IMPROVING PATIENT CARE
M.E. Beth Smith, DO; Annette Totten, PhD; David H. Hickam, MD, MPH; Rongwei Fu, PhD; Ngoc Wasson, MPH; Basmah Rahman, MPH; Makalapua Motu’apuaka, BS; Somnath Saha, MD, MPH
Disclaimer: The findings and conclusions in this article are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this article should be construed as an official position of AHRQ, the U.S. Department of Health and Human Services, or the U.S. Department of Veterans Affairs.
Acknowledgment: The authors thank Robin Paynter, MLIS; Leah Williams, BS; Alexander Ginsburg, MA; Elaine Graham, MLS; Sujata Thakurta, MA; Bernadette Zakher, MBBS; Susan Carson, MPH; and AHRQ Task Order Officer, Christine Chang, MD.
Grant Support: By AHRQ (contract 290-2007-10057-I, Task Order 8). Dr. Saha is supported by the U.S. Department of Veterans Affairs.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2182.
Requests for Single Reprints: M.E. Beth Smith, DO, Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Smith, Totten, Hickman, Fu, and Saha, Ms. Wasson, Ms. Rahman, and Ms. Motu’apuaka: Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098.
Author Contributions: Conception and design: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, S. Saha.
Analysis and interpretation of the data: M.E.B. Smith, A. Totten, D.H. Hickam, R. Fu, N. Wasson, S. Saha.
Drafting of the article: M.E.B. Smith, D.H. Hickam, N. Wasson, B. Rahman, S. Saha.
Critical revision of the article for important intellectual content: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, S. Saha.
Final approval of the article: M.E.B. Smith, A. Totten, N. Wasson, B. Rahman, S. Saha.
Provision of study materials or patients: D.H. Hickam, N. Wasson, M. Motu’apuaka.
Statistical expertise: R. Fu, N. Wasson.
Administrative, technical, or logistic support: N. Wasson, B. Rahman, M. Motu’apuaka.
Collection and assembly of data: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, B. Rahman, M. Motu’apuaka, S. Saha.
Smith MB, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, et al. Pressure Ulcer Treatment Strategies: A Systematic Comparative Effectiveness Review. Ann Intern Med. 2013;159:39-50. doi: 10.7326/0003-4819-159-1-201307020-00007
Download citation file:
Published: Ann Intern Med. 2013;159(1):39-50.
Pressure ulcers affect as many as 3 million Americans and are major sources of morbidity, mortality, and health care costs.
To summarize evidence comparing the effectiveness and safety of treatment strategies for adults with pressure ulcers.
MEDLINE, EMBASE, CINAHL, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database for English- or foreign-language studies; reference lists; gray literature; and individual product packets from manufacturers (January 1985 to October 2012).
Randomized trials and comparative observational studies of treatments for pressure ulcers in adults and noncomparative intervention series (n > 50) for surgical interventions and evaluation of harms.
Data were extracted and evaluated for accuracy of the extraction, quality of included studies, and strength of evidence.
174 studies met inclusion criteria and 92 evaluated complete wound healing. In comparison with standard care, placebo, or sham interventions, moderate-strength evidence showed that air-fluidized beds (5 studies [n = 908]; high consistency), protein-containing nutritional supplements (12 studies [n = 562]; high consistency), radiant heat dressings (4 studies [n = 160]; moderate consistency), and electrical stimulation (9 studies [n = 397]; moderate consistency) improved healing of pressure ulcers. Low-strength evidence showed that alternating-pressure surfaces, hydrocolloid dressings, platelet-derived growth factor, and light therapy improved healing of pressure ulcers. The evidence about harms was limited.
Applicability of results is limited by study quality, heterogeneity in methods and outcomes, and inadequate duration to assess complete wound healing.
Moderate-strength evidence shows that healing of pressure ulcers in adults is improved with the use of air-fluidized beds, protein supplementation, radiant heat dressings, and electrical stimulation.
Agency for Healthcare Research and Quality.
