15667 articles - 08.09.10
1: Ann Intern Med. 2010 Sep 7;153(5):325-334.
Menke J, Larsen J.
University Hospital and Evangelisches Krankenhaus, Goettingen, Germany.
Background: Contrast-enhanced magnetic resonance angiography (MRA) is a noninvasive, radiation-free imaging method for studying peripheral arterial disease (PAD) of the lower extremities. Purpose: To summarize evidence of prospective studies about how well MRA identifies or excludes arterial steno-occlusions (50% to 100% lumen reduction) in adults with PAD symptoms. Data Sources: PubMed and 3 other databases were searched from 1998 to 2009 without language restrictions. Study Selection: Two independent reviewers selected 32 studies that compared MRA with intra-arterial digital subtraction angiography in PAD. Eligible studies were prospective and provided data to reconstruct 2 x 2 or 3 x 3 contingency tables (<50% stenosis vs. >/=50% stenosis or occlusion of arterial segments) in at least 10 patients with PAD symptoms. Data Extraction: Two reviewers independently assessed the study quality and extracted the study data, with disagreements resolved by consensus. Data Synthesis: The 32 included studies generally had high methodological quality. About 26% of the 1022 included patients had critical limb ischemia with pain at rest or tissue loss. Overall, the pooled sensitivity of MRA was 94.7% (95% CI, 92.1% to 96.4%) and the specificity was 95.6% (CI, 94.0% to 96.8%) for diagnosing segmental steno-occlusions. The pooled positive and negative likelihood ratios were 21.56 (CI, 15.70 to 29.69) and 0.056 (CI, 0.037 to 0.083), respectively. Magnetic resonance angiography correctly classified 95.3%, overstaged 3.1%, and understaged 1.6% of arterial segments. Limitation: Similar to most studies of computed tomographic angiography in PAD, the primary studies reported the diagnostic accuracy of MRA on a per-segment basis, not a per-patient basis. Conclusion: This meta-analysis of 32 prospective studies further increases the evidence that contrast-enhanced MRA has high accuracy for identifying or excluding clinically relevant arterial steno-occlusions in adults with PAD symptoms. Primary Funding Source: None.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20820041&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20820041 [PubMed - as supplied by publisher]2: Am J Clin Nutr. 2010 Sep 1; [Epub ahead of print]
Perez-Jimenez J, Hubert J, Hooper L, Cassidy A, Manach C, Williamson G, Scalbert A.
From Clermont Universite, Universite d'Auvergne, Unite de Nutrition Humaine, Clermont-Ferrand, France.
BACKGROUND: To identify associations between polyphenol intake and health and disease outcomes in cohort studies, it is important to identify biomarkers of intake for the various compounds commonly consumed as part of the diet. OBJECTIVE: The objective of this systematic review was to assess the usefulness of polyphenol metabolites excreted in urine as biomarkers of polyphenol intake in humans. DESIGN: The method included a structured search strategy for polyphenol intervention studies on Ovid MEDLINE, EMBASE (Ovid), and Cochrane databases; formal inclusion and exclusion criteria; data extraction into an Access database; validity assessment; and meta-analysis. RESULTS: One hundred sixty-two controlled intervention studies with polyphenols were included, and mean recovery yield and correlations with the dose ingested were determined for 40 polyphenols. Polyphenols such as daidzein, genistein, glycitein, enterolactone, and hydroxytyrosol showed both a high recovery yield (12-37%) and a high correlation with the dose (Pearson's correlation coefficients: 0.67-0.87), which showed good sensitivity and robustness as biomarkers of intake throughout the different studies. Weaker recovery for anthocyanins (0.06-0.2%) and weaker correlations with dose [Pearson's correlation coefficients: 0.21-0.52 for hesperidin, naringenin, (-)-epicatechin, (-)-epigallocatechin, quercetin, and 3 microbial metabolites of isoflavones (dihydrodaidzein, equol, and O-desmethylangolensin)] suggest that they are currently less suitable as biomarkers of intake. CONCLUSIONS: These data confirm the value of certain urinary polyphenols as biomarkers of intake. A validation in populations is now needed to evaluate their specificity, sensitivity, and responsiveness to dose under free-living conditions.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20810980&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20810980 [PubMed - as supplied by publisher]3: Am J Clin Nutr. 2010 Sep 1; [Epub ahead of print]
Sofi F, Abbate R, Gensini GF, Casini A.
Department of Medical and Surgical Critical Care, Thrombosis Centre, University of Florence, Florence, Italy.
BACKGROUND: The Mediterranean diet has long been reported to be protective against the occurrence of several and different health outcomes. OBJECTIVE: We aimed to update our previous meta-analysis of published cohort prospective studies that investigated the effects of adherence to the Mediterranean diet on health status. DESIGN: We conducted a comprehensive literature search through electronic databases up to June 2010. RESULTS: The updated review process showed 7 prospective studies published in the past 2 y that were not included in the previous meta-analysis (1 study for overall mortality, 3 studies for cardiovascular incidence or mortality, 1 study for cancer incidence or mortality, and 2 studies for neurodegenerative diseases). These recent studies included 2 health outcomes not previously investigated (ie, mild cognitive impairment and stroke). The meta-analysis for all studies with a random-effects model that was conducted after the inclusion of these recent studies showed that a 2-point increase in adherence to the Mediterranean diet was associated with a significant reduction of overall mortality [relative risk (RR) = 0.92; 95% CI: 0.90, 0.94], cardiovascular incidence or mortality (RR = 0.90; 95% CI: 0.87, 0.93), cancer incidence or mortality (RR = 0.94; 95% CI: 0.92, 0.96), and neurodegenerative diseases (RR = 0.87; 95% CI: 0.81, 0.94). The meta-regression analysis showed that sample size was the most significant contributor to the model because it significantly influenced the estimate of the association for overall mortality. CONCLUSION: This updated meta-analysis confirms, in a larger number of subjects and studies, the significant and consistent protection provided by adherence to the Mediterranean diet in relation to the occurrence of major chronic degenerative diseases.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20810976&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20810976 [PubMed - as supplied by publisher]4: JAMA. 2010 Sep 1;304(9):992-1000.
