Q&A

This evaluation of the use of enzyme-linked immunosorbent assay (ELISA) D-dimer test in routine clinical practice supports other evidence that the assay has a high sensitivity to exclude pulmonary embolism in patient populations in which there is clinical suspicion. Nevertheless, the assay incorrectly excluded the diagnosis of pulmonary embolism in 2 cases.

Other examples of clinical decision-making exist for which the acceptable negative predictive value for screening is set at 100%—eg, the diagnosis of phenylketonuria in newborns.

Physicians who do not want to miss cases of acute pulmonary embolism when they clinically suspect the diagnosis should not rely solely on negative D-dimer assay results when the value to rule out the diagnosis is set at 500 ng/mL. If a lower value is used to define normal—eg, 250 ng/mL, as used in other studies—no cases of acute pulmonary embolism would have been missed in this group of patients. Regardless of the cutoff used, the assay will yield many false-positive results.

This evaluation of the use of enzyme-linked immunosorbent assay (ELISA) D-dimer test in routine clinical practice supports other evidence that the assay has a high sensitivity to exclude pulmonary embolism in patient populations in which there is clinical suspicion. Nevertheless, the assay incorrectly excluded the diagnosis of pulmonary embolism in 2 cases.

Other examples of clinical decision-making exist for which the acceptable negative predictive value for screening is set at 100%—eg, the diagnosis of phenylketonuria in newborns.

Physicians who do not want to miss cases of acute pulmonary embolism when they clinically suspect the diagnosis should not rely solely on negative D-dimer assay results when the value to rule out the diagnosis is set at 500 ng/mL. If a lower value is used to define normal—eg, 250 ng/mL, as used in other studies—no cases of acute pulmonary embolism would have been missed in this group of patients. Regardless of the cutoff used, the assay will yield many false-positive results.

This evaluation of the use of enzyme-linked immunosorbent assay (ELISA) D-dimer test in routine clinical practice supports other evidence that the assay has a high sensitivity to exclude pulmonary embolism in patient populations in which there is clinical suspicion. Nevertheless, the assay incorrectly excluded the diagnosis of pulmonary embolism in 2 cases.

Other examples of clinical decision-making exist for which the acceptable negative predictive value for screening is set at 100%—eg, the diagnosis of phenylketonuria in newborns.

Physicians who do not want to miss cases of acute pulmonary embolism when they clinically suspect the diagnosis should not rely solely on negative D-dimer assay results when the value to rule out the diagnosis is set at 500 ng/mL. If a lower value is used to define normal—eg, 250 ng/mL, as used in other studies—no cases of acute pulmonary embolism would have been missed in this group of patients. Regardless of the cutoff used, the assay will yield many false-positive results.

Women with diabetes mellitus should not be screened or treated for asymptomatic bacteriuria. Unlike other clinical conditions in which screening for asymptomatic urinary tract infection (UTI) has proved valuable (pregnancy, urologic surgery, renal transplantation), women with diabetes derive no meaningful benefit. Previous recommendations by the US Preventive Services Task Force neither recommended for or against screening or treatment of asymptomatic bacteriuria in diabetic women.

Women with diabetes mellitus should not be screened or treated for asymptomatic bacteriuria. Unlike other clinical conditions in which screening for asymptomatic urinary tract infection (UTI) has proved valuable (pregnancy, urologic surgery, renal transplantation), women with diabetes derive no meaningful benefit. Previous recommendations by the US Preventive Services Task Force neither recommended for or against screening or treatment of asymptomatic bacteriuria in diabetic women.

Women with diabetes mellitus should not be screened or treated for asymptomatic bacteriuria. Unlike other clinical conditions in which screening for asymptomatic urinary tract infection (UTI) has proved valuable (pregnancy, urologic surgery, renal transplantation), women with diabetes derive no meaningful benefit. Previous recommendations by the US Preventive Services Task Force neither recommended for or against screening or treatment of asymptomatic bacteriuria in diabetic women.

Celecoxib is as effective as other nonsteroidal anti-inflammatory drugs (NSAIDs) for treating the symptoms of osteoarthritis or rheumatoid arthritis. However, patients taking celecoxib are less likely to discontinue the medication because of gastrointestinal upset than patients taking traditional NSAIDs. Nevertheless, celecoxib does not decrease the incidence of serious gastrointestinal adverse events with long-term therapy.

Celecoxib is as effective as other nonsteroidal anti-inflammatory drugs (NSAIDs) for treating the symptoms of osteoarthritis or rheumatoid arthritis. However, patients taking celecoxib are less likely to discontinue the medication because of gastrointestinal upset than patients taking traditional NSAIDs. Nevertheless, celecoxib does not decrease the incidence of serious gastrointestinal adverse events with long-term therapy.

Celecoxib is as effective as other nonsteroidal anti-inflammatory drugs (NSAIDs) for treating the symptoms of osteoarthritis or rheumatoid arthritis. However, patients taking celecoxib are less likely to discontinue the medication because of gastrointestinal upset than patients taking traditional NSAIDs. Nevertheless, celecoxib does not decrease the incidence of serious gastrointestinal adverse events with long-term therapy.

Under optimal conditions, tissue plasminogen activator (tPA) may be a viable option for treatment of acute ischemic stroke; however, this study showed that protocol is not adhered to in practice and that these protocol deviations are associated with increased mortality and other adverse events. Based on these findings, tPA should not be used in routine clinical practice to treat acute stroke until individual hospitals develop protocols to guarantee the medication’s appropriate use.

Under optimal conditions, tissue plasminogen activator (tPA) may be a viable option for treatment of acute ischemic stroke; however, this study showed that protocol is not adhered to in practice and that these protocol deviations are associated with increased mortality and other adverse events. Based on these findings, tPA should not be used in routine clinical practice to treat acute stroke until individual hospitals develop protocols to guarantee the medication’s appropriate use.

Under optimal conditions, tissue plasminogen activator (tPA) may be a viable option for treatment of acute ischemic stroke; however, this study showed that protocol is not adhered to in practice and that these protocol deviations are associated with increased mortality and other adverse events. Based on these findings, tPA should not be used in routine clinical practice to treat acute stroke until individual hospitals develop protocols to guarantee the medication’s appropriate use.

Despite lack of research on the effectiveness of osteoporosis screening to reduce fractures, there is sufficient evidence that bone density measurements accurately predict short-term fracture risk and that treating asymptomatic women with osteoporosis reduces fracture risk.

According to this report, a reasonable recommendation is to screen all women older than 65 years and postmenopausal women younger than 65 years who have low weight (or body mass index) or who have never used hormone replacement therapy.¹

The US Preventive Services Task Force noted that the optimal screening frequency has not been studied, but suggested a frequency of not more than every 2 years for older women or every 5 years for younger postmenopausal women. Also of note: other sources, notably the bisphosphonates package labeling, advise against monitoring therapy with repeated dual-energy x-ray absorptiometry or other methods.

Despite lack of research on the effectiveness of osteoporosis screening to reduce fractures, there is sufficient evidence that bone density measