The American journal of medicine
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Aggressive treatment of bacteremia in patients at high risk of septic shock may prove to be beneficial and cost-effective since these patients account for 50% of the mortality. The purpose of this study was to identify risk factors for septic shock in bacteremic patients. ⋯ Our results provide a positive predictive value that is similar to that of the clinical scores of severity proposed by other authors in selected populations. Our classification, in conjunction with a clinical classification, would allow improvement in the prognosis of patients with bacteremia by early treatment of those at high risk for developing septic shock. Validation of these results with further studies involving a larger population that includes patients with suspected infections, as well as bacteremic patients, is needed.
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To develop a scoring system for stratifying patients in intensive care units (ICUs) by risk of developing nosocomial pneumonia (NP) and to identify the time period associated with the highest risk. ⋯ ICU patients can be stratified into high- and low-risk groups for NP using a bedside scoring system. Endotracheal intubation, altered mental status, and NG tube are associated with the highest risk of NP during the first 1 to 6 days of their presence after 72 hours of stay in the ICU. After this time period, the risk associated with these factors decreases. Bronchoscopy may be an independent risk factor for NP that has not been previously recognized. This procedure, often done in the ICU for respiratory toilet, may be an avoidable risk in this group of patients.
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The association between cigarette smoking and delayed wound healing is well recognized in clinical practice, although extensive controlled studies have yet to be performed. The documented effects of the toxic constituents of cigarette smoke--particularly nicotine, carbon monoxide, and hydrogen cyanide--suggest potential mechanisms by which smoking may undermine expeditious wound repair. Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue. ⋯ The reduced capacity for wound repair is a particular concern in patients undergoing plastic or reconstructive surgery. Compared with nonsmokers, smokers have a higher incidence of unsatisfactory healing after face-lift surgery, as well as a greater degree of complications following breast surgery. Smokers should be advised to stop smoking prior to elective surgery or when recovering from wounds resulting from trauma, disease, or emergent surgery.
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Cigarette smoking is the most preventable cause of cardiovascular morbidity and mortality. Smoking has been associated with a two-to fourfold increased risk of coronary heart disease, a greater than 70% excess rate of death from coronary heart disease, and an elevated risk of sudden death. These risks are compounded in the presence of hypertension, hypercholesterolemia, glucose intolerance, and diabetes, all of which exhibit a synergistic effect with smoking. ⋯ Notably, smoking cessation results in a dramatic reduction in the risk of mortality from both coronary heart disease and stroke. In light of the fact that the incidence of smoking has declined primarily among educated sectors of the U. S. population, future efforts must focus on providing effective education, including smoking cessation techniques, to the less-educated groups.
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Two recent studies have implicated smoking as a principal risk factor for increasing the time patients spend in the postanesthesia care unit (PACU) following a wide range of surgical procedures. Hospitals are performing an increasing number of surgical procedures, with growing pressure to do more on an outpatient basis. With more internal and external pressures to streamline the rising costs of medical care, increased focus is being placed on the length of stay in the PACU. ⋯ But it suggests that even these patients, who may view themselves as "healthy smokers," are significantly different from their nonsmoking counterparts. Further, varying the degree of smoking from heavy to light does not negate the increased PACU time. Therefore, any degree of smoking must now be viewed as having serious consequences in the immediate postoperative period and must be discouraged.