Lasswell SM, Barfield WD, Rochat RW, Blackmon L.
Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, USA.
CONTEXT: For more than 30 years, guidelines for perinatal regionalization have recommended that very low-birth-weight (VLBW) infants be born at highly specialized hospitals, most commonly designated as level III hospitals. Despite these recommendations, some regions continue to have large percentages of VLBW infants born in lower-level hospitals. OBJECTIVE: To evaluate published data on associations between hospital level at birth and neonatal or predischarge mortality for VLBW and very preterm (VPT) infants. DATA SOURCES: Systematic search of published literature (1976-May 2010) in MEDLINE, CINAHL, EMBASE, and PubMed databases and manual searches of reference lists. STUDY SELECTION AND DATA EXTRACTION: Forty-one publications met a priori inclusion criteria (randomized controlled trial, cohort, and case-control studies measuring neonatal or predischarge mortality among live-born infants < or = 1500 g or < or = 32 weeks' gestation delivered at a level III vs lower-level facility). Paired reviewers independently assessed publications for inclusion and extracted data using standardized forms. Discrepancies were decided by a third reviewer. Publications were reviewed for quality by 3 authors based on 2 content areas: adjustment for confounding and description of hospital levels. We calculated weighted, combined odds ratios (ORs) using a random-effects model and comparative unadjusted pooled mortality rates. DATA SYNTHESIS: We observed increased odds of death for VLBW infants (38% vs 23%; adjusted OR, 1.62; 95% confidence interval [CI], 1.44-1.83) and VPT infants (15% vs 17%; adjusted OR, 1.55; 95% CI, 1.21-1.98) born outside of level III hospitals. Consistent results were obtained when restricted to higher-quality evidence (mortality in VLBW infants, 36% vs 21%; adjusted OR, 1.60; 95% CI, 1.33-1.92 and in VPT infants, 7% vs 12%; adjusted OR, 1.42; 95% CI, 1.06-1.88) and infants weighing less than 1000 g (59% vs 32%; adjusted OR, 1.80; 95% CI, 1.31-2.46). No significant differences were found through subgroup analysis of study characteristics. Meta-regression by year of publication did not reveal a change over time (slope, 0.00; P = .87). CONCLUSION: For VLBW and VPT infants, birth outside of a level III hospital is significantly associated with increased likelihood of neonatal or predischarge death.
Publication Types: Meta-Analysis Research Support, U.S. Gov't, Non-P.H.S. Research Support, U.S. Gov't, P.H.S.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20810377&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20810377 [PubMed - indexed for MEDLINE]5: Annu Rev Med. 2010 Jan 27; [Epub ahead of print]
Woodcock J, Behrman RE, Dal Pan GJ.
Center for Drug Evaluation and Research, Food and Drug Administration, Rockville, MD 20857; email: janet.woodcock@fda.hhs.gov.
Contemporary medicine is a large and complex system involving many participants, all of whom play a critical role in managing the risks intrinsic to medical product use. Despite the robust premarket review and approval process of the U.S. Food and Drug Administration (FDA), new information will inevitably be learned in the postmarketing period about the safety of medicines and how they are and should be used. For much of this information, FDA relies on public reports about possible adverse events. In turn, the public depends on FDA to communicate the most up-to-date safety information on medical products to better inform treatment decisions. Expanding the scope and strengthening the capabilities of the drug safety surveillance system are among key FDA projects designed to reduce avoidable injury and death from medication use. Although improving drug safety is our goal and obligation to the public, FDA cannot protect the public adequately without the active involvement of all participants in healthcare. Expected final online publication date for the Annual Review of Medicine Volume 62 is January 07, 2011. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.">Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20809798&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20809798 [PubMed - as supplied by publisher]6: JAMA. 2010 Aug 30; [Epub ahead of print]
Bhatt DL, Eagle KA, Ohman EM, Hirsch AT, Goto S, Mahoney EM, Wilson PW, Alberts MJ, D'Agostino R, Liau CS, Mas JL, Rother J, Smith SC Jr, Salette G, Contant CF, Massaro JM, Steg PG; for the REACH Registry Investigators.
Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (Dr Bhatt); University of Michigan Cardiovascular Center, Ann Arbor (Dr Eagle); Division of Cardiology, Duke University, Durham, North Carolina (Dr Ohman); Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis (Dr Hirsch); Tokai University School of Medicine, Isehara, Japan (Dr Goto); Saint Luke's Mid America Heart Institute, Kansas City, Missouri (Dr Mahoney); Emory University School of Medicine, Atlanta, Georgia (Dr Wilson); Department of Neurology, Northwestern University Medical School, Chicago, Illinois (Dr Alberts); Statistics and Consulting Unit, Boston University, Boston, Massachusetts (Drs D'Agostino and Massaro); Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan (Dr Liau); Paris-Descartes University, INSERM U894, Department of Neurology, Hopital Sainte-Anne, Paris, France (Dr Mas); Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany (Dr Rother); Center for Cardiovascular Science and Medicine, University of North Carolina at Chapel Hill (Dr Smith Jr); Sanofi-Aventis, Paris (Dr Salette); TIMI Study Group, Boston (Dr Contant); INSERM U698, Universite Paris 7, and Hopital Bichat, AP-HP, Paris (Dr Steg).
CONTEXT: Clinicians and trialists have difficulty with identifying which patients are highest risk for cardiovascular events. Prior ischemic events, polyvascular disease, and diabetes mellitus have all been identified as predictors of ischemic events, but their comparative contributions to future risk remain unclear. OBJECTIVE: To categorize the risk of cardiovascular events in stable outpatients with various initial manifestations of atherothrombosis using simple clinical descriptors. Design, Setting, and PATIENTS: Outpatients with coronary artery disease, cerebrovascular disease, or peripheral arterial disease or with multiple risk factors for atherothrombosis were enrolled in the global Reduction of Atherothrombosis for Continued Health (REACH) Registry and were followed up for as long as 4 years. Patients from 3647 centers in 29 countries were enrolled between 2003 and 2004 and followed up until 2008. Final database lock was in April 2009. MAIN OUTCOME MEASURES: Rates of cardiovascular death, myocardial infarction, and stroke. RESULTS: A total of 45 227 patients with baseline data were included in this 4-year analysis. During the follow-up period, a total of 5481 patients experienced at least 1 event, including 2315 with cardiovascular death, 1228 with myocardial infarction, 1898 with stroke, and 40 with both a myocardial infarction and stroke on the same day. Among patients with atherothrombosis, those with a prior history of ischemic events at baseline (n = 21 890) had the highest rate of subsequent ischemic events (18.3%; 95% confidence interval [CI], 17.4%-19.1%); patients with stable coronary, cerebrovascular, or peripheral artery disease (n = 15 264) had a lower risk (12.2%; 95% CI, 11.4%-12.9%); and patients without established atherothrombosis but with risk factors only (n = 8073) had the lowest risk (9.1%; 95% CI, 8.3%-9.9%) (P < .001 for all comparisons). In addition, in multivariable modeling, the presence of diabetes (hazard ratio [HR], 1.44; 95% CI, 1.36-1.53; P < .001), an ischemic event in the previous year (HR, 1.71; 95% CI, 1.57-1.85; P < .001), and polyvascular disease (HR, 1.99; 95% CI, 1.78-2.24; P < .001) each were associated with a significantly higher risk of the primary end point. CONCLUSION: Clinical descriptors can assist clinicians in identifying high-risk patients within the broad range of risk for outpatients with atherothrombosis.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20805624&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20805624 [PubMed - as supplied by publisher]7: Am J Med. 2010 Sep;123(9):856-62.
Reed J, deShazo RD, Houle TT, Stringer S, Wright L, Moak JS 3rd.
Department of Medicine, The University of Mississippi Medical Center, Jackson, MS, USA.
OBJECTIVE: We asked if certain clinical features were useful predictors of sarcoid rhinosinusitis in general populations of patients with chronic rhinosinusitis. METHODS: Our patients with sarcoid rhinosinusitis and those from the literature formed the study group. A group of 21 randomly selected patients from The University of Mississippi Medical Center Allergy Clinic with chronic rhinosinusitis composed the control group. RESULTS: Our literature search identified 73 patients with sarcoid rhinosinusitis reported since 1999. Twenty patients met inclusion criteria and were added to 16 of our patients to compose the study group of 36 patients. The majority of the study group was African-American (61%) and female (69%) and had pulmonary sarcoidosis (67%) and other forms of extrapulmonary sarcoidosis in addition to sarcoid rhinosinusitis (86%). The 5 most common upper respiratory signs/symptoms were nasal obstruction (86%), nasal crusting (47%), anosmia (44%), epistaxis (28%), and nasal polyposis (25%). Odds ratios for sarcoid rhinosinusitis were 2.5 for persistent nasal obstruction, 7.7 for epistaxis, 16.0 for anosmia, and 18.8 for nasal crusting. For each symptom, the odds of sarcoid rhinosinusitis increased by 9.4 (95% confidence interval, 1.8-49.9). Nasal crusting was associated with the coexistence of atrophic rhinosinusitis at nasal endoscopy. Treatment with oral corticosteroids and other immunosuppressive therapy, primarily methotrexate, was frequently required. CONCLUSION: The coexistence of chronic rhinosinusitis and 2 of the signs of nasal crusting, anosmia, or epistaxis are highly specific for sarcoid rhinosinusitis. Even in the absence of an established diagnosis of sarcoidosis, sinonasal biopsy should be considered for diagnosing these patients with chronic rhinosinusitis.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20800155&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20800155 [PubMed - in process]8: JAMA. 2010 Aug 25;304(8):890-6.
Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzales R.
Primary and Specialty Medical Care Service, Veterans Affairs Puget Sound Health Care System, and Department of Medicine, University of Washington School of Medicine, Seattle, USA.
