patients in Maldives.

METHODS

A cross-sectional study was conducted with 127 patients, divided into early (≤ 6 h) and delayed (> 6 h) presenters to the hospital. The data collection for the study was carried out by interviewing AMI patients, focusing on their socio-demographic characteristics, coronary artery disease risk factors, clinical symptoms, situational factors, and behavioral and cognitive responses to symptoms.

RESULTS

The median onset-to-door time was 230 (IQR 420) minutes. The mean age of AMI patients was 50.9 (SD ± 12.9) years old, and 39.4% of them had delayed presentation to the hospital. Smokers (adj OR = 0.3; 95% CI: 0.1, 0.9; P = 0.047) and those with previous episodes of chest pain or AMI (adj OR = 0.2; 95% CI: 0.03, 0.91; P = 0.038) were significant factors for early presentation to the hospital, while denial of symptoms (adj OR = 29.3; 95% CI: 1.6, 547.2; P = 0.024) and lack of knowledge (adj OR = 7.2; 95% CI: 1.77, 29.43; P = 0.006) led to a delayed decision to seek treatment. Situational factors such as onset at the workplace (adj OR = 5.8; 95% CI: 1.24, 26.83; P = 0.025) had lower odds of delay, whereas referral cases (adj OR = 7.7; 95% CI: 1.9, 30.94; P = 0.004) and use of sea ambulance (adj OR = 11.1; 95% CI: 2.8, 43.8; P = 0.001) were prone to delay in presentation to the hospital.

CONCLUSION

Sea ambulance, referral cases, lack of knowledge, and denial of symptoms are significant factors associated with prehospital delay among patients with AMI. Public awareness about the benefits of early presentation and improvement of the means of transportation between islands is suggested to improve emergency cardiac care in the country.

Technical note: Application and potentiality of quantitative ultrasonometry for the evaluation of bone mineral density status

The evaluation of bone mineral density (BMD) is an important task in paleopathology. Techniques commonly applied in bone quantity assessment, such as DXA or radiogrammetry (XR), suffer from several limitations when applied to skeletal remains. In recently published research, we developed a new methodology and new reference curves for the evaluation of BMD on human skeletal remains, applying for the first time Quantitative Ultrasonometry (QUS), a user-friendly, portable, and reliable clinical technique. This study aims to apply this new methodology to an archeological sample and to compare the results with those obtained through XR. We apply QUS and XR to a sample of 104 adults from Medieval Italian cemeteries. Fragility fractures were recorded. Descriptive statistics and comparisons between sexes, age-at-death cohorts, and individuals with and without fragility fractures were performed. Moreover, univariate and multivariate logistic regression models were used to define the parameters most predictive of fracture risk in past populations. The comparison between sexes showed no significant results concerning BMD parameters, whereas a decrease in BMD with increasing age is confirmed. The comparison between fracture and non-fracture individuals and the logit model demonstrated that QUS parameters, especially UBPI, are more reliable predictors of fracture risk in comparison to XR. Our results confirmed that QUS is a valuable technique that can be efficiently applied to archeological remains, also considering its portability. We also propose a modification of the previously published QUS standard curves, to easily assess osteopenia and osteoporosis in archeological material.

Smoking Has No Influence on Outcomes after Repair of the Medial Meniscus in the Hypo and Avascular Zones-A Pilot Study

Complete loss of the meniscus inevitably leads to knee joint degeneration. Smoking is an important factor predicting poor outcome in orthopedics; however, data about its role in meniscus surgery are inconclusive. Smoking could be an important negative factor in isolated meniscus repair. The aim of this paper was to determine the influence of smoking on functional outcomes after isolated all-inside medial meniscus repair. This study included 50 consecutive patients with isolated, traumatic tear of the medial meniscus who underwent knee joint arthroscopy between 2016 and 2019. All-inside arthroscopic repair of the medial meniscus was performed in each case. All patients followed a uniform, postoperative rehabilitation protocol for 8 weeks. The follow-up examination was based on the functional scores at 3 and 6 months postoperatively. According to smoking status there were 17 smokers and 33 non-smokers. The mean number of cigarettes smoked per day was 11, for a mean of 7.4 years, and the mean pack-years index value was 4.9. There was no correlation between smoking years, number of cigarettes smoked per day, pack-years index, and functional outcomes. The arthroscopic inspection of the knee joints revealed cartilage lesions (≤IIº) in eight subjects, suggesting the secondary pathology to the meniscus tear. In this study, we found no evidence of an association between smoking indices and functional outcomes after all-inside repair of chronic medial meniscus tear. The nature of the chronic meniscal tear could be smoking-resistant owing to the poor blood supply to the sites in which these specific lesions occur.

The epidemiological status of osteoporotic hip fractures: A bicentric comparative and retrospective study

BACKGROUND

Osteoporotic hip fractures have posed a significant burden to society, and more epidemiological data is required.

OBJECTIVE

To compare the epidemiological differences of hip fracture patients in Spain and China.

METHOD

This was a retrospective comparative study. Comparisons were made in terms of morbidity, demographic and anthropometric characteristics, length of stay, cost of hospitalization, and mortality by consulting the medical histories of osteoporotic hip fractures in two hospitals. The t test was used for measurement data, and the X2 test was used for count data. The difference is statistically significant when p< 0.05.

RESULTS

A total of 757 patients were enrolled in this study, with 426 from Virgen Macarena University Hospital (HUVM) and 331 from Xi'an Daxing Hospital (XDH). The average age was 81.4 ± 9.26 and 76.0 ± 8.08 years; the proportion of women was 74.9% and 68.0%, respectively. The incidence of osteoporotic hip fractures in Seville residents over 50 years old was approximately 239 per 100,000 residents, compared to 158 per 100,000 residents in Xi'an. The timing of surgery in Spanish patients was significantly longer than in Chinese patients, 78.7 ± 48.2 vs. 60.7 ± 43.1 hours, p= 0.000. There were 81 deaths in Spain and 43 deaths in China during the one-year follow-up period (p= 0.026).

CONCLUSIONS

In terms of incidence, demographics, surgical methods, and mortality, there are significant differences between hip fracture patients in Seville, Spain and Xi'an, China.

Efficacy and safety evaluation of adjuvant auricular acupuncture for smoking cessation: A study protocol of randomized, assessor-blinded, pragmatic pilot trial

BACKGROUND

Smoking negatively impacts public health. There are several treatments to quit smoking, and nicotine replacement treatment (NRT) reportedly doubles the smoking cessation rate, with some limitations. Acupuncture is an alternative option with proven effects on smoking cessation. However, there has been no definite report that indicates the efficacy and safety of auricular acupuncture (AA) combined with NRT on smoking cessation.

