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Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians

July 1, 2014 Comments off

Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians
Source: Annals of Internal Medicine

Description:
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the utility of screening pelvic examination for the detection of pathology in asymptomatic, nonpregnant, adult women.

Methods:
This guideline is based on a systematic review of the published literature in the English language from 1946 through January 2014 identified using MEDLINE and hand-searching. Evaluated outcomes include morbidity; mortality; and harms, including overdiagnosis, overtreatment, diagnostic procedure–related harms, fear, anxiety, embarrassment, pain, and discomfort. The target audience for this guideline includes all clinicians, and the target patient population includes asymptomatic, nonpregnant, adult women. This guideline grades the evidence and recommendations using the ACP’s clinical practice guidelines grading system.

Recommendation:
ACP recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women (strong recommendation, moderate-quality evidence).

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Ready or Not: Responding to Measles in the Postelimination Era

May 16, 2014 Comments off

Ready or Not: Responding to Measles in the Postelimination Era
Source: Annals of Internal Medicine

Although endemic measles was eliminated in the United States in 2000, two concurrent measles outbreaks at opposite ends of the country offer a sobering reminder of the threat of this global disease. As more parents decline to vaccinate their children, measles incidence is increasing—a fact that alarms me both as a hospital epidemiologist and as a parent of a vulnerable infant too young to receive the measles vaccine. Because infected patients are likely to seek medical care, hospitals and clinics may inadvertently fuel transmission if those with measles are not rapidly triaged and isolated. Yet, because of the success of the measles vaccine, many clinicians have never seen measles and may not be able to recognize its features. It is crucial that providers become familiar with this deadly disease and apply the necessary control measures to contain it.

Primary Care Behavioral Interventions to Reduce Illicit Drug and Nonmedical Pharmaceutical Use in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

May 7, 2014 Comments off

Primary Care Behavioral Interventions to Reduce Illicit Drug and Nonmedical Pharmaceutical Use in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement
Source: Annals of Internal Medicine

Description:
Update of the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for illicit drug use.

Methods:
The USPSTF reviewed the evidence on interventions to help adolescents who have never used drugs to remain abstinent and interventions to help adolescents who are using drugs but do not meet criteria for a substance use disorder to reduce or stop their use.

Population:
This recommendation applies to children and adolescents younger than age 18 years who have not been diagnosed with a substance use disorder.

Recommendation:
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents. (I statement)

Reducing Firearm-Related Injuries and Deaths in the United States: Executive Summary of a Policy Position Paper From the American College of Physicians

April 10, 2014 Comments off

Reducing Firearm-Related Injuries and Deaths in the United States: Executive Summary of a Policy Position Paper From the American College of Physicians
Source: Annals of Internal Medicine

Firearm violence is not only a criminal justice issue but also a public health threat. A comprehensive, multifaceted approach is necessary to reduce the burden of firearm-related injuries and deaths on individuals, families, communities, and society in general. Strategies to reduce firearm violence will need to address culture, substance use and mental health, firearm safety, and reasonable regulation, consistent with the Second Amendment, to keep firearms out of the hands of persons who intend to use them to harm themselves and others, as well as measures to reduce mass casualties associated with certain types of firearms.

As an organization representing physicians who have first-hand experience with the devastating impact firearm-related injuries and deaths have on the health of their patients, the ACP has a responsibility to participate in efforts to mitigate these needless tragedies. Because patients trust their physicians to advise them on issues that affect their health, physicians can help to educate the public on the risks of firearms and the need for firearm safety through their encounters with their patients. This Executive Summary provides a synopsis of the full position paper, which is available in Appendix 1.

The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-analysis

February 24, 2014 Comments off

The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-analysis
Source: Annals of Internal Medicine

Background:
Research suggests that access to firearms in the home increases the risk for violent death.

Purpose:
To understand current estimates of the association between firearm availability and suicide or homicide.

Data Sources:
PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and Web of Science were searched without limitations and a gray-literature search was performed on 23 August 2013.

Study Selection:
All study types that assessed firearm access and outcomes between participants with and without firearm access. There were no restrictions on age, sex, or country.

Data Extraction:
Two authors independently extracted data into a standardized, prepiloted data extraction form.

Data Synthesis:
Odds ratios (ORs) and 95% CIs were calculated, although published adjusted estimates were preferentially used. Summary effects were estimated using random- and fixed-effects models. Potential methodological reasons for differences in effects through subgroup analyses were explored. Data were pooled from 16 observational studies that assessed the odds of suicide or homicide, yielding pooled ORs of 3.24 (95% CI, 2.41 to 4.40) and 2.00 (CI, 1.56 to 3.02), respectively. When only studies that used interviews to determine firearm accessibility were considered, the pooled OR for suicide was 3.14 (CI, 2.29 to 4.43).