Pressure ulcers affect 3 million adults in the United States. Healing rates, which are dependent on comorbid conditions, clinical interventions, and ulcer severity, vary. Ulcer severity is assessed using various staging or grading systems, but the National Pressure Ulcer Advisory Panel staging system is most commonly used (Figure 1) (1). Ulcers can range from stage I with intact skin to stage IV with full-thickness tissue loss and exposed bone, tendon, or muscle. They can also be described as unstageable when the base of a full-thickness ulcer is covered with slough or as suspected deep-tissue injury when the skin is intact but the underlying tissue has evidence of damage. Comorbid conditions predisposing pressure ulcer development and affecting ulcer healing include those affecting patient mobility (such as spinal cord injury), wound environments (such as incontinence), and wound healing (such as diabetes and vascular disease). Delayed healing can add to the length of hospitalization, impede return to full functioning (2), and require long-term care. Cost estimates for pressure ulcer treatment range between $37 800 and $70 000 per ulcer, with total annual costs in the United States as high as $11 billion (1, 3).
National Pressure Ulcer Advisory Panel pressure ulcer stages.
Pressure ulcer stages I to IV and the 2 additional categories of suspected deep-tissue injury and unstageable are defined. National Pressure Ulcer Advisory Panel copyright; photos used with permission. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
* Not pictured.
Pressure ulcer treatment involves various approaches, including interventions to treat the conditions that lead to pressure ulcers (support surfaces and nutritional support), interventions to protect and promote healing of the ulcer (wound dressings; topical applications; and various adjunctive therapies, such as electrical stimulation, light therapy, and vacuum-assisted devices), and surgical repair of the ulcer (1, 3). Treatments for pressure ulcers have been described and evaluated with varying degrees of rigor and completeness (3, 4) with continued uncertainty around the best treatment options. The purpose of this review is to examine the comparative effectiveness and harms of therapies and approaches to treating pressure ulcers (5). Common terms used in this article are defined in the Glossary.
We followed a standard protocol for systematic reviews and developed an analytic framework with input from key informants (clinicians, wound care researchers, and patient advocates) to answer the following key questions: In adults with pressure ulcers, what is the comparative effectiveness of treatment strategies for improved health outcomes, including but not limited to complete wound healing, healing time, reduced wound size, pain, and prevention of serious complications of infection? What are the harms of treatments for pressure ulcers? See Figure 2 for more details.
Analytic framework of pressure ulcer treatment strategies.
From reference 5.
We also attempted to discern whether the balance of benefits and harms of treatment options varied according to characteristics of the pressure ulcer, patient, or setting in which care was delivered. We met regularly throughout the review with members of a technical expert panel, some of whom served as key informants during the development phase, to oversee the clinical applicability, content completeness, and methodological rigor of the review process.
The population comprises adults with pressure ulcers. Interventions include support surfaces; nutritional supplements; local wound applications (including wound dressings, topical therapies, and biological agents); surgical procedures; and various adjunctive therapies with comparators of standard wound care, placebo, or sham therapy. In some cases, alternative treatment options were compared. At the recommendation of our technical expert panel, complete wound healing was considered the most clinically important outcome, but we also included other measures of wound improvement, such as reduction in ulcer size or rate of change over time, pain, and prevention of serious complications. Harms of therapy included but were not limited to pain, dermatologic complications, bleeding, and infection.
We searched for relevant English- and foreign-language studies and systematic reviews in MEDLINE, EMBASE, CINAHL, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, gray literature, scientific information packets, and reference lists. Given the technological advancement in treatment interventions, we restricted our search to January 1985 to October 2012 to find studies of current relevance.
We included randomized trials and comparative observational studies of treatments for pressure ulcers in adults. We included noncomparative intervention series (n > 50) for surgical interventions and evaluation of harms. Exclusion criteria were wrong population (children; adolescents; and patients with non–pressure-related ulcers, including but not limited to venous ulcers and diabetic foot ulcers), studies of interventions without comparators, hospice care settings unless complete wound healing was an outcome measured, and case reports.
At least 2 investigators independently evaluated each study to determine inclusion eligibility. Disagreement was settled by consensus or adjudication by a senior investigator when consensus could not be reached.