METHODS

This is a randomized, assessor-blind, and pragmatic pilot study. We will recruit 40 participants who want to stop smoking and randomly allocate them into an NRT group and an NRT + AA group with a 1:1 ratio. Participants will receive NRT for 4 weeks and the NRT + AA group will receive additional AA treatment with 5 AA points (Shenmen (TF4), lung (CO14), throat (TF3), inner nose (TG4), and endocrine (CO18)) twice a week for 4 weeks. Follow-up will be conducted 1 and 3 months after intervention completion. The primary outcome will be tobacco consumption and abstinence rate determined by calculating the rate of change in cigarette use and a urine test. Secondary outcomes will be the quality of life (EuroQol-5D and visual analogue scale), nicotine dependence (Fagerstrom test for nicotine dependence), nicotine withdrawal (Minnesota nicotine withdrawal scale), physical effects, satisfaction, and safety measurement (adverse events).

RESULTS

We will investigate the efficacy and safety of AA combined with NRT treatment for smoking cessation.

CONCLUSION

Our study will provide additional clinical evidence for AA as an adjuvant treatment for smoking cessation.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service (registration number: KCT0007212).

Risk Factors of Relapse After Smoking Cessation: Results in China Family Panel Studies From 2010 to 2018

Background

Tobacco use is still highly prevalent globally in spite of the tobacco control efforts made by the governments. In view of the harm of smoking and relapse after smoking cessation, the purpose of this study is to establish a competitive risk model to determine potential risk factors for smoking relapse.

Methods

The population-based cohort of ex-smokers over the age of 18 years was obtained from the China Family Panel Studies (CFPS) database from 2010 to 2018. Competing risk models were conducted to identify the risk factors for relapse.

Results

A total of 1,019 subjects were included in this study, of which 311 (30.52%) subjects relapsed during the follow-up period. A multivariate analysis indicated that age < 40 years [hazard ratio (HR) 19.142; 95% CI: 10.641–34.434, p < 0.01], cohabitation (HR: 1.422; 95% CI: 1.081–1.87, p = 0.01), and often depression [HR 1.422; 95% CI, (1.081–1.87), p = 0.01] were associated with a great risk of relapse while the age of quitting smoking < 60 years (HR: 0. 436; 95% CI: 0.229–0.831, p < 0.01) and joining the Chinese Communist Party (CCP) (HR 0.611; 95% CI: 0.397–0.939, p = 0.03) were reduced risk factors for relapse.

Conclusions

Approximately 3 in 10 ex-smokers were observed to relapse. There are various risk factors for relapse as well. In the face of such a serious situation, it is urgent to take action to control smoking.

Patient preferences for lifestyle behaviours in osteoporotic fracture prevention: a cross-European discrete choice experiment

Using a discrete choice experiment, we aimed to assess patients' preferences with regard to adopting lifestyle behaviours to prevent osteoporotic fractures. Overall, the 1042 patients recruited from seven European countries were favourable to some lifestyle behaviours (i.e., engaging in moderate physical activity, taking calcium and vitamin D supplements, reducing their alcohol consumption and ensuring a normal body weight).

INTRODUCTION

Alongside medical therapy, healthy lifestyle habits are recommended for preventing osteoporotic fractures. In this study, we aimed to assess patients' preferences with regard to adopting lifestyle changes to prevent osteoporotic fractures.

METHODS

A discrete choice experiment was conducted in seven European countries. Patients with or at risk of osteoporosis were asked to indicate to what extent they would be motivated to adhere to 16 lifestyle packages that differed in various levels of 6 attributes. The attributes and levels proposed were physical activity (levels: not included, moderate or high), calcium and vitamin D status (levels: not included, taking supplements, improving nutrition and assuring a minimal exposure to sunlight daily), smoking (levels: not included, quit smoking), alcohol (levels: not included, moderate consumption), weight reduction (levels: not included, ensure a healthy body weight) and fall prevention (levels: not included, receiving general advice or following a 1-day fall prevention program). A conditional logit model was used to estimate a patient's relative preferences for the various attributes across all participants and per country.

RESULTS

In total, 1042 patients completed the questionnaire. Overall, patients were favourable to lifestyle behaviours for preventing osteoporotic fractures. However, among the lifestyle behaviours proposed, patients were consensually not prone to engage in a high level of physical activity. In addition, in Ireland, Belgium, the Netherlands and Switzerland, patients were also not inclined to participate in a 1-day fall prevention program and Belgian, Swiss and Dutch patients were not prone to adhere to a well-balanced nutritional program. Nevertheless, we observed globally that patients felt positively about reducing their alcohol consumption, engaging in moderate physical activity, taking calcium and vitamin D supplements and ensuring a normal body weight, all measures aimed at preventing fractures.

CONCLUSIONS

In a patient-centred approach, fracture prevention should take these considerations and preferences into account.

Impact of Cadmium Mediated by Tobacco Use in Musculoskeletal Diseases

Tobacco use has a negative impact on health due to its relationship with the development of high-mortality diseases, such as pulmonary cancer. However, the effect of cadmium (Cd), present in tobacco smoke, on the development of joint diseases has been scarcely studied. The objective of this review is to discuss the evidence regarding the mechanisms by which Cd exposure, through tobacco smoke, may lead to the development of osteoarthritis (OA), osteoporosis (OP), and rheumatoid arthritis (RA). There's evidence suggesting a string association between moderate to severe OA development and tobacco use, and that a higher blood concentration of Cd can trigger oxidative stress (OS) and inflammation, favoring cartilage loss. At the bone level, the Cd that is inhaled through tobacco smoke affects bone mineral density, resulting in OP mediated by a decrease in the antioxidant enzymes, which favors the bone resorption process. In RA, tobacco use promotes the citrullination process through Cd exposure and increases OS and inflammation. Understanding how tobacco use can increase the damage at the articular level mediated by a toxic metal, i.e., Cd, is important. Finally, we propose prevention, control, and treatment strategies for frequently disabling diseases, such as OA, OP, and RA to reduce its prevalence in the population.