CONTEXT: Pertussis is often overlooked as a cause of chronic cough, especially in adolescents and adults. Several symptoms are classically thought to be suggestive of pertussis, but the diagnostic value of each of them is uncertain. OBJECTIVE: To systematically review the evidence regarding the diagnostic value of 3 classically described symptoms of pertussis: paroxysmal cough, posttussive emesis, and inspiratory whoop. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: We searched MEDLINE (January 1966-April 2010), EMBASE (January 1969 to April 2010), and the bibliographies of pertinent articles to identify relevant English-language studies. Articles were selected that included children older than 5 years, adolescents, or adults and confirmed the diagnosis of pertussis among patients with cough illness (of any duration) with an a priori-defined accepted reference standard. Two authors independently extracted data from articles that met selection criteria and resolved any discrepancies by consensus. DATA SYNTHESIS: Five prospective studies met inclusion criteria; 3 were used in the analysis. Presence of posttussive emesis (summary likelihood ratio [LR], 1.8; 95% confidence interval [CI], 1.4-2.2) or inspiratory whoop (summary LR, 1.9; 95% CI, 1.4-2.6) increases the likelihood of pertussis. Absence of paroxysmal cough (summary LR, 0.52; 95% CI, 0.27-1.0) or posttussive emesis (summary LR, 0.58; 95% CI, 0.44-0.77) reduced the likelihood. Absence of inspiratory whoop was less useful (summary LR, 0.78; 95% CI, 0.66-0.93). No studies evaluated combinations of findings. CONCLUSIONS: In a nonoutbreak setting, data to determine the diagnostic usefulness of symptoms classically associated with pertussis are limited and of relatively weak quality. The presence or absence of posttussive emesis or inspiratory whoop modestly change the likelihood of pertussis; therefore, clinicians must use their overall clinical impression to decide about additional testing or empirical treatment.
Publication Types: Review
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20736473&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20736473 [PubMed - indexed for MEDLINE]9: Med Care. 2010 Aug 13; [Epub ahead of print]
Chisholm-Burns MA, Lee JK, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, Graff Zivin J, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz T.
From the *Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ; daggerMedication Access Program; double daggerHealth Disparities Initiatives and Community Outreach, Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ; section signSchool of International Relations and Pacific Studies, University of California, San Diego, La Jolla, CA; paragraph signDepartment of Pharmacology, The University of Arizona College of Medicine, Tucson, AZ; parallelArizona Health Sciences Library, Tucson, AZ; and **Information Technology, The University of Arizona College of Pharmacy, Tucson, AZ.
BACKGROUND:: One approach postulated to improve the provision of health care is effective utilization of team-based care including pharmacists. OBJECTIVE:: The objective of this study was to conduct a comprehensive systematic review with focused meta-analyses to examine the effects of pharmacist-provided direct patient care on therapeutic, safety, and humanistic outcomes. METHODS:: The following databases were searched from inception to January 2009: NLM PubMed; Ovid/MEDLINE; ABI/INFORM; Health Business Fulltext Elite; Academic Search Complete; International Pharmaceutical Abstracts; PsycINFO; Cochrane Database of Systematic Reviews; National Guideline Clearinghouse; Database of Abstracts of Reviews of Effects; ClinicalTrials.gov; LexisNexis Academic Universe; and Google Scholar. Studies selected included those reporting pharmacist-provided care, comparison groups, and patient-related outcomes. Of these, 56,573 citations were considered. Data were extracted by multidisciplinary study review teams. Variables examined included study characteristics, pharmacists' interventions/services, patient characteristics, and study outcomes. Data for meta-analyses were extracted from randomized controlled trials meeting meta-analysis criteria. RESULTS:: A total of 298 studies were included. Favorable results were found in therapeutic and safety outcomes, and meta-analyses conducted for hemoglobin A1c, LDL cholesterol, blood pressure, and adverse drug events were significant (P < 0.05), favoring pharmacists' direct patient care over comparative services. Results for humanistic outcomes were favorable with variability. Medication adherence, patient knowledge, and quality of life-general health meta-analyses were significant (P < 0.05), favoring pharmacists' direct patient care. CONCLUSIONS:: Pharmacist-provided direct patient care has favorable effects across various patient outcomes, health care settings, and disease states. Incorporating pharmacists as health care team members in direct patient care is a viable solution to help improve US health care.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20720510&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20720510 [PubMed - as supplied by publisher]10: JAMA. 2010 Aug 18;304(7):779-86.
Wong CL, Holroyd-Leduc J, Simel DL, Straus SE.
Division of Geriatrics, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. camilla.wong@utoronto.ca
CONTEXT: Delirium occurs in many hospitalized older patients and has serious consequences including increased risk for death and admission to long-term care. Despite its importance, health care clinicians often fail to recognize delirium. Simple bedside instruments may lead to improved identification. OBJECTIVE: To systematically review the evidence on the accuracy of bedside instruments in diagnosing the presence of delirium in adults. DATA SOURCES: Search of MEDLINE (from 1950 to May 2010), EMBASE (from 1980 to May 2010), and references of retrieved articles to identify studies of delirium among inpatients. STUDY SELECTION: Prospective studies of diagnostic accuracy that compared at least 1 delirium bedside instrument to the Diagnostic and Statistical Manual of Mental Disorders-based diagnosis made by a geriatrician, psychiatrist, or neurologist. DATA SYNTHESIS: There were 6570 unique citations identified with 25 prospectively conducted studies (N = 3027 patients) meeting inclusion criteria and describing use of 11 instruments. Positive results that suggested delirium with likelihood ratios (LRs) greater than 5.0 were present for the Global Attentiveness Rating (GAR), Memorial Delirium Assessment Scale (MDAS), Confusion Assessment Method (CAM), Delirium Rating Scale Revised-98 (DRS-R-98), Clinical Assessment of Confusion (CAC), and Delirium Observation Screening Scale (DOSS). Normal results that decreased the likelihood of delirium with LRs less than 0.2 were calculated for the GAR, MDAS, CAM, DRS-R-98, Delirium Rating Scale (DRS), DOSS, Nursing Delirium Screening Scale (Nu-DESC), and Mini-Mental State Examination (MMSE). The Digit Span test and Vigilance "A" test in isolation have limited utility in diagnosing delirium. Considering the instrument's ease of use, test performance, and clinical importance of the heterogeneity in the confidence intervals (CIs) of the LRs, the CAM has the best available supportive data as a bedside delirium instrument (summary-positive LR, 9.6; 95% CI, 5.8-16.0; summary-negative LR, 0.16; 95% CI, 0.09-0.29). Of all scales, the MMSE (score <24) was the least useful for identifying a patient with delirium (LR, 1.6; 95% CI, 1.2-2.0). CONCLUSION: The choice of instrument may be dictated by the amount of time available and the discipline of the examiner; however, the best evidence supports use of the CAM, which takes 5 minutes to administer.
