Journal of general internal medicine
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Sedative-hypnotics are frequently prescribed for insomnia in hospital but are associated with preventable harms. ⋯ A sedative-hypnotic reduction quality improvement bundle implemented across 5 hospitals was associated with a sustained reduction in sedative-hypnotic prescriptions.
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Review
What Constitutes Evidence? Colorectal Cancer Screening and the U.S. Preventive Services Task Force.
The United States Preventive Services Task Force is perhaps America's best-known source of evidence-based medicine (EBM) recommendations. This paper reviews aspects of the history of one such recommendation-screening for colorectal cancer (CRC)-to explore how the Task Force evaluates the best available evidence to reach its conclusions. Although the Task Force initially believed there was inadequate evidence to recommend CRC screening in the 1980s, it later changed its mind. ⋯ In declining to extrapolate in this instance, the Task Force underscored the lack of reliable data that proved that the benefits of such testing would outweigh the harms. The history of CRC screening reminds us that scientific evaluation relies not only on methodological sophistication but also on a combination of intellectual, cognitive and social processes. General internists-and their patients-should realize that EBM recommendations are often not definitive but rather thoughtful data-based advice.
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Lung cancer screening (LCS) for former and current smokers requires that current smokers are counseled on tobacco treatment. In the USA, over 4 million former smokers are estimated to be eligible for LCS based on self-report for "not smoking now." Tobacco use and exposure can be measured with the biomarker cotinine, a nicotine metabolite reflecting recent exposure. ⋯ Former smokers eligible for LCS should be asked about recent tobacco use and exposure and considered for cotinine testing. Nearly 1.5 million "former smokers" eligible for LCS may be current tobacco users who have been missed for counseling. The high percentage of "passive smokers" is at least double that of the general nonsmoking population. Counseling about the harms of tobacco use and exposure and resources is needed.
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Anticoagulation poses unique challenges for women of reproductive age. Clinicians prescribing anticoagulants must counsel patients on issues ranging from menstruation and the possibility of developing a hemorrhagic ovarian cyst to teratogenic risks and safety with breastfeeding. Abnormal uterine bleeding affects up to 70% of young women who are treated with anticoagulation. ⋯ During pregnancy, enoxaparin remains the preferred anticoagulant and warfarin is contraindicated. Breastfeeding women may use warfarin, but direct oral anticoagulants are not recommended given their limited safety data. This practical guide for clinicians is designed to inform discussions of risks and benefits of anticoagulation therapy for women of reproductive age.
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Racial/ethnic disparities in anticoagulation management are well established. Differences in warfarin monitoring can contribute to these disparities and should be measured. ⋯ We did not find a race/ethnicity nor language disparity in INR monitoring; safety-net site was the main source of variation.