Arch Intern Med
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This article discusses the evolution of smokeless tobacco in the United States and interprets the available data on cardiovascular risk factors and cardiovascular mortality associated with its use. There has been a resurgence of smokeless tobacco use since 1970. Smokeless tobacco consistently produces levels of nicotine higher than those seen with smoking and causes similar sympathetic neural stimulation and acute cardiovascular effects. ⋯ Although the evidence is not conclusive, the adverse cardiovascular effects of smokeless tobacco use are less than those caused by smoking but are more than those found in nonusers. It is advisable to counsel all current users of smokeless tobacco to quit. Behavioral counseling, sustained-release bupropion hydrochloride therapy, and nicotine replacement therapy may be safe therapeutic modalities for treatment of smokeless tobacco use.
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The number of patients undergoing major noncardiac surgery has steadily increased over the last decade. Cardiovascular complications are important and often feared by patients, surgeons, and anesthesiologists. Although preoperative risk assessment has improved since Goldman and colleagues published their landmark article that introduced the Multifactorial Index of Cardiac Risk 25 years ago, it continues to require modification, especially with the increasing prevalence of heart failure and the increase in procedures performed in the elderly. This review will summarize preoperative assessment and perioperative management with an emphasis on heart failure.
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The incidence of esophageal adenocarcinoma has been rising rapidly over the past few decades. The major risk factors predisposing to the development of adenocarcinoma are long-standing gastroesophageal reflux disease and Barrett esophagus, but other factors may be involved as cancer can occur in their absence. ⋯ As neither medical nor surgical therapies have been proven to prevent adenocarcinoma, endoscopic screening of patients with chronic reflux and endoscopic surveillance of patients diagnosed with Barrett esophagus are usually performed in an effort to detect adenocarcinomas at earlier stages. The evidence supporting strategies in the management of patients with gastroesophageal reflux and Barrett esophagus is presented.
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Meta Analysis
Using the coronary artery calcium score to predict coronary heart disease events: a systematic review and meta-analysis.
Primary prevention of coronary heart disease is most appropriate for patients at relatively high risk. Measurement of coronary artery calcium has been proposed as a way to improve risk assessment, but it is unknown whether it adds predictive information to standard risk factor assessment. ⋯ The coronary artery calcium score is an independent predictor of coronary heart disease events.
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Intravascular catheters and urinary catheters are the 2 most commonly inserted medical devices in the United States, and they are likewise the two most common causes of nosocomially acquired bloodstream infection. Biofilm formation on the surfaces of indwelling catheters is central to the pathogenesis of infection of both types of catheters. The cornerstone to any preventive strategy of intravascular catheter infections is strict attention to infection control practices. ⋯ Prevention of urinary catheter-associated infection is hindered by the numbers and types of organisms present in the periurethral area as well as by the typically longer duration of catheter placement. Antimicrobial agents in general have not been effective in preventing catheter-associated urinary tract infection in persons with long-term, indwelling urethral catheters. Preventive strategies that avoid the use of antimicrobial agents may be necessary in this population.