Publication Types: Research Support, Non-U.S. Gov't Review
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20716741&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20716741 [PubMed - indexed for MEDLINE]11: JAMA. 2010 Aug 18;304(7):755-62.
Bennett-Guerrero E, Ferguson TB Jr, Lin M, Garg J, Mark DB, Scavo VA Jr, Kouchoukos N, Richardson JB Jr, Pridgen RL, Corey GR; SWIPE-1 Trial Group.
Division of Perioperative Clinical Research, Duke Clinical Research Institute, Duke University Medical Center, PO Box 3094, Durham, NC 27710, USA. Elliott.BennettGuerrero@Duke.edu
CONTEXT: Despite the routine use of prophylactic systemic antibiotics, sternal wound infection still occurs in 5% or more of cardiac surgical patients and is associated with significant excess morbidity, mortality, and cost. The gentamicin-collagen sponge, a surgically implantable topical antibiotic, is currently approved in 54 countries. A large, 2-center, randomized trial in Sweden reported in 2005 that the sponge reduced surgical site infection by 50% in cardiac patients. OBJECTIVE: To test the hypothesis that the sponge prevents infection in cardiac surgical patients at increased risk for sternal wound infection. DESIGN, SETTING, AND PARTICIPANTS: Phase 3 single-blind, prospective randomized controlled trial, 1502 cardiac surgical patients at high risk for sternal wound infection (diabetes, body mass index >30, or both) were enrolled at 48 US sites between December 21, 2007, and March 11, 2009. INTERVENTION: Single-blind randomization to insertion of 2 gentamicin-collagen sponges (total gentamicin of 260 mg) between the sternal halves at surgical closure (n = 753) vs no intervention (control group: n = 749). All patients received standardized care including prophylactic systemic antibiotics and rigid sternal fixation. MAIN OUTCOME MEASURES: The primary end point was sternal wound infection occurring through 90 days postoperatively as adjudicated by a clinical events classification committee blinded to study treatment group. The primary study comparison was done in the intent-to-treat population. Secondary outcomes included (1) superficial wound infection (involving subcutaneous tissue but not extending down to sternal fixation wires), (2) deep wound infection (involving the sternal wires, sternal bone, and/or mediastinum), and (3) score for additional treatment, presence of serous discharge, erythema, purulent exudate, separation of the deep tissues, isolation of bacteria, and duration of inpatient stay (ASEPSIS; minimum score of 0 with no theoretical maximum). RESULTS: Of 1502 patients, 1006 had diabetes (67%) and 1137 were obese (body mass index >30) (76%). In the primary analysis, there was no significant difference in sternal wound infection in 63 of 753 patients randomized to the gentamicin-collagen sponge group (8.4%) compared with 65 of 749 patients randomized to the control group (8.7%) (P = .83). No significant differences were observed between the gentamicin-collagen sponge group and the control group, respectively, in superficial sternal wound infection (49/753 [6.5%] vs 46/749 [6.1%]; P = .77), deep sternal wound infection (14/753 [1.9%] vs 19/749 [2.5%]; P = .37), ASEPSIS score (mean [SD], 1.9 [6.4] vs 2.0 [7.2]; P = .67), or rehospitalization for sternal wound infection (23/753 [3.1%] vs 24/749 [3.2%]; P = .87). CONCLUSION: Among US patients with diabetes, high body mass index, or both undergoing cardiac surgery, the use of 2 gentamicin-collagen sponges compared with no intervention did not reduce the 90-day sternal wound infection rate. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00600483.
Publication Types: Clinical Trial, Phase III Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20716738&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20716738 [PubMed - indexed for MEDLINE]12: Med J Aust. 2010 Aug 16;193(4 Suppl):S24-30.
Malhi GS, Adams D, Berk M.
CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, and Discipline of Psychiatry, University of Sydney, Sydney, NSW. gin.malhi@sydney.edu.au
OBJECTIVE: To provide a practical overview of the pharmacological management of adults with bipolar disorder in primary care and the role of general practitioners in the pharmacotherapy of this complex disorder. DATA SOURCES: Published guidelines for the treatment of bipolar disorder, plus Cochrane reviews, meta-analyses, review articles and reports from randomised controlled trials that were published up to May 2009. STUDY SELECTION: Over 500 articles on the treatment of bipolar disorder were reviewed, with an emphasis on meta-analyses and systematic reviews of randomised controlled trials. Where evidence was more limited, open trials and non-controlled data were also reviewed. DATA EXTRACTION: Key recommendations relevant to GPs were synthesised and rated according to National Health and Medical Research Council levels of evidence. DATA SYNTHESIS: Lithium, valproate and atypical antipsychotics are first-line treatment options for acute mania, and monotherapy is ideal if it produces an adequate response. For depressive episodes, recommendations are less definitive and the use of antidepressants is controversial. Most patients require maintenance treatment, during which pharmacotherapy should be used to prevent relapse, and psychological and social interventions should be considered. CONCLUSIONS: Bipolar disorder is a lifelong episodic illness that affects 1%-2% of the population, many of whom are principally managed by their GPs. Pharmacological treatment with mood-stabilising agents is the primary form of management, although this is ideally provided in conjunction with psychosocial interventions.