An Overlooked Bone Metabolic Disorder: Cigarette Smoking-Induced Osteoporosis

Cigarette smoking (CS) leads to significant bone loss, which is recognized as an independent risk factor for osteoporosis. The number of smokers is continuously increasing due to the addictive nature of smoking. Therefore it is of great value to effectively prevent CS-induced osteoporosis. However, there are currently no effective interventions to specifically counteract CS-induced osteoporosis, owing to the fact that the specific mechanisms by which CS affects bone metabolism are still elusive. This review summarizes the latest research findings of important pathways between CS exposure and bone metabolism, with the aim of providing new targets and ideas for the prevention of CS-induced osteoporosis, as well as providing theoretical directions for further research in the future.

Factors Predictive of Early Complications Following Total Ankle Arthroplasty

Background:

The safety of outpatient total ankle arthroplasty (TAA), and factors predictive of early complications are poorly understood. The objective of this study was to determine the frequency of early complications in patients undergoing outpatient TAA compared to a matched inpatient TAA cohort. Factors predictive of early complications following TAA are elucidated.

Methods:

A retrospective review of prospectively collected data from the 2011-2018 American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database was performed. An unadjusted analysis comparing complication rates in outpatient, and inpatient TAA was performed followed by a propensity score–matched cohort analysis. A multivariate logistic regression model was then used to identify significant independent predictors for complications, reoperation, and readmission following TAA.

Results:

A total of 1487 patients (198 outpatient, 1289 inpatient) undergoing TAA were included in the study. Inpatient TAA was associated with increased 30-day readmission compared with outpatient TAA (3.54% vs 0.51%, P = .032) in a matched cohort analysis. Thirty-eight (2.6%) patients had a minor complication, with 16 (1.1%) patients having a major complication after TAR. Nineteen (1.3%) patients underwent reoperation, and 42 (2.8%) patients were readmitted within 30 days of the index TAR. Multivariate analysis identified factors predictive of early complications to include length of stay (LOS) >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus.

Conclusion:

From this relatively limited data set, outpatient TAA appears to be safe for management of end-stage ankle arthritis in select patients. Inpatient status was associated with an increased rate of 30-day readmission following TAA. Postoperative length of stay >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus were identified to be associated with early postoperative complications following TAA in this cohort.

Level of Evidence

Level III, retrospective cohort study.

Factors Associated With Prehospital Delay Among Patients With Acute Myocardial Infarction in the Era of Percutaneous Coronary Intervention - Insights From the OACIS Registry

BACKGROUND

The Japan Circulation Society launched the STOP-MI campaign in 2014, focusing on immediate hospital arrival for acute myocardial infarction (AMI) treatment. This study aimed to determine the factors influencing longer prehospital time among patients with AMI in Japan.

METHODS AND RESULTS

This study analyzed a total of 4,625 AMI patients enrolled in the Osaka Acute Coronary Insufficiency Study registry from 1998 to 2014. The prehospital time delay was defined as the time interval from the onset of initial symptoms to hospital arrival time ≥2 h. Among eligible patients, 2,927 (63.3%) had a prehospital time ≥2 h. In multivariable analyses, age 65-79 years (adjusted odds ratio [AOR] 1.19, 95% confidence interval [CI] 1.02-1.39), age ≥80 years (AOR 1.42, 95% CI 1.13-1.79), diabetes mellitus (AOR 1.33, 95% CI 1.16-1.52), and onset time of 0:00-5:59 h (AOR 1.63, 95% CI 1.37-1.95) were positively associated with prehospital time ≥2 h, whereas smoking (AOR 0.78, 95% CI 0.68-0.90) and ambulance use (AOR 0.37, 95% CI 0.32-0.43) were negatively associated with prehospital time ≥2 h.

CONCLUSIONS

Older age, diabetes mellitus, and nighttime onset were associated with prehospital time delay for AMI patients, whereas smoking and ambulance use were associated with no prehospital time delay. Healthcare providers and patients could help reduce the time to get to a medical facility by being aware of these findings.

Serum heavy metals of passive smoker females and its correlation to bone biomarkers and risk of osteoporosis

Serum total and free calcium reflect the status of the body health and disease. Smoking is risk factor for many diseases as cardiovascular, lung, and cancers. The goal of this work is to evaluate the correlation between serum lead, cadmium arsenate resulting from passive smoking, and bone status in females. This study was conducted on two hundred women (age 30-50 years) divided into four groups (each 50). Group I, control, included non-smoking healthy women. Group II included heavy smoker (>20 cigarettes/day). Group III, nonsmoker women with osteoporosis, have many fractures. Group IV, smoking women with osteoporosis, included heavy smokers (>20 cigarettes/day) with osteoporotic women and have many fractures. Data obtained showed that T-score of osteoporotic smokers was -3.5 that indicated reduced bone mineral density (BMD) while serum total and ionized calcium were statistically significant decreased in smokers with or without osteoporosis compared with nonsmokers (p < 0.001). A negative correlation between total and free calcium and cadmium levels in smokers was compared with nonsmokers (r =-0.65). The levels of C-terminal pro-peptide of pro-collagen type I (PICP) and N-terminal pro-peptide of procollagen type I (PINP) were higher in smoker osteoporotic women than nonsmokers. It was concluded that cadmium resulting from smoking may compete with absorption of calcium and reduced its level and BMD and increased incidence of osteoporosis. The elevated PICP and PINP indicated decreased rate of proto collagen I turnover in bone tissue and increased incidence of osteoporosis.

Osteopathic model of the development and prevention of occupational musculoskeletal disorders

Context

The direct and indirect costs of work-related musculoskeletal disorders are significant. Prevention is the most effective way to control these costs. To do that, we must understand how these disorders develop.

Objectives

To use the five models of osteopathic care to illustrate how cellular processes and neural reflexes interact to create work-related musculoskeletal pathology and to provide evidence-informed musculoskeletal injury and disability prevention recommendations.

Methods

A literature review of electronic databases (Google Scholar, PubMed, OVID, Cochrane Central Register of Controlled Trials, PEDro, and OSTMED.DR) from inception to October 16, 2019 and hand-search of publication references was performed for systematic reviews, cohort studies, case-control studies, and randomized controlled trials. The search terms reflected topics related to occupational injury and injury prevention, and included supplementary laboratory studies and narrative reviews related to the biological aspects of musculoskeletal injury. The eligible studies contained the following criteria: (1) the population of working age; (2) exposures to known risk factors, musculoskeletal disorders, and psychosocial factors; (3) written in English; (4) full text papers published in peer-reviewed journals; and (5) systematic review, cohort study, case-control study, and randomized controlled trial methodology. Studies were excluded if they included outcomes of productivity and costs only or outcomes that were assessed through qualitative methods only.