From the included studies, details of the patient population, study design, analysis, follow-up, and results were extracted by a team member and reviewed for accuracy and completeness by an investigator. For comparability across studies, when possible, ulcer stage or grade was translated to the corresponding stage as defined by the National Pressure Ulcer Advisory Panel (Appendix Table 1). Investigators rated the quality (risk of bias) of the individual studies and strength of the body of evidence, and results were reviewed by at least 1 other investigator for accuracy, with disagreements being settled by consensus (6–8). We used an approach adapted from the Agency for Healthcare Research and Quality (AHRQ) Methods Guide for Effectiveness and Comparative Effectiveness Reviews (9) for determining the strength of evidence as “high,” “moderate,” “low,” or “insufficient” on the basis of the design, quantity, size, and quality (risk of bias) of studies, consistency across studies, precision of estimates and directness of evidence.
Appendix Table 1. Stages of Pressure Ulcer Equivalency
Data were synthesized qualitatively with attention to characteristics, such as ulcer grade and location, patient characteristics and settings, and risk of bias of individual studies.
We conducted meta-analyses in selected instances for comparisons examining the outcome of complete wound healing where the number, quality, and homogeneity of studies permitted. We chose to limit meta-analysis to the outcome of complete wound healing because this was the principal health outcome of interest and because of the wide variability in the measurement of other outcomes, including reduction in wound size. When a meta-analysis was conducted, we used relative risk as the effect measure. We assessed the presence of statistical heterogeneity among the studies using standard chi-square tests and the magnitude of heterogeneity using the I2 statistic (10). We used random-effects models to account for variation among studies (11) and fixed-effects Mantel–Haenszel models when variation among studies was estimated to be zero. Sensitivity analysis was conducted to assess the effect of quality on combined estimates, and meta-regression was conducted to assess the association of effect measure with study duration. All quantitative analyses were done using STATA, version 11.0 (StataCorp, College Station, Texas).
This research was funded by AHRQ. The draft report was reviewed by content experts, AHRQ program officers, and collaborative partners. Investigators worked with AHRQ staff to develop and refine the scope, analytic framework, and key questions; resolve issues arising during the project; and review the final report to ensure methodological standards for systematic reviews were met. The complete report (5), including the list of included and excluded studies, can be found at www.effectivehealthcare.ahrq.gov. The AHRQ had no role in study selection, quality assessment, synthesis, or development of conclusions. The investigators are solely responsible for the content and the decision to submit the manuscript for publication.
The results of the search and study selection are shown in Appendix Figure 1. We reviewed 7149 abstracts and titles and 1846 full-text articles; we found 174 studies (182 full-text articles) that met our inclusion criteria. Gray literature was assessed but did not provide additional results. Study quality was generally poor, sample sizes were small, and follow-up was frequently too short to assess complete wound healing.
Summary of evidence search and selection.
Full-text articles that were reviewed include additional studies identified through other sources, hand-searches of reference lists, peer review and public comment, scientific information packets, and gray literature searches. Quality-of-life outcomes and results related to histologic outcomes are in the full report (5) but not included in this article.
The overall findings and strength of the evidence are summarized in the Table and Appendix Table 2, and the risk-of-bias assessments for individual studies are summarized in the Supplement. We found data on the outcomes of complete wound healing and wound improvement, including reduction in wound size, rate of change over time, or change in ulcer stage, but not on outcomes of pain and prevention of serious complications. Most studies enrolled older hospital patients and long-term care residents with stage II to IV pressure ulcers, although some studies enrolled younger, neurologically impaired adults. When available, we reported on whether the effectiveness of interventions varied according to characteristics of the pressure ulcer, patient, or setting in which care was delivered, but in general, few studies conducted subgroup analysis and data were insufficient to draw any conclusions in these subgroups.