Publication Types: Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20712557&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20712557 [PubMed - in process]13: Med Care. 2010 Sep;48(9):792-808.
Viswanathan M, Kraschnewski JL, Nishikawa B, Morgan LC, Honeycutt AA, Thieda P, Lohr KN, Jonas DE.
RTI International, Research Triangle Park, NC 27709-2194, USA. viswanathan@rti.org
OBJECTIVES: We conducted a systematic review on outcomes and costs of community health worker (CHW) interventions. CHWs are increasingly expected to improve health outcomes cost-effectively for the underserved. RESEARCH DESIGN: We searched Medline, Cochrane Collaboration resources, and the Cumulative Index to Nursing and Allied Health Literature for studies conducted in the United States and published in English from 1980 through November 2008. We dually reviewed abstracts, full-text articles, data abstractions, quality ratings, and strength of evidence grades and resolved disagreements by consensus. RESULTS: We included 53 studies on outcomes of CHW interventions and 6 on cost or cost-effectiveness. For outcomes, limited evidence (5 studies) suggests that CHW interventions can improve participant knowledge compared with alternative approaches or no intervention. We found mixed evidence for participant behavior change (22 studies) and health outcomes (27 studies). Some studies suggested that CHW interventions can result in greater improvements in participant behavior and health outcomes compared with various alternatives, but other studies suggested that CHW interventions provide no statistically different benefits than alternatives. We found low or moderate strength of evidence suggesting that CHWs can increase appropriate health care utilization for some interventions (30 studies). Six studies with economic information yielded insufficient data to evaluate the cost-effectiveness of CHW interventions relative to other interventions. CONCLUSIONS: CHWs can improve outcomes for underserved populations for some health conditions. The effectiveness of CHWs in many health care areas requires further research that addresses the methodologic limitations of prior studies and that contributes to translating research into practice.
Publication Types: Research Support, U.S. Gov't, P.H.S.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20706166&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20706166 [PubMed - in process]14: J Gen Intern Med. 2010 Aug 12; [Epub ahead of print]
Fluit CR, Bolhuis S, Grol R, Laan R, Wensing M.
Department for Evaluation, Quality and Development of Medical Education, Radboud University Nijmegen Medical Centre, 306 IWOO, PO Box 9101, 6500HB, Nijmegen, The Netherlands, C.Fluit@owi.umcn.nl.
BACKGROUND: Learning in a clinical environment differs from formal educational settings and provides specific challenges for clinicians who are teachers. Instruments that reflect these challenges are needed to identify the strengths and weaknesses of clinical teachers. OBJECTIVE: To systematically review the content, validity, and aims of questionnaires used to assess clinical teachers. DATA SOURCES: MEDLINE, EMBASE, PsycINFO and ERIC from 1976 up to March 2010. REVIEW METHODS: The searches revealed 54 papers on 32 instruments. Data from these papers were documented by independent researchers, using a structured format that included content of the instrument, validation methods, aims of the instrument, and its setting. RESULTS: Aspects covered by the instruments predominantly concerned the use of teaching strategies (included in 30 instruments), supporter role (29), role modeling (27), and feedback (26). Providing opportunities for clinical learning activities was included in 13 instruments. Most studies referred to literature on good clinical teaching, although they failed to provide a clear description of what constitutes a good clinical teacher. Instrument length varied from 1 to 58 items. Except for two instruments, all had to be completed by clerks/residents. Instruments served to provide formative feedback ( instruments) but were also used for resource allocation, promotion, and annual performance review (14 instruments). All but two studies reported on internal consistency and/or reliability; other aspects of validity were examined less frequently. CONCLUSIONS: No instrument covered all relevant aspects of clinical teaching comprehensively. Validation of the instruments was often limited to assessment of internal consistency and reliability. Available instruments for assessing clinical teachers should be used carefully, especially for consequential decisions. There is a need for more valid comprehensive instruments.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20703952&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20703952 [PubMed - as supplied by publisher]15: J Gen Intern Med. 2010 Aug 10; [Epub ahead of print]
Van Meter ME, McKee KY, Kohlwes RJ.
Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 10, Houston, TX, 77030-4009, USA, mevanmeter@mdanderson.org.
BACKGROUND: Malignant pleural effusions (MPE) are a frequent cause of dyspnea and discomfort at the end of cancer patients' lives. The tunneled indwelling pleural catheter (TIPC) was approved by the FDA in 1997 and has been investigated as a treatment for MPE. OBJECTIVE: To systematically review published data on the efficacy and safety of the TIPC for treatment of MPE. DESIGN: We searched the MEDLINE, EMBASE, and ISI Web of Science databases to identify studies published through October 2009 that reported outcomes in adult patients with MPE treated with a TIPC. Data were aggregated using summary statistics when outcomes were described in the same way among multiple primary studies. MAIN MEASURES: Symptomatic improvement and complications associated with use of the TIPC. KEY RESULTS: Nineteen studies with a total of 1,370 patients met criteria for inclusion in the review. Only one randomized study directly compared the TIPC with the current gold standard treatment, pleurodesis. All other studies were case series. Symptomatic improvement was reported in 628/657 patients (95.6%). Quality of life measurements were infrequently reported. Spontaneous pleurodesis occurred in 430/943 patients (45.6%). Serious complications were rare and included empyema in 33/1168 patients (2.8%), pneumothorax requiring a chest tube in 3/51 (5.9%), and unspecified pneumothorax in 17/439 (3.9%). Minor complications included cellulitis in 32/935 (3.4%), obstruction/clogging in 33/895 (3.7%) and unspecified malfunction of the catheter in 11/121 (9.1%). The use of the TIPC was without complication in 517/591 patients (87.5%). CONCLUSIONS: Based on low-quality evidence in the form of case series, the TIPC may improve symptoms for patients with MPE and does not appear to be associated with major complications. Prospective randomized studies comparing the TIPC to pleurodesis are needed before the TIPC can be definitively recommended as a first-line treatment of MPE.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20697963&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20697963 [PubMed - as supplied by publisher]16: Clin Invest Med. 2010 Aug 1;33(4):E240-53.