Results

The literature search resulted in 1,074 citations; 26 clinical studies and 14 systematic reviews were used in this review. A comprehensive workplace musculoskeletal disorder prevention program should match demands to capacity, correct dysfunctional movement patterns, and limit tissue vulnerability (biomechanical-structural model); restore alpha-gamma balance, tonic-phasic synergistic function, and autonomic balance (neurological model); maximize physiologic reserve (metabolic-energy model) component of a prevention program; optimize respiration and circulation (respiratory-circulatory model); and address cognitive distortions (behavioral-biopsychosocial model).

Conclusions

The presented osteopathic model of the development and prevention of work-related musculoskeletal disorders suggests that a combination of preventive interventions will be more effective than any single preventive intervention.

Prevalence and correlates of bone and joint diseases and its association with falls among older adults in India: Evidence from LASI, 2017-18

This study explores the prevalence and correlates of bone and joint diseases and its association with falls among older adults in India. Data from the Longitudinal Aging Study in India (2017-18) were utilized for analysis (n = 31,464). Bivariate and logistic regression was used to fulfill the study objectives. The findings revealed that 19.71% of older adults had bone and joint disease, which was higher among women (22.79%) than men (16.25%). The strongest predictors of such diseases included being currently employed, physically inactive, having difficulties in performing functional activities and higher economic status. The fall in the last two years was reported by 12.63% of older adults, and bone and joints diseases were significantly associated with falls (AOR = 1.287; 95% CI: 1.117-1.483) after adjusting for several socio-demographic and health covariates. These findings imply that policymakers and providers must implement interventions designed to reduce the risk of those diseases and associated falls.

The association between manual handling operations and pain in the hands and arms in the context of the 2018 BIBB/BAuA Employment Survey

BACKGROUND

Manual handling operations (MHO) are tasks performed by hand that require repetitive and forceful hand and arm movements. MHO are currently performed in many workplaces in skilled and unskilled jobs in the production and service sectors. MHO are considered as work-related health risk factors. The relationship between MHO and the occurrence of disorders of the upper extremities has been established. MHO can cause diseases such as tenosynovitis or carpal tunnel syndrome. This study aims to assess the current prevalence of MHO in the German workforce and to evaluate the relationship between MHO and the occurrence of hand and arm complaints.

METHODS

The analysis was based on the German 2018 BIBB/BAuA Employment Survey. For this analysis we included subjects aged between 16 and 66 who work at least 35 h per week. The self-reported frequency of MHO (never; rarely; sometimes; often) was considered as the exposure of interest and was stratified by gender and occupation. Prevalence ratios (PR) were used to report the relationship between MHO and self-reported pain in the hands and arms (robust log-linear Poisson regression). Adjustments were made for age, gender, actual weekly working hours, psychosocial workload, and other physical workloads. The regression analyses considered complete cases.

RESULTS

The analyses included 14,299 employees. Frequent MHO were reported by 32.6% of men and 31.1% of women. These workloads were often reported by respondents who work in the agricultural sector (men: 70.1%; women: 79.0%), in unskilled (men: 59.4%; women: 66.9%), and skilled manual occupations (men: 72.7%; women: 66.7%). A higher frequency of self-reported MHO was associated with a higher prevalence of hand complaints (PR 2.26 CI 2.00-2.55 "often" vs. "never" = ref.) as well as arm pain (PR 1.73 CI 1.55-1.92 for "often" vs. "never" = ref.).

CONCLUSION

MHO are still frequent in many occupations. The shown association between MHO and pain in the hands and arms demonstrates the importance of MHO in the current German workforce and the necessity to further develop prevention strategies.

Skeletal System Biology and Smoke Damage: From Basic Science to Medical Clinic

Cigarette smoking has a negative impact on the skeletal system, as it reduces bone mass and increases fracture risk through its direct or indirect effects on bone remodeling. Recent evidence demonstrates that smoking causes an imbalance in bone turnover, making bone vulnerable to osteoporosis and fragility fractures. Moreover, cigarette smoking is known to have deleterious effects on fracture healing, as a positive correlation between the daily number of cigarettes smoked and years of exposure has been shown, even though the underlying mechanisms are not fully understood. It is also well known that smoking causes several medical/surgical complications responsible for longer hospital stays and a consequent increase in the consumption of resources. Smoking cessation is, therefore, highly advisable to prevent the onset of bone metabolic disease. However, even with cessation, some of the consequences appear to continue for decades afterwards. Based on this evidence, the aim of our review was to evaluate the impact of smoking on the skeletal system, especially on bone fractures, and to identify the pathophysiological mechanisms responsible for the impairment of fracture healing. Since smoking is a major public health concern, understanding the association between cigarette smoking and the occurrence of bone disease is necessary in order to identify potential new targets for intervention.

Prevalence and Factors Associated with Musculoskeletal Disorders among Secondary Schoolteachers in Hail, Saudi Arabia: A Cross-Sectional Survey

Musculoskeletal disorders (MSDs) are one of the most common occupational health hazards and serious health concerns among teachers. About 39% to 95% of teachers suffer from musculoskeletal pain that can lead to a decline in their performance, frequent sick leaves and early retirement, and can have a negative impact on their quality of life. The aim of this study was to investigate the prevalence of and risk factors for MSDs among secondary schoolteachers in Hail, Saudi Arabia. A cross-sectional study was conducted through an electronic survey. A self-reported and validated Arabic version of the Nordic Musculoskeletal Questionnaire (NMQ) was used. Participants were recruited randomly through a two-stage sampling technique. A total of 251 respondents (57.8% males and 42.2% females) returned the questionnaire. The overall prevalence of MSDs was 87.3%. Female teachers (95.3%) suffered more than their male counterparts (81.4%). The most common site was the lower back (62.55%), followed by the shoulders (53.39%) and knees (41.04%). Most of the participants (72.7%) reported MSDs in multiple sites. Binomial logistic regression predicted that smoking is a significant risk factor for lower back disorders (p < 0.05). A high prevalence of MSDs can be due to a substantial lack of awareness and practice of ergonomics, which warrant the development of preventive strategies and educational programs.

Students' perceptions of a university 'No Smoking' policy and barriers to implementation: a cross- sectional study

OBJECTIVES

Effective policies are an important tool for reducing tobacco use. We examine student perceptions of the existing no-smoking policy in the country's largest national university and identify perceived barriers to its implementation. We explore student support for a 100% tobacco-free campus policy.

DESIGN

We conducted a cross-sectional survey using a self-administered on-line questionnaire.

