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Proteína Morfogenética Ósea 2/efectos adversos , Proteína Morfogenética Ósea 2/uso terapéutico , Conflicto de Intereses , Industria Farmacéutica , Degeneración del Disco Intervertebral/cirugía , Sesgo de Publicación , Fusión Vertebral , Factor de Crecimiento Transformador beta/efectos adversos , Factor de Crecimiento Transformador beta/uso terapéutico , Humanos , Proteínas Recombinantes/efectos adversos , Proteínas Recombinantes/uso terapéuticoAsunto(s)
Armas de Fuego/legislación & jurisprudencia , Rol del Médico , Salud Pública , Violencia , Humanos , Estados UnidosAsunto(s)
Manejo de la Enfermedad , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/terapia , Síndrome Coronario Agudo/epidemiología , Antagonistas Adrenérgicos beta/administración & dosificación , Consumo de Bebidas Alcohólicas , Angina de Pecho/tratamiento farmacológico , Peso Corporal , LDL-Colesterol/sangre , Clopidogrel , Comorbilidad , Costo de Enfermedad , Depresión/tratamiento farmacológico , Depresión/epidemiología , Complicaciones de la Diabetes/diagnóstico , Complicaciones de la Diabetes/terapia , Electrocardiografía , Ejercicio Físico/fisiología , Prueba de Esfuerzo , Hemoglobina Glucada/análisis , Conductas Relacionadas con la Salud , Humanos , Hipertensión/prevención & control , Estilo de Vida , Infarto del Miocardio/prevención & control , Isquemia Miocárdica/tratamiento farmacológico , Isquemia Miocárdica/economía , Isquemia Miocárdica/epidemiología , Revascularización Miocárdica , Examen Físico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Inhibidores de Agregación Plaquetaria/uso terapéutico , Guías de Práctica Clínica como Asunto , Calidad de Vida , Medición de Riesgo , Factores de Riesgo , Conducta de Reducción del Riesgo , Cese del Hábito de Fumar , Ticlopidina/administración & dosificación , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéuticoRESUMEN
The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic. The information contained herein should never be used as a substitute for clinical judgment. CME OBJECTIVE: To review strategies to evaluate and reduce perioperative risk.
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Pruebas Diagnósticas de Rutina , Complicaciones Intraoperatorias/prevención & control , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios , Humanos , Medición de Riesgo , Factores de RiesgoRESUMEN
BACKGROUND: Accurate measurement of people's risk perceptions is important for numerous bodies of research and in clinical practice, but there is no consensus about the best measure. OBJECTIVE: This study evaluated three measures of women's breast cancer risk perception by assessing their psychometric and test characteristics. DESIGN: A cross-sectional mailed survey to women from a primary care population asked participants to rate their chance of developing breast cancer in their lifetime on a 0% to 100% numerical scale and a verbal scale with five descriptive categories, and to compare their risk to others (seven categories). Six hundred three of 956 women returned the survey (63.1%), and we analyzed surveys from the 566 women without a self-reported personal history of breast or ovarian cancer. RESULTS: Scores on the numeric, verbal, and comparative measures were correlated with each other (r > 0.50), worry (r > 0.51), the Gail estimate (r > 0.26), and family history (r > 0.25). The numerical scale had the strongest correlation with annual mammogram (r = 0.19), and its correlation with the Gail estimate was unassociated with participants' sociodemographics. The numerical and comparative measures had the highest sensitivity (0.89-0.90) and specificity (0.99) for identifying women with very high risk perception. The numerical and comparative scale also did well in identifying women with very low risk perception, although the numerical scale had the highest specificity (0.96), whereas the comparative scale had the highest sensitivity (0.89). CONCLUSION: Different measures of women's perceptions about breast cancer risk have different strengths and weaknesses. Although the numerical measure did best overall, the optimal measure depends on the goals of the measure (i.e., avoidance of false positives or false negatives).
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Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/psicología , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/diagnóstico por imagen , Estudios Transversales , Errores Diagnósticos , Femenino , Humanos , Mamografía , Persona de Mediana Edad , Percepción , Philadelphia , Psicometría , Reproducibilidad de los Resultados , Proyectos de Investigación , Medición de Riesgo , Factores de Riesgo , Autorrevelación , Sensibilidad y Especificidad , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To determine whether racial differences in hospital mortality worsened after implementation of a New Jersey law in 1993 that reduced subsidies for uninsured hospital care and changed hospital payment from rate regulation to price competition. DATA SOURCES/STUDY SETTING: State discharge data for New Jersey and New York from 1990 to 1996. STUDY DESIGN: We used an interrupted time series design to compare risk-adjusted in-hospital mortality rates between states over time. Adjusting for patient characteristics, baseline interstate differences, and common intertemporal trends, we compared the effect sizes for whites and blacks in the following 4 groups: overall, uninsured, insured under age 65, and Medicare patients. DATA COLLECTION/EXTRACTION METHODS: The study sample included 1,357,394 patients admitted to New Jersey or New York hospitals between 1990 to 1996 with stroke, hip fracture, pneumonia, pulmonary embolism, congestive heart failure, or acute myocardial infarction (AMI). PRINCIPAL FINDINGS: The increase in mortality in New Jersey versus New York was significantly larger among blacks than among whites for AMI (2.4% points vs 0.1% points, P-value for difference .026) but not for the other 6 conditions. In groupings of conditions for which hospital admission is non-discretionary and conditions in which admission is discretionary, we found qualitatively larger increases in mortality for blacks but no statistically significant racial differences among patients overall, uninsured patients, insured patients under age 65, or Medicare patients. CONCLUSIONS: Market-based reform and reductions in subsidies for hospital care for the uninsured in New Jersey were associated with worsening racial disparities in in-hospital mortality for AMI but not for 6 other common conditions.