Choong K, Cupido C, Nelson E, Arnold DM, Burns K, Cook D, Meade M; ACCADEMY.
Department of Pediatrics and Critical Care, McMaster Children's Hospital, McMaster University, Hamilton, Ontario. choongk@mcmaster.ca
BACKGROUND: End-of-life decisions regarding the administration, withdrawal or withholding of life-sustaining therapy in the critical care setting can be challenging. Disagreements between health care providers and family members occur, especially when families believe strongly in preserving life, and physicians are resistant to providing medically "futile" care. Such disagreements can cause tension and moral distress among families and clinicians. PURPOSE: To outline the roles and responsibilities of physicians, substitute decision makers, and the judicial system when decisions must be made on behalf of incapable persons, and to provide a framework for conflict resolution during end-of-life decision-making for physicians practicing in Canada. SOURCE: We used a case-based example to illustrate our objectives. We employed a comprehensive approach to understanding end-of-life decision making that included: 1) a search for relevant literature; 2) a review of provincial college policies; 3) a review of provincial legislation on consent; 4) a consultation with two bioethicists and 5) a consultation with two legal experts in health law. PRINCIPAL FINDINGS: In Canada, laws about substitute decision-making for health care are primarily provincial or territorial. Thus, laws and policies from professional regulatory bodies on end-of-life care vary across the country. We tabulated the provincial college policies on end-of-life care and the provincial legislation on consent and advance directives, and constructed a 10-step approach to conflict resolution. CONCLUSION: Knowledge of underlying ethical principles, understanding of professional duties, and adoption of a process for mediation and conflict resolution are essential to ensuring that physicians and institutions act responsibly in maintaining a patients' best interests in the context of family-centred care.
Publication Types: Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20691142&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20691142 [PubMed - in process]17: Am J Clin Nutr. 2010 Aug 4; [Epub ahead of print]
Muhlhausler BS, Gibson RA, Makrides M.
School of Agriculture, Food, and Wine, The University of Adelaide, Adelaide, Australia.
BACKGROUND: n minus 3 (omega-3) Long-chain polyunsaturated fatty acids (LC-PUFAs) inhibit fat cell differentiation and fat storage in adults, and this has led to the hypothesis that maternal n minus 3 LC-PUFA supplementation may reduce fat mass in children. OBJECTIVE: The objective of this systematic review was to evaluate the effect of n minus 3 LC-PUFA supplementation in pregnancy or lactation on infant and child body composition in randomized controlled trials. DESIGN: MEDLINE and EMBASE databases were searched for relevant articles. Human trials that supplemented the maternal diet with n minus 3 LC-PUFAs during pregnancy or lactation and assessed either body fat mass or body mass index in children were included. Trials had to be randomized in design. The quality of all included studies was assessed against set criteria, and results of eligible trials were compared. RESULTS: There were only 3 human trials (4 publications) that met our inclusion criteria. There was considerable disparity in study design and trial quality. The results were variable and showed positive, negative, or neutral effects of maternal n minus 3 LP-PUFA supplementation on body fat mass in children. CONCLUSIONS: This systematic review highlights the paucity of robust data from human studies to evaluate the effect of increased n minus 3 LC-PUFA exposure during the perinatal period on body fat mass in the offspring. Further studies are required in which the intervention is confined to the perinatal period and that are sufficiently powered, have appropriate controls, have adequate blinding of participants and investigators, and have high retention rates.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20685946&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20685946 [PubMed - as supplied by publisher]18: JAMA. 2010 Aug 4;304(5):536-43.
Tiwari A, Fong DY, Yuen KH, Yuk H, Pang P, Humphreys J, Bullock L.