SETTING

This study was conducted at Qatar University (QU), the largest national institution of higher education in Qatar.

PARTICIPANTS

A total of 199 students participated out of a stratified random sample of students aged ≥18 years with active registration in the Spring 2020 semester.

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed students' knowledge of and attitudes towards QU's current no-smoking policy, the perceived barriers to its implementation, and support for a 100% tobacco-free policy.

RESULTS

Only 26% (95% CI 19.97 to 32.03) and 16.6% (95% CI 11.70 to 22.49) of respondents correctly identified the current policy on traditional and electronic cigarettes, respectively. Less than 30% of respondents held positive attitudes towards policy enforcement, and more male respondents reported positive attitudes towards compliance than women. Support for a 100% tobacco-free policy was at 77.2%, but it was significantly lower among tobacco users compared with non-users (35.9% and 91.8%, respectively; p<0.001). Failure to establish clear penalties, opposition from smoking students, and lack of cessation services were perceived as major barriers to implementation.

CONCLUSIONS

Clear and comprehensive tobacco-free policies are important tools for creating environments conducive to rejecting smoking and seeking cessation support. The findings underscore the need to increase awareness about the policy, advocate for clear penalties for violations, and promote cessation services on campus. Qualitative research is needed to further understand perceived barriers to successful enforcement of the policy.

Smoking and the patient with a complex lower limb injury

Smoking is known to increase the risk of peri-operative complications in Orthoplastic surgery by impairing bone and wound healing. The effects of nicotine replacement therapies (NRTs) and electronic cigarettes (e-cigarettes) has been less well established. Previous reviews have examined the relationship between smoking and bone and wound healing separately. This review provides surgeons with a comprehensive and contemporaneous account of how smoking in all forms interacts with all aspects of complex lower limb trauma. We provide a guide for surgeons to refer to during the consent process to enable them to tailor information towards smokers in such a way that the patient may understand the risks involved with their surgical treatment. We update the literature with recently discovered methods of monitoring and treating the troublesome complications that occur more commonly in smokers effected by trauma.

The Impact of Smoking on Clinical Results Following the Rotator Cuff and Biceps Tendon Complex Arthroscopic Surgery

The purpose of this study was to investigate the association of smoking and functional outcomes after arthroscopic treatment of complex shoulder injuries: rotator cuff tears (RCTs) with biceps tendon (LHBT) tears. This retrospective case-control study has been conducted on a cohort of patients who underwent shoulder arthroscopy between 2015 and 2017 due to complex injury treatment. The outcomes were assessed using the American Shoulder and Elbow Surgeons Score (ASES), the University of California at Los Angeles (UCLA) Shoulder Score, need for non-steroid anti-inflammatory drugs (NSAIDs) consumption and the visual analog scale (VAS). Complications and changes in smoking status were also noted. A cohort of 59 patients underwent shoulder arthroscopy, due to complex LHBT pathology and RCTs, and were enrolled in the final follow-up examination; with mean duration of 26.03 months. According to smoking status, 27 of patients were classified as smokers, and the remaining 32 were non-smokers. In the examined cohort, 36 patients underwent the LHBT tenotomy and 23 tenodesis. We observed a relationship between smoking status and distribution of various RCTs (p < 0.0001). The mean postoperative ASES and UCLA scores were 80.81 and 30.18 in the smoker's group and 84.06 and 30.93 in the non-smoker's group, respectively. There were no statistically significant differences in pre/postoperative ASES and postoperative UCLA scores between smokers and non-smokers (p > 0.05). The VAS was significantly lower in the non-smokers' group (p = 0.0021). Multi-tendon injuries of the shoulder are a serious challenge for surgeons, and to obtain an excellent functional outcome, we need to limit the negative risk factors, including smoking. Furthermore, there is a significant association between smoking and the occurrence of massive rotator cuff tears, and the pain level measured by the VAS. Simultaneous surgical treatment of RC and LHBT lesions in the smoker population allowed us to obtain the functional outcomes approximated to non-smokers in the long-term follow-up. Of course, we cannot assert that smoking is the real cause of all complications, however, we may assume that this is a very important, negative factor in shoulder arthroscopy.

The influence of snuff and smoking on bone accretion in late adolescence. The Tromsø study, Fit Futures

Areal bone mineral density (aBMD) predicts future fracture risk. This study explores associations between use of tobacco and bone accretion in Norwegian adolescents. Our results indicate that use of snuff is negatively associated with accretion of aBMD in adolescence and may be a signal of increased future fracture risk.

PURPOSE

Bone mineral accrual in childhood and adolescence is a long-term primary preventive strategy of osteoporosis. Areal bone mineral density (aBMD) is a surrogate measure of bone strength and a predictor of fracture risk. The aim of this population-based 2-year follow-up cohort study was to explore associations between use of snuff and smoking and changes (∆) in aBMD in Norwegian girls and boys aged 15-17 years at baseline.

METHODS

The first wave of the Tromsø study, Fit Futures was conducted from 2010 to 2011. Femoral neck (FN), total hip (TH), and total body (TB) bone mineral content (BMC) and aBMD were measured by dual-energy X-ray absorptiometry. Information on use of snuff, smoking habits, and other lifestyle related variables were collected through self-administered questionnaires. Two years later, during 2012-2013, the measurements were repeated in the second wave. The present study included 349 girls and 281 boys and compared "non-users" (n = 243 girls, 184 boys) with "users" (n = 105 girls, 96 boys) of snuff and "non-smokers" (n = 327 girls, 249 boys) with "smokers" (n = 21 girls, 31 boys) using linear regression adjusted for age, baseline height and weight, change in height and weight, pubertal maturation, physical activity, ethnicity, alcohol consumption, diagnosis known to affect bone, and medication known to affect bone. The influence of "double use" on bone accretion was also explored.

RESULTS

In girls, no associations between use of snuff and ∆aBMD were found. In boys, use of snuff was associated with reduced bone accretion in all ∆aBMD models. Sensitivity analysis with exclusion of "sometimes" users of snuff strengthened associations at femoral sites in girls and attenuated all associations in boys. In girls, no associations between smoking and ∆aBMD were found. In boys, only the association with TB ∆aBMD was significant in the fully adjusted models. In girls, "double users" analyses showed similar association to smoking. In boys, nearly all models showed statistically significant associations with a difference of ~ 1-2% in ∆aBMD between "non-users" and "double users" during 2 years of follow-up.

CONCLUSIONS

Our results indicate that tobacco use in late adolescence could be detrimental to bone accretion and may be a signal of increased fracture risk in adult life.