Table. Summary of Evidence of Benefits and Harms of Pressure Ulcer Treatment Strategies
Appendix Table 2. Summary of Evidence of Differences of Intervention Effectiveness
We found 24 studies (21 trials and 3 observational studies) that provided evidence on various support surfaces, including air-fluidized beds, alternating-pressure beds and chair cushions, and low–air-loss beds. Of these, 4 were rated good-quality, 10 as fair-quality, and 10 as poor-quality. Eight studies evaluated the outcome of complete wound healing (12–19). No differences were found in complete wound healing when comparing types of support surfaces. We found moderate-strength evidence that wound improvement (including rate of reduction in wound size and ulcer stage) was superior with air-fluidized beds, although they were most often compared with standard hospital beds rather than other advanced support surfaces. This was based on 5 studies with highly consistent results (20–24). Healing was similar between alternating-pressure mattresses and other support surfaces (19, 25–27) (low-strength evidence), and different types of alternating-pressure mattresses provided similar benefit (moderate-strength evidence) (12, 13, 28–31). Evidence about the effectiveness of alternating-pressure seat cushions was insufficient because only 2 studies with very different populations were identified (32, 33). We found low-strength evidence that low–air-loss beds are similar to foam surfaces or foam mattresses (4 studies) (15, 17, 33, 34), and wound healing did not differ when comparing low–air-loss beds with low–air-loss overlays (1 study) (35). Most studies of support surfaces were older and compared these surfaces with standard care that may not be considered high-quality care today.
We found 16 studies (11 trials and 5 observational studies) that addressed nutritional support, including protein-containing nutritional supplementation and specific nutrient supplementation with vitamins or minerals, such as ascorbic acid (vitamin C) or zinc. Three trials were rated good-quality (36–38), 2 were fair-quality (39, 40), and 6 were poor-quality (41–46). Four observational studies were rated fair-quality (47–50), and 1 was poor-quality (51). Eight studies considered the outcome of complete wound healing (36, 38–42, 46, 48).
Although the formulations varied greatly, most of the 12 studies of protein supplementation found greater reduction in ulcer size with supplementation than without, but not more complete wound healing. Because of the small number of head-to-head trials, the existing evidence base does not clarify whether any specific type of protein supplementation is superior to others. Low-strength evidence indicated no benefits in wound healing with vitamin C based on 1 good-quality study (n = 88) (37). Evidence about zinc supplementation was insufficient to draw conclusions (49).
We identified 89 original studies that examined the effectiveness of local wound applications for pressure ulcers in 7115 patients. Seventy-six of the original studies were clinical trials. Of these, 11 were rated good-quality, 20 were fair-quality, and 45 were poor-quality. Sample sizes ranged from 10 to 168 patients. There were 13 observational studies. One cohort study was rated fair-quality, and the other observational studies were poor-quality. Fifty-nine studies addressed the outcome of complete wound healing (52–111). No differences were found in complete wound healing when comparing types of local wound applications.
We found 10 studies (1 good-quality , 2 fair-quality [53, 54], and 7 poor-quality [55–59, 112, 113]) that compared hydrocolloid with gauze dressings and provided low-strength evidence indicating greater reduction in wound size with hydrocolloid dressings. Statistical heterogeneity precluded quantitative pooling of results across these studies. Complete wound healing was equivalent with hydrocolloid and foam dressings (pooled relative risk, 1.12 [95% CI, 0.88 to 1.41]; I2 = 16.4%; P = 0.301) (8 studies; moderate-strength evidence) (72–79). Radiant heat dressings produced more rapid reduction in wound size than other dressings based on moderately consistent results from 2 good-quality and 2 fair-quality trials, but there was no evidence of benefit in terms of complete wound healing (pooled relative risk, 1.23 [CI, 0.70 to 2.14]; I2 = 0.0%; P = 0.916) (83–86). Evidence about the comparative effectiveness of other dressing types was insufficient.
