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Several clinical decision rules (CDRs) are available for evaluation of patients with possible pulmonary embolism (PE). It is not known which of these rules, if any, is best to use. In this multicenter, prospective study, 4 CDRs—the Wells rule, the revised Geneva score, and the simplified versions of these scores—were combined with the results of d-dimer testing to determine the likelihood of PE. The CDRs performed equally well in excluding PE or indicating the need for further testing.
Peripheral artery disease (PAD) is an important cause of morbidity and mortality that is known to be strongly associated with smoking in men. In women, the relationship of smoking to PAD risk is less well-described. In this large cohort study, smoking significantly increased risk for symptomatic PAD in women in a dose-dependent manner. Smokers who quit reduced their risk for PAD, but risk remained higher than that of never-smokers. Physicians should inform women that smoking increases their risk for PAD and that smoking cessation will reduce that risk.
Studies suggest that the Veterans Health Administration (VHA) provides better care for some chronic illnesses than does the private sector, but whether the same pattern exists for cancer diagnoses is uncertain. This observational study of men older than 65 years with cancer compared VHA patients with patients who had other types of insurance. Colorectal cancer was diagnosed at earlier stages in the VHA population, and adjusted rates of curative surgery for colon cancer, standard chemotherapy for diffuse large B-cell non-Hodgkin lymphoma, and bisphosphonate therapy for multiple myeloma were higher. The VHA population had lower adjusted rates of certain types of radiation therapy for prostate cancer. Adjusted rates were similar for 9 other measures.
This review provides a broad overview of the current state of stereotactic body radiation therapy (SBRT) for solid malignant tumors. Reviewers identified 124 relevant studies. No published comparative studies have addressed the relative effectiveness and safety of SBRT versus other external-beam radiation therapies. Stereotactic body radiation therapy seems to be widely diffused as a treatment of various types of cancer, although most studies have focused only on its use for treating thoracic tumors. Comparative studies are needed to provide evidence that the theoretical advantages of SBRT over other radiation therapies are seen in the clinical setting.
In July 2010, the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom released a guideline that addressed the diagnosis, prevention, and management of delirium. This article summarizes the main recommendations on prevention of delirium. Considering prevention a feasible and cost-effective health strategy, the guideline development group made 13 specific recommendations that addressed stability of the care environment (both the care team and location) and provision of a tailored, multicomponent intervention for persons at risk for delirium.
The National Clinical Guideline Centre (NCGC) develops evidence-based clinical guidelines on behalf of NICE. This article summarizes the main methods used in guideline development, including how topics are identified, who participates in the process, and how evidence from systematic reviews is used to form clinical recommendations.
The Department of Health in the United Kingdom has charged NICE to make recommendations that are based on both clinical effectiveness and cost-effectiveness. This article describes how cost-effectiveness is evaluated and accounted for in guidelines developed by the NCGC. Six recent case studies are presented, in which consideration of cost-effectiveness has informed recommendations for clinical guidelines on alcohol use disorders, chronic obstructive pulmonary disease, glaucoma, lower urinary tract symptoms, non–ST-segment elevation myocardial infarction and unstable angina, and venous thromboembolism prophylaxis.
As we come to the end of the third decade since AIDS was first recognized, the advances in our understanding of its pathophysiology, treatment, and prevention have been extraordinary. It is now time to focus on the challenges associated with controlling and ending the HIV/AIDS pandemic. Toward that end, AIDS researchers and public health personnel worldwide are aggressively pursuing 3 key areas of scientific research: efficient identification of HIV-infected individuals through voluntary testing and timely and appropriate initiation of antiretroviral therapy, a cure for HIV infection, and prevention of new infections.
In this issue, Keating and colleagues found that patients treated in the VHA for common types of cancer received the same or better quality of care than patients with Medicare coverage who were treated in the community. The editorialists view these findings about cancer care and previous findings about VHA care for chronic conditions as a poignant reminder that a national, integrated, government-run health care system can be successful.
In association with the publication of the summary of the NICE guidelines on dementia, the Editors discuss steps being taken at Annals of Internal Medicine to promote dissemination of high-quality guidelines. They review the recently released Institute of Medicine standards for clinical practice guidelines.
While reading e-mail message 39, I suddenly felt tears in my eyes; tears not for my patient, but for myself. I had chosen a career in medicine to dedicate myself to healing the lives of others, and before my training was even complete, I was dealing with the end of life, such as the one in message 38, on another Tuesday night.