2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older

OBJECTIVE

To establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older.

METHODS

Points to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated.

RESULTS

Two overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6.

CONCLUSION

These first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.

AMIC for Focal Osteochondral Defect of the Talar Shoulder

BACKGROUND

The management of a focal osteochondral lesion of the talus (OLT) is challenging. Evidence concerning the role of the autologous matrix-induced chondrogenesis (AMIC) procedure in patients with focal OLT is promising. The purpose of the present study was to investigate clinical outcomes and radiographic findings of the AMIC technique for focal unipolar OLT.

MATERIAL AND METHODS

The present study was performed according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Twenty-four patients who underwent AMIC for focal OLT were prospectively recruited at our institution. All the surgeries were performed by two experienced surgeons through malleolar osteotomy and autologous cancellous bone grafting. The outcomes of interest were the American orthopedic foot and ankle score (AOFAS), the foot-function index (FFI), and the magnetic resonance observation of cartilage repair tissue (MOCART). Surgical duration, hospitalization length, and complications were also collected.

RESULTS

24 patients were included in the present study. The mean follow-up was 25.17 ± 13.1 months. The mean age of the patients at surgery was 46.75 ± 15.2 years, the mean BMI 26.92 ± 5.7 kg/m², and 50% (12 of 24) of patients were female. The right ankle was involved in 62.5% (15 of 24) of patients. The mean defect size was 6.95 ± 2.9 mm². The mean surgical duration was 112 ± 20 min while the mean hospitalization 5.58 ± 1.7 days. At last follow-up, the AOFAS increased by 27.8 points (p < 0.0001), while the FFI reduced by 25.3 points (p < 0.0001) and the MOCART score increased by 28.33 points (p < 0.0001). No complications were observed.

CONCLUSION

The AMIC procedure for focal osteochondral defects of the talar shoulder is feasible and reliable at midterm follow-up.

Zoledronic Acid Is Not Equally Potent on Osteoclasts Generated From Different Individuals

Zoledronic acid is a bisphosphonate commonly used to treat bone diseases such as osteoporosis and cancer‐induced bone disease. Patients exhibit a variable sensitivity to zoledronic acid; the underlying explanation for this remains unclear. The objective of this study was to obtain more knowledge in this regard. We hypothesized that osteoclasts generated from different individuals would show a variable sensitivity to zoledronic acid in vitro. Osteoclasts were generated using monocytes from 46 healthy female blood donors (40 to 66 years). Matured osteoclasts were reseeded onto bone slices precoated with different concentrations of zoledronic acid. IC50 values were determined based on total eroded bone surface after 3 days of resorption. The IC50 for inhibition of osteoclastic bone resorption varied from 0.06 to 12.57μM zoledronic acid; thus, a more than 200‐fold difference in sensitivity to zoledronic acid among osteoclasts from different individuals was observed. Multiple linear regression analyses showed that the determined IC50 correlated with smoking status, and the average number of nuclei per osteoclast in vitro. Further analyses showed that: (i) increasing protein levels of mature cathepsin K in osteoclast cultures rendered the osteoclasts less sensitive to zoledronic acid; (ii) surprisingly, neither the gene nor the protein expression of farnesyl diphosphate synthase was found to correlate with the IC50; and (iii) trench‐forming osteoclasts were found to be more sensitive to zoledronic acid than pit‐forming osteoclasts within the same cell culture. Thus, we conclude that there indeed is a high degree of variation in the potency of zoledronic acid on osteoclasts when generated from different individuals. We propose that our findings can explain some of the varying clinical efficacy of zoledronic acid therapy observed in patients, and may therefore be of clinical importance, which should be investigated in a clinical trial combining in vitro and in vivo investigations. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The Relationship between Urinary Incontinence Quality of Life and Sleep Quality in Women Over the Age of 60 Years

Aim

The study aimed to investigate the relationship between urinary incontinence quality of life and sleep quality in women over the age of 60 years.

Method

This cross-sectional study was conducted between May 15 and July 5, 2013. Data were collected from a total of 332 women including 68 women from 3 nursing homes in a provincial center of Eskisehir and 269 women living alone or with family in their own homes in a street of that city. Women’s urinary incontinence quality of life was assessed using the incontinence quality of life scale and sleep quality was assessed using the Pittsburgh sleep quality index.

Results

Mean age of the participating women was 71.00±7.42 years. Only 10.8% of the women had incontinence diagnosis; prevalence of anamnesis-based incontinence was 87.7%. Those who lived in their own homes, who had a urinary incontinence diagnosis, who experienced urinary incontinence according to their anamnesis, who were smokers, and who had a poor sleep quality had lower Incontinence Quality of Life Scale scores. Additionally, their quality of life was negatively affected (p<0.05). Poor sleep quality and diagnosis of urinary incontinence were important predictors of the Incontinence Quality of Life Scale of women over 60 years of age and explained 18% of the total variance. The Incontinence Quality of Life Scale scores of the women decreased by 5.67 points in the presence of poor sleep quality and 6.48 points in the presence of urinary incontinence diagnosis.

Conclusion

Urinary incontinence is a common problem seen in older women, is considered as a usual problem due to aging, and is ignored or not taken care of. It also has a negative impact on the quality of life and sleep.

Smoking is associated with a higher risk of unplanned medical visits among adult patients with diabetes, using retrospective electronic medical record data from 2014 to 2016

BACKGROUND

Smoking exacerbates the complications of diabetes, but little is known about whether patients with diabetes who smoke have more unplanned medical visits than those who do not smoke. This study examines the association between smoking status and unplanned medical visits among patients with diabetes.

METHODS

Data were drawn from electronic medical records (EMR's) from a large healthcare provider in the Northern Plains region of the US, from adult (≥18 years old) patients with type 1 or type 2 diabetes who received care at least once during 2014-16 (N = 62,149). The association between smoking status (current, former, or never smoker) and having ≥1 unplanned visit (comprised of emergency department visits, hospitalizations, hospital observations, and urgent care) was examined after adjusting for age, race/ethnicity, and body mass index (BMI). The top ten most common diagnoses for unplanned visits were examined by smoking status.

RESULTS

Both current and former smoking were associated with an approximately 1.2-fold increase in the odds of having at least one unplanned medical visit in the 3-year period (OR = 1.22, 95% CI = 1.16-129; OR = 1.23, 95% CI = 1.19-1.28, respectively), relative to never-smokers. Most common diagnoses for all patients were pain-related. However, diagnoses related to musculoskeletal system and connective tissue disorders were more common among smokers. Smoking is associated with a higher rate of unplanned medical visits among patients with diabetes in this regional healthcare system.