The most commonly evaluated topical therapies were debriding enzymes (primarily collagenase), phenytoin solution, dextranomer paste, and collagen applications. Low-strength evidence showed that dextranomer is less effective than other wound dressings based on 1 good-quality trial (114) and 1 poor-quality trial (115). Evidence about enzymes and phenytoin was inconsistent and insufficient to draw conclusions. Collagen applications did not seem to provide wound-healing benefit compared with standard care, based on low-strength evidence from 1 good-quality (116) and 2 poor-quality (95, 117) trials. The most commonly evaluated biological agent was platelet-derived growth factor, for which 1 fair-quality (110) and 3 poor-quality (103, 107, 118, 119) studies provided low-strength evidence of benefit compared with placebo in promoting healing of severe (stage III or IV) ulcers. Evidence about the effectiveness of other biological agents was insufficient.
Surgical interventions for pressure ulcers identified in studies that met our inclusion criteria were primarily surgical flaps (most commonly myocutaneous and fasciocutaneous flaps). One poor-quality trial (120) and 5 fair-quality intervention series (121–125), including 1094 pressure ulcers in 647 patients, provided evidence on the effectiveness of surgical techniques to treat stage III or IV pressure ulcers. We found low-strength evidence for a lower rate of ulcer recurrence with sacral ulcers than ischial ulcers, a higher rate of recurrent ulcer among patients with spinal cord injuries than among others, and greater wound dehiscence rates with surgeries in which bone was removed. Because of heterogeneity in patient populations and surgical procedures, there was insufficient evidence that 1 approach to closure of stage III or IV pressure ulcers was superior to another.
Thirty-four trials (3 good-quality, 29 fair-quality, and 2 poor-quality) and 5 observational studies (2 fair-quality and 3 poor-quality) that evaluated adjunctive therapies met our inclusion criteria. Adjunctive therapies identified in our review included electrical stimulation, electromagnetic therapy, therapeutic ultrasound, negative-pressure wound therapy, hydrotherapy, light therapy, and laser therapy. Evidence about other adjunctive therapies—including vibration, shock wave, and hyperbaric oxygen—was limited to small, single studies that provided insufficient evidence for comparative effectiveness conclusions. Seventeen studies addressed the outcome of complete wound healing (126–142). Moderately consistent results from 1 good-quality (126) and 8 fair-quality (127–131, 143–145) trials showed that electrical stimulation improved healing rates (moderate-strength evidence) but evidence about the effect of electrical stimulation on complete wound healing was insufficient because of heterogeneous findings across studies.
Low-strength evidence showed that light therapies provided benefit in terms of reduced wound size but not complete wound healing (139, 140, 146–148). There was also low-strength evidence that electromagnetic therapy (132, 133, 149, 150), therapeutic ultrasound (135–137), negative-pressure wound therapy (138, 151, 152), and laser therapy (137, 142, 153) were no different from sham treatment or standard care in wound-healing outcomes. There was insufficient evidence to draw conclusions about hydrotherapy (152, 154).
The reported harms of support surface options were minimal, although harms were infrequently and inconsistently reported in studies of this option.
There was insufficient evidence to adequately describe the harms of nutritional supplementation in this patient population.
Moderate-strength evidence from 36 studies showed that the most common harms of wound dressings and topical agents were dermatologic complications, including irritation, inflammation, and maceration. However, variability across studies precluded an estimate of adverse events for specific dressings or topical therapies, and evidence was insufficient to determine whether certain types of dressings or topical therapies were more likely to cause these complications than others. Few harms were reported with biological agents, but the evidence about the harms of these agents was insufficient to reach conclusions about adverse event rates.
We found low-strength evidence that more adverse events occur with surgery for ischial ulcers than for sacral or trochanteric ulcers (121, 122). Surgical flap failures requiring reoperation ranged from 12% to 24% (121, 124).
Low-strength evidence showed that the most common adverse effect of electrical stimulation was local skin irritation and that harms were more common in frail elderly populations than in younger populations (126–128). There was insufficient evidence to evaluate the harms of electromagnetic therapy, therapeutic ultrasound, negative-pressure wound therapy, and hydrotherapy. Light (139, 140, 146–148) and laser (137, 141, 142, 153) therapy were not associated with substantial adverse events on the basis of low-strength evidence.