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Población Negra , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/tendencias , Mortalidad Hospitalaria/tendencias , Población Blanca , Humanos , New Jersey , New YorkRESUMEN
OBJECTIVE: To determine whether hospital mortality rates changed in New Jersey after implementation of a law that changed hospital payment from a regulated system based on hospital cost to price competition with reduced subsidies for uncompensated care and whether changes in mortality rates were affected by hospital market conditions. DATA SOURCES/STUDY SETTING: State discharge data for New Jersey and New York from 1990 to 1996. Study Design. We used an interrupted time series design to compare risk-adjusted in-hospital mortality rates between states over time. We compared the effect sizes in markets with different levels of health maintenance organization penetration and hospital market concentration and tested the sensitivity of our results to different approaches to defining hospital markets. DATA COLLECTION/EXTRACTION METHODS: The study sample included all patients under age 65 admitted to New Jersey or New York hospitals with stroke, hip fracture, pneumonia, pulmonary embolism, congestive heart failure, hip fracture, or acute myocardial infarction (AMI). PRINCIPAL FINDINGS: Mortality among patients in New Jersey improved less than in New York by 0.4 percentage points among the insured (p=.07) and 0.5 percentage points among the uninsured (p=.37). There was a relative increase in mortality for patients with AMI, congestive heart failure, and stroke, especially for uninsured patients with these conditions, but not for patients with the other four conditions we studied. Less competitive hospital markets were significantly associated with a relative decrease in mortality among insured patients. CONCLUSIONS: Market-based reforms may adversely affect mortality for some conditions but it appears the effects are not universal. Insured patients in less competitive markets fared better in the transition to price competition.
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Competencia Económica , Reforma de la Atención de Salud/economía , Mortalidad Hospitalaria , Calidad de la Atención de Salud , Atención no Remunerada/economía , Adulto , Sector de Atención de Salud , Mortalidad Hospitalaria/tendencias , Humanos , Cobertura del Seguro , Modelos Lineales , Persona de Mediana Edad , New Jersey/epidemiología , New York/epidemiología , Ajuste de RiesgoRESUMEN
In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the second of 2 that provide guidance on the management of patients with chronic stable angina. This document covers treatment and follow-up of symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A previous guideline covered diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months and asymptomatic patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests.
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Angina de Pecho/terapia , Enfermedad de la Arteria Coronaria/terapia , Atención Primaria de Salud , Angina de Pecho/tratamiento farmacológico , Enfermedad Crónica , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Muerte Súbita Cardíaca/prevención & control , Humanos , Monitoreo Fisiológico , Infarto del Miocardio/prevención & controlRESUMEN
In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which the ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the first of 2 that will provide guidance on the management of patients with chronic stable angina. This document will cover diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on history or on electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A future guideline will cover pharmacologic therapy and follow-up.
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Angina de Pecho/diagnóstico , Angina de Pecho/etiología , Enfermedad de la Arteria Coronaria/diagnóstico , Angina de Pecho/fisiopatología , Enfermedad Crónica , Enfermedad de la Arteria Coronaria/complicaciones , Humanos , Atención Primaria de Salud , Medición de Riesgo , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
The purpose of this study was to measure the effects of social and economic variables, disease-related variables, and child gender on the decisions of parents in Kerala, India, to seek care for their children and on their choice of providers in the allopathic vs. the alternative system. A case-control analysis was done using data from the Kerala section of the 1996 Indian National Family Health Survey, a cross-sectional survey of a probability sample of households conducted by trained interviewers with a close-ended questionnaire. Of the 469 children who were eligible for this study because they had at least one common symptom suggestive of acute respiratory illness or diarrhea during the 2 weeks before the interview, 78 (17%) did not receive medical care, while the remaining 391 (83%) received medical care. Of the 391 children who received medical care, 342 (88%) received allopathic medical care, and 48 (12%) received alternative medical care. In multivariable analyses, parents chose not to seek medical care for their children significantly more often when the illness was mild, the child had a specific diagnosis, the mother had previously made fewer antenatal visits, and the family had a higher economic status. When parents sought medical care for their children, care was sought significantly more often in the alternative provider system when the child was a boy, the family lived in a rural area, and the family had a lower social class. We conclude that, in Kerala, disease severity and economic status predict whether children with acute respiratory infection or diarrhea are taken to medical providers. In contrast, most studies of this issue carried out in other populations have identified economic status as the primary predictor of medical system utilization. Also in Kerala, the gender of the child did not influence whether or not the child was taken for treatment but did influence whether care was sought in the alternative or the allopathic system.