CONCLUSIONS

Results from this study reveal higher rates of unplanned visits among smokers and former smokers, as well as increased frequencies of unplanned medical visits among current smokers.

Salivary Osteocalcin as Potential Diagnostic Marker of Periodontal Bone Destruction among Smokers

: The objective of the study was to assess the levels and diagnostic accuracy of salivary osteocalcin (OC), osteonectin (ON), and deoxypyridinoline-containing degradation fragment of the C-terminal telopeptide region of type I collagen (CTX) in adult smokers with periodontal bone destruction. Towards this, ninety systemically healthy patients (groups I: healthy, II: periodontitis with non-smokers, and III: periodontitis with current smokers) were included in the study. The results showed a positive correlation (weak to moderate) was observed for OC, ON, and CTX with probing pocket depth (PPD; r = 0.40, 0.32, and 0.36) and alveolar bone loss (BL; r = 0.58, 0.38, and 0.51) (p < 0.01). Smoker periodontitis was best discriminated from healthy controls using 15.25 ng/mL of OC (AUC: 0.870; 95% CI: 0.757-0.943; YI (Youden Index): 0.693; p < 0.0001). However, with a cut-off of BL at 33.33%, 19.24 ng/mL of salivary OC gave the best discrimination (AUC: 0.809; 95% CI: 0.686-0.900; Se: 80.0%; Sp: 73.47%, and YI: 0.534). A 16.45 ng/mL amount of OC gave excellent discrimination (AUC: 0.811; 95% CI: 0.688-0.901; Se: 92.31%; Sp: 65.22%, and YI: 0.575) among healthy and smoker periodontitis when PD at 6mm was considered as cut-off. Conclusion: The best discrimination between healthy controls and smoker periodontitis was obtained at 15.25 ng/mL of salivary OC.

Predictors of return to work in patients with occupational hand injury

Work-related hand injuries are the primary cause of disability and prolonged time away from work. This prospective cohort study was conducted to determine the predictors of return to work (RTW) after traumatic work-related hand injuries. Our study included 280 patients who were referred to the Plastic and Reconstructive Center for treatment of their occupational hand injuries from July 2017 to February 2018. Several functional questionnaires were completed, and they were followed up at 1, 3 and 8 weeks. Telephone interviews were done 3 months later. Approximately half the subjects had returned to work during the first 3 months after a median time away of 57 days. No relationship was found between age, gender, marital status, hand dominance and RTW time. Nevertheless, there was correlation between RTW time with cigarette smoking, injury severity and disability. Our study findings suggest that injury severity and higher work disability scores are prognostic factors for RTW. Also, smoking was associated with later RTW, which could be the result of poor circulation and delayed healing. Employers should implement injury prevention programs with appropriate rehabilitation that takes into consideration the severity of the hand injury, and health strategies to improve unhealthy lifestyle factors such as smoking.

The patterns of Non-communicable disease Multimorbidity in Iran: A Multilevel Analysis

The prevalence of non-communicable diseases is increasing worldwide. Multimorbidity and long-term medical conditions is common among these patients. This study aimed to investigate the patterns of non-communicable disease multimorbidity and their risk factors at the individual and aggregated level. Data was inquired from the nationwide survey performed in 2011, according to the WHO stepwise approach on NCD risk factors. A latent class analysis on multimorbidity components (11 chronic diseases) was performed and the association of some individual and aggregated risk factors (urbanization) with the latent subclasses was accessed using multilevel multinomial logistic regression. Latent class analysis revealed four distinct subclasses of multimorbidity among the Iranian population (10069 participants). Musculoskeletal diseases and asthma classes were seen in both genders. In males, the odds of membership in the diabetes class was 41% less by increasing physical activity; but with increased BMI, the odds of membership in the diabetes class was 1.90 times higher. Tobacco smoking increased the odds of membership in the musculoskeletal diseases class, 1.37 and 2.30 times for males and females, respectively. Increased BMI and low education increased the chances of females' membership in all subclasses of multimorbidity. At the province level, with increase in urbanization, the odds of membership in the diabetes class was 1.28 times higher among males (P = 0.027). Increased age, higher BMI, tobacco smoking and low education are the most important risk factors associated with NCD multimorbidity among Iranians. Interventions and policies should be implemented to control these risk factors.

Comparison of Bone Turnover Markers between Young Adult Male Smokers and Nonsmokers

Background

This study aims to compare the differences in the means of bone formation and resorption markers between young adult male smokers and nonsmokers.

Methods

This study employed a cross-sectional, descriptive design. Thirty-five smokers and 38 nonsmokers were recruited. All participants completed self-reported questionnaires about demographics, physical activity, and smoking status. In addition, blood specimens were collected to determine serum levels of bone turnover markers.

Results

Regarding bone formation markers, the least square means (LSM) for osteoprotegerin (OPG) and procollagen type I N-terminal propeptide (PINP) were similar for smoking and nonsmoking groups. Regarding bone resorption markers, the LSM serum carboxyl-terminal telopeptide of collagen type I (CTXI) level was found to be significantly lower in smokers than nonsmokers [0.82 ± 0.83 vs. 1.30 ± 0.82 ng/mL, F (1, 66) = 5.73, p = 0.020]. The LSM for soluble-receptor activator of nuclear factor-kappa B ligand (sRANKL) [1.64 ± 0.60 vs. 1.69 ± 0.62 ng/mL, F (1,64) = 10.74, p = 0.002] and RANKL/OPG [2.62 ± 1.09 vs. 2.81 ± 1.10 ng/mL, F (1,65) = 5.88, p = 0.018] were different for smoking and nonsmoking groups. Exploration of the moderating influence of physical activity on smoking effects revealed significant effect for the interaction between smoking status and physical activity on sRANKL [F (2, 64) = 8.63, p = 0.001] and RANKL/OPG ratio [F (2, 65) = 5.49, p = 0.006].

Conclusion

Our study provides evidence for the effect of smoking on bone resorption markers in young adult males. Such effects should be carefully considered side by side with other lifestyles that may lead to poor bone health and increased risk for osteoporosis.