There was insufficient evidence to draw any other conclusions about the effectiveness or harms of interventions based on features of the pressure ulcers, characteristics of the patient, or features of the patient care setting.
We identified 174 studies that addressed the comparative effectiveness and harms of pressure ulcer treatment and found moderate-strength evidence that air-fluidized beds, protein-containing nutritional supplements, radiant heat dressings, and electrical stimulation improved healing of pressure ulcers. Alternating-pressure surfaces, platelet-derived growth factor, hydrocolloid dressings, and light therapy may also improve healing, although the evidence was more limited and of low strength. Dermatologic reaction was noted with several local wound applications and adjunctive therapies, but in general evidence about the harms of treatments was limited.
Our review expands on previous systematic reviews by including observational studies, surgical interventions, and evaluation of harms of treatment and by extending the search to October 2012 (4). Our findings are qualitatively similar to those of other studies, with the exception of the benefit of air-fluidized surfaces and lack of evidence of benefit with electromagnetic therapy. Because the most comprehensive systematic review was published in 2008, 4 additional studies on air-fluidized surfaces were available and led to our finding of moderate-strength evidence that air-fluidized beds were more effective than other surfaces, primarily standard hospital beds, in reducing wound size. Few trials compared air-fluidized beds with other advanced support surfaces, precluding strong conclusions about comparative effectiveness. Our findings were consistent with a recent update on support surfaces by the Cochrane Collaboration (155, 156). The Cochrane review also reported some benefit from the use of sheepskins, but this finding was based on a study excluded from our review because it was published in 1964. The authors of this review concluded, as we did, that the evidence base was weak, with small studies that had serious methodological limitations. Our finding of no significant wound improvement with electromagnetic therapy is also consistent with a previous Cochrane review (157) but inconsistent with others that commented on a trend toward an improved healing rate (4, 158, 159). The clinical significance of this trend remains unknown.
The applicability of our findings to real-world clinical settings is supported by the broad representation of patients with pressure ulcers cared for in various settings with interventions representing most of the therapeutic methods commonly used. However, several other features limit applicability of this review. These include the frequent use of the surrogate outcome of reduction in wound size rather than complete wound healing and that, in practice, the treatment of pressure ulcers is typically multimodal and often involves the sequential use of different therapies. Most studies were of poor- to fair-quality; small; underpowered to detect statistically significant differences; and highly variable in patient populations, ulcer characteristics (for example, anatomical site, duration, and stage), interventions (even within a given intervention category, such as different types of foam dressings), and comparators (especially in implementation of standard, or usual, care), which limited our ability to combine or compare results across studies. Studies of surgery are also limited in that most were observational and conducted in 1 center or a few centers at most. Because surgical technique and quality are often operator- or site-dependent and outcomes are influenced by local practices, staffing, and other features of the environment, it is difficult to generalize our findings for surgical interventions.
Implications for clinical and policy decision making are difficult to generate from our review, given the limitations in applicability, potential influence of selective reporting and publication bias, and lack of high-strength evidence, with most of our findings being based on low-strength or insufficient evidence. Future studies are needed with larger sample sizes, more rigorous adherence to methodological standards, information about cointerventions, standardization of comparators, and longer follow-up to allow for clinically meaningful outcome measures, including complete wound healing. Similarly, stratification of findings by patient characteristics (for example, comorbid conditions and ulcer stage) would help determine the applicability of different interventions for specific patients and situations. It is particularly important for future studies to report findings according to ulcer stage because the rate of healing, conditions necessary to promote healing, and treatment choices may differ for partial- and full-thickness ulcers.
We found limited evidence for better wound healing with air-fluidized beds, protein supplementation, radiant heat dressings, and electrical stimulation than with standard care, placebo, or sham interventions. However, the benefit seen in all cases was reduction in wound size or better healing rates rather than completely healed wounds. In addition, there was low-strength or insufficient evidence about treatment harms, and the balance of benefits versus costs and harms for pressure ulcer therapies remains unclear. Advancing pressure ulcer care will require more rigorous study to solidify the evidence base for this widely used, and needed, set of treatments.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only