School of Nursing, The University of Hong Kong, 4/F, William MW Mong Block 21, Sassoon Road, Pokfulam, Hong Kong. afytiwar@hkucc.hku.hk
CONTEXT: Intimate partner violence (IPV) against women can have negative mental health consequences for survivors; however, the effect of interventions designed to improve survivors' depressive symptoms is unclear. OBJECTIVE: To determine whether an advocacy intervention would improve the depressive symptoms of Chinese women survivors of IPV. DESIGN, SETTING, AND PARTICIPANTS: Assessor-blinded randomized controlled trial of 200 Chinese women 18 years or older with a history of IPV, conducted from February 2007 to June 2009 in a community center in Hong Kong, China. INTERVENTION: The intervention group (n = 100) received a 12-week advocacy intervention comprising empowerment and telephone social support. The control group (n = 100) received usual community services including child care, health care and promotion, and recreational programs. MAIN OUTCOME MEASURES: Primary outcome was change in depressive symptoms (Chinese version of the Beck Depression Inventory II) between baseline and 9 months. Secondary outcomes were changes in IPV (Chinese Revised Conflict Tactics Scales), health-related quality of life (12-Item Short Form Health Survey), and perceived social support (Interpersonal Support Evaluation List) between baseline and 9 months. Usefulness of the intervention and usual community services was evaluated at 9 months. RESULTS: At 3 months, the mean change in depressive symptom score was 11.6 (95% CI, 9.5 to 13.7) in the control group and 14.9 (95% CI, 12.4 to 17.5) in the intervention group; respective changes at 9 months were 19.6 (95% CI, 16.6 to 22.7) and 23.2 (95% CI, 20.4 to 26.0). Intervention effects at 3 and 9 months were not significantly different (P = .86). The intervention significantly reduced depressive symptoms by 2.66 (95% CI, 0.26 to 5.06; P = .03) vs the control, less than the 5-unit minimal clinically important difference. Statistically significant improvement was found in partner psychological aggression (-1.87 [95% CI, -3.34 to -0.40]; mean change at 3 months, 1.5 [95% CI, -1.0 to 3.9] in the control group and 0.3 [95% CI, -0.7 to 1.4] in the intervention group; mean change at 9 months, -6.4 [95% CI, -7.8 to -5.0] and -8.9 [95% CI, -10.6 to -7.2]) and perceived social support (2.18 [95% CI, 0.48 to 3.89]; mean change at 3 months, 6.4 [95% CI, 4.9 to 7.8] and 9.2 [95% CI, 7.7 to 10.8]; mean change at 9 months, 12.4 [95% CI, 10.5 to 14.3] and 14.4 [95% CI, 12.7 to 16.1]) but not in physical assault, sexual coercion, or health-related quality of life. By end of study, more women in the intervention group found the advocacy intervention useful or extremely useful in improving intimate relationships vs those in the control group receiving usual community services (93.8% vs 81.7%; difference, 12.1% [95% CI, 2.1% to 22.0%]; P = .02) and in helping them to resolve conflicts with their intimate partners (97.5% vs 84.1%; difference, 13.4% [95% CI, 4.7% to 22.0%]; P = .001). CONCLUSION: Among community-dwelling abused Chinese women, an advocacy intervention did not result in a clinically meaningful improvement in depressive symptoms. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01054898.
Publication Types: Randomized Controlled Trial Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20682933&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20682933 [PubMed - indexed for MEDLINE]19: JAMA. 2010 Aug 4;304(5):527-35.
Walton MA, Chermack ST, Shope JT, Bingham CR, Zimmerman MA, Blow FC, Cunningham RM.
Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, USA. waltonma@umich.edu
CONTEXT: Emergency department (ED) visits present an opportunity to deliver brief interventions to reduce violence and alcohol misuse among urban adolescents at risk of future injury. OBJECTIVE: To determine the efficacy of brief interventions addressing violence and alcohol use among adolescents presenting to an urban ED. DESIGN, SETTING, AND PARTICIPANTS: Between September 2006 and September 2009, 3338 patients aged 14 to 18 years presenting to a level I ED in Flint, Michigan, between 12 pm and 11 pm 7 days a week completed a computerized survey (43.5% male; 55.9% African American). Adolescents reporting past-year alcohol use and aggression were enrolled in a randomized controlled trial (SafERteens). INTERVENTION: All patients underwent a computerized baseline assessment and were randomized to a control group that received a brochure (n = 235) or a 35-minute brief intervention delivered by either a computer (n = 237) or therapist (n = 254) in the ED, with follow-up assessments at 3 and 6 months. Combining motivational interviewing with skills training, the brief intervention for violence and alcohol included review of goals, tailored feedback, decisional balance exercise, role plays, and referrals. MAIN OUTCOME MEASURES: Self-report measures included peer aggression and violence, violence consequences, alcohol use, binge drinking, and alcohol consequences. RESULTS: About 25% (n = 829) of screened patients had positive results for both alcohol and violence; 726 were randomized. Compared with controls, participants in the therapist intervention showed self-reported reductions in the occurrence of peer aggression (therapist, -34.3%; control, -16.4%; relative risk [RR], 0.74; 95% confidence interval [CI], 0.61-0.90), experience of peer violence (therapist, -10.4%; control, +4.7%; RR, 0.70; 95% CI, 0.52-0.95), and violence consequences (therapist, -30.4%; control, -13.0%; RR, 0.76; 95% CI, 0.64-0.90) at 3 months. At 6 months, participants in the therapist intervention showed self-reported reductions in alcohol consequences (therapist, -32.2%; control, -17.7%; odds ratio, 0.56; 95% CI, 0.34-0.91) compared with controls; participants in the computer intervention also showed self-reported reductions in alcohol consequences (computer, -29.1%; control, -17.7%; odds ratio, 0.57; 95% CI, 0.34-0.95). CONCLUSION: Among adolescents identified in the ED with self-reported alcohol use and aggression, a brief intervention resulted in a decrease in the prevalence of self-reported aggression and alcohol consequences. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00251212.
Publication Types: Randomized Controlled Trial Research Support, N.I.H., Extramural
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20682932&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20682932 [PubMed - indexed for MEDLINE]20: Ann Intern Med. 2010 Aug 3;153(3):194-9.
Qaseem A, Snow V, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians.
American College of Physicians, Philadelphia, Pennsylvania 19106, USA. aqaseem@acponline.org
The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP's Guidelines Committee and the staff of the Clinical Programs and Quality of Care Department develop the clinical recommendations. The ACP develops 2 different types of clinical recommendations: clinical practice guidelines and clinical guidance statements. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading. All ACP clinical practice guidelines and clinical guidance statements, if not updated, are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Publication Types: Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20679562&dopt=ExternalLink
Translate in Italian, in French, in German, in Spanish, in Portuguese
PMID: 20679562 [PubMed - indexed for MEDLINE]