Evidence for Gender-Specific Bone Loss Mechanisms in Periprosthetic Osteolysis

Osteolysis adjacent to total hip replacement (THR) prostheses is a major cause of their eventual failure. Periprosthetic osteolysis is associated with the production of bioactive particles, produced by the wear of articulating prosthesis surfaces. Wear particles invade the periprosthetic tissue, inducing inflammation and bone resorption. Previous studies have shown that osteocytes, the most numerous cell type in mineralised bone, can respond to wear particles of multiple orthopaedic material types. Osteocytes play important roles in bone resorption, regulating bone resorption by osteoclasts and directly through osteocytic osteolysis, also known as perilacunar remodelling. In this study, we perform a histological analysis of bone biopsies obtained from cohorts of male and female patients undergoing either primary THR surgery or revision THR surgery for aseptic loosening. The osteocyte lacunae area (Ot.Lac.Ar) and percentage lacunar area/bone area (%Ot.Lac.Ar/B.Ar) were significantly larger overall in revision THR bone than bone from similar sites in primary THR. Analysis by patient gender showed that increased Ot.Lac.Ar, indicative of increased perilacunar remodelling, was restricted to female revision samples. No significant differences in osteoclast parameters were detectable between the cohorts. These findings suggest previously unrecognised gender-specific mechanisms of bone loss in orthopaedic wear particle-induced osteolysis in humans.

The economic cost of tobacco smoking and secondhand smoke in Greece: Musculoskeletal disorders the leading contributor to smoking-related morbidity

INTRODUCTION

The high proportion of the population in Greece that is active and passive smoking makes smoking the leading risk factor for death and disability. Tobacco use creates a high cost to society and yet relevant research for Greece is limited.

METHODS

The cost-of-illness approach is used to estimate the economic cost of smoking and, for the first time, of secondhand smoke (SHS) exposure in Greece. The analysis covers more health conditions, causally related to smoking, than those included in such studies.

RESULTS

Based on data from the Global Burden of Diseases Study 2017, total economic cost of tobacco smoking and SHS exposure is estimated to be €7.2 billion in 2017, which is equivalent to almost 4% of GDP in Greece. SHS exposure accounts for 8.9% of total cost. Direct cost of smoking is slightly less than indirect cost. Indirect cost is relatively higher for males. Musculoskeletal disorders and diabetes are found to comprise the greatest fraction of morbidity cost of smoking and SHS exposure, respectively. Cardiovascular diseases are found to be the main cause of mortality costs for both smoking and SHS exposure.

CONCLUSIONS

Total economic cost of tobacco smoking and SHS exposure in Greece is estimated to be more than double the revenue from tobacco taxes. Smoking imposes a heavy economic burden, underlining the need for efficient interventions, including effective implementation and enforcement of existing anti-tobacco policies.

Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review

BACKGROUND

The purpose of this article was to review the basic science pertaining to the harmful effects of cigarette smoke, summarize recent clinical outcome studies, and examine the benefits of smoking cessation and the efficacy of current smoking cessation strategies.

METHODS

The literature concerning basic science, clinical outcomes, and smoking cessation was reviewed; over half (56%) of the 52 articles reviewed were published in the last 5 years.

RESULTS

Smoking is associated with low bone mineral density, delayed fracture union, peri-implant bone loss, and implant failure. Orthopedic surgical patients who smoke have increased pain and lower overall patient satisfaction, along with significantly increased rates of wound healing complications.

DISCUSSION/CONCLUSION

Active smoking is a significant modifiable risk factor and should be discontinued before foot and ankle surgery whenever possible. Orthopedic surgeons play an important role in educating patients on the effects of smoking and facilitating access to smoking cessation resources.

LEVEL OF EVIDENCE

Level V, expert opinion.

Cardiopulmonary and Muscular Interactions: Potential Implications for Exercise (In)tolerance in Symptomatic Smokers Without Chronic Obstructive Pulmonary Disease

Smoking and physical inactivity are important preventable causes of disability and early death worldwide. Reduced exercise tolerance has been described in smokers, even in those who do not fulfill the extant physiological criteria for chronic obstructive pulmonary disease (COPD) and are not particularly sedentary. In this context, it is widely accepted that exercise capacity depends on complex cardio-pulmonary interactions which support oxygen (O₂) delivery to muscle mitochondria. Although peripheral muscular factors, O₂ transport disturbances (including the effects of increased carboxyhemoglobin) and autonomic nervous system unbalance have been emphasized, other derangements have been more recently described, including early microscopic emphysema, pulmonary microvascular disease, ventilatory and gas exchange inefficiency, and left ventricular diastolic dysfunction. Using an integrative physiological approach, the present review summarizes the recent advances in knowledge on the effects of smoking on the lung-heart-muscle axis under the stress of exercise. Special attention is given to the mechanisms connecting physiological abnormalities such as early cardio-pulmonary derangements, inadequate oxygen delivery and utilization, and generalized bioenergetic disturbances at the muscular level with the negative sensations (sense of heightened muscle effort and breathlessness) that may decrease the tolerance of smokers to physical exercise. A deeper understanding of the systemic effects of smoking in subjects who did not (yet) show evidences of COPD and ischemic heart disease - two devastating smoking related diseases - might prove instrumental to fight their ever-growing burden.

Smoking is associated with greater pain intensity and pain-related occupational disability in Japanese workers

PURPOSE

Pain symptom, such as that caused by musculoskeletal disorders, is a major cause of occupational disability. As nicotine intake from smoking increases pain sensitivity, smokers may experience stronger pain and be more likely to experience pain-related disability than non-smokers. The study aim was to examine whether smoking was associated with pain-related occupational disability via pain intensity.

METHODS

Participants were 1189 workers with pain aged 20-74 years in Japan. Participants completed a self-report questionnaire, which included a question to measure pain-related occupational disability with ordinal-option: (1) without pain-related disability, (2) pain-related presenteeism, and (3) pain-related absenteeism. An ordinal logistic regression model was used to calculate multivariable-adjusted proportional odds ratios (OR) with 95% confidence intervals (CI) for the prevalence of pain-related occupational disability according to smoking status. A multiple mediation analysis was also conducted to assess whether pain sensitivity mediated the association between smoking and pain-related occupational disability. Adjusted variables were demographic variables, socioeconomic status, work-related psychosocial factors, general psychological factors, and pain duration.

RESULTS

Current smoking and pain were associated with pain-related occupational disability compared with non-smoking and pain (multivariable OR 1.78; 95% CI 1.26-2.52). Greater pain intensity partially mediated the association of current smoking and pain with pain-related occupational disability. The mediation rate (indirect/total effect) was 25%.

CONCLUSION

Smoking and pain were associated with pain-related occupational disability, partially through greater pain intensity, among Japanese workers.