Limitations:
Firearm accessibility was determined by survey interviews in most studies; misclassification of accessibility may have occurred. Heterogeneous populations of varying risks were synthesized to estimate pooled odds of death.

Conclusion:
Access to firearms is associated with risk for completed suicide and being the victim of homicide.

Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force

December 18, 2013 Comments off

Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force
Source: Annals of Internal Medicine

Background: Vitamin and mineral supplements are commonly used to prevent chronic diseases.

Purpose: To systematically review evidence for the benefit and harms of vitamin and mineral supplements in community-dwelling, nutrient-sufficient adults for the primary prevention of cardiovascular disease (CVD) and cancer.

Data Sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects were searched from January 2005 to 29 January 2013, with manual searches of reference lists and gray literature.

Study Selection: Two investigators independently selected and reviewed fair- and good-quality trials for benefit and fair- and good-quality trials and observational studies for harms.

Data Extraction: Dual quality assessments and data abstraction.

Data Synthesis: Two large trials (n = 27 658) reported lower cancer incidence in men taking a multivitamin for more than 10 years (pooled unadjusted relative risk, 0.93 [95% CI, 0.87 to 0.99]). The study that included women showed no effect in that group. High-quality studies (k = 24; n = 324 653) of single and paired nutrients (such as vitamins A, C, or D; folic acid; selenium; or calcium) were scant and heterogeneous and showed no clear evidence of benefit or harm. Neither vitamin E nor β-carotene prevented CVD or cancer, and β-carotene increased lung cancer risk in smokers.

Limitations: The analysis included only primary prevention studies in adults without known nutritional deficiencies. Studies were conducted in older individuals and included various supplements and doses under the set upper tolerable limits. Duration of most studies was less than 10 years.

Conclusion: Limited evidence supports any benefit from vitamin and mineral supplementation for the prevention of cancer or CVD. Two trials found a small, borderline-significant benefit from multivitamin supplements on cancer in men only and no effect on CVD.

Prescription Drug Abuse: A Policy Position Paper From the American College of Physicians

December 10, 2013 Comments off

Prescription Drug Abuse: A Policy Position Paper From the American College of Physicians
Source: Annals of Internal Medicine

Prescription drug abuse is found throughout all aspects of the U.S. population and is a serious public health problem. Physicians and other health professionals with prescribing privileges are entrusted with the authority to use medications in the treatment of their patients and therefore have an important role in helping to ensure safe and effective use of this treatment option and the deterrence of its abuse. This paper is intended to provide guidance to prescribers and policymakers regarding measures to effectively address the problem of prescription drug abuse and offers the following recommendations:

1. ACP supports appropriate and effective efforts to reduce all substance abuse. These include educational, prevention, diagnostic, and treatment efforts. As physicians dealing with the health effects of this condition, we also support medical research on addiction and its causes and treatment.

2. ACP supports a comprehensive national policy on prescription drug abuse containing education, monitoring, proper disposal, and enforcement elements.

3. ACP supports the consideration by physicians of the full array of treatments available for the effective treatment and management of pain.

4. ACP supports the establishment of a national Prescription Drug Monitoring Program (PDMP). Until such a program is implemented, ACP supports efforts to standardize state PDMPs through the federal National All Schedules Prescription Electronic Reporting (NASPER) program. Prescribers and dispensers should check PDMPs in their own and neighboring states (as permitted) prior to writing or filling prescriptions for medications containing controlled substances. All PDMPs should maintain strong protections to assure confidentiality and privacy.

5. ACP supports efforts to educate physicians, patients, and the public on the appropriate medical uses of controlled drugs and the dangers of both medical and nonmedical use of prescription drugs.

6. ACP favors a balanced approach to permit safe and effective medical treatment utilizing controlled substances and efforts to reduce prescription drug abuse. However, educational, documentation, and treatment requirements toward this goal should not impose excessive administrative burdens on prescribers or dispensers.

7. ACP recognizes that defined maximum dosage (i.e., morphine equivalent) and duration of therapy limitations are not applicable to every clinical encounter. ACP favors establishment of evidence-based, nonbinding guidelines regarding recommended maximum dosage and duration of therapy that a patient taking controlled substance medications may receive.

8. Patients identified by Medicare, Medicaid, private insurance plans, or law enforcement authorities as being at significant risk of prescription drug abuse may be required to participate in a drug monitoring program and undergo random drug testing. Physicians may be required to report suspected cases of drug abuse, but should not be mandated to conduct random drug testing without the patient’s consent. The financial cost of mandatory drug testing should be borne by the authority requiring the testing; neither the patient nor the physician should bear the financial cost of random drug testing mandated by a third-party authority.

9. ACP recommends the consideration of patient-provider treatment agreements between physician and patients as a tool for the treatment of pain.

10. ACP recommends the passage of legislation by all 50 states permitting electronic prescription for controlled substances.

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