JAMA : the journal of the American Medical Association
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While clinical guidelines are considered an important mechanism to improve the quality of medical care, problems with implementation may limit their effectiveness. Few empirical data exist about the effect of computer-based systems for application of clinical guidelines on quality of care. ⋯ Use of a computer-based system for clinical guidelines for management of patients with occupational exposure to body fluids improved documentation, compliance with guidelines, and percentage of charges spent on indicated activities, while decreasing overall charges. The parameters returned to baseline when the computer system was removed.
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In recent decades, there has been a rapid and substantial increase in tobacco consumption in China, particularly by men, but little is known from local epidemiologic studies about the pattern of smoking-related deaths. ⋯ Cigarette smoking is already a major cause of death in China, and among middle-aged Shanghai men, about 20% of all deaths during the 1980s were due to smoking. The excess was greatest among men who began smoking before the age of 25 years, about 47% of whom would, at 1987 mortality rates, die between the ages of 35 and 69 years (compared with only 29% of nonsmokers). These estimates reflect the consequences of past smoking patterns. The future health effects of current smoking patterns are likely to be greater because of the recent large increase in cigarette consumption, particularly at younger ages, in China.
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This article analyzes judicial determinations on the "right to die" from Quinlan to Cruzan, Glucksberg, and Vacco. The body of law known as right-to-die cases extends ordinary treatment refusal doctrine to end-of-life decisions. The courts, having affirmed a right to refuse life-sustaining treatment, held that certain categorical distinctions that had been drawn lacked a rational basis. ⋯ Notably, five members of the Court wrote or joined in concurring opinions that took a more liberal view. The Court powerfully approved aggressive palliation of pain. The Supreme Court, hinting that it would find state legalization of physician-assisted suicide constitutional, invited the nation to pursue an earnest debate on physician assistance in the dying process.
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An underappreciated characteristic of prostate cancer screening is that it may detect some prostate cancers solely by serendipity or chance. Serendipity, previously described in the detection of colonic neoplasms, could affect prostate cancer detection when a screening test result is abnormal for reasons other than the presence of prostate cancer, but prostate cancer is coincidentally detected during the subsequent evaluation of the abnormal screening result. We reviewed published articles about prostate cancer screening, searching for evidence of serendipity. ⋯ Whether serendipity is advantageous in prostate cancer screening depends on the as yet uncertain outcomes for men with smaller prostate cancers. However, given our estimates of the potential magnitude of the impact of serendipity, the currently popular DRE- and PSA-based screening strategy may not be optimal. If smaller prostate cancers are important, then we are not finding enough; if they are unimportant, then we are finding too many that we may feel compelled to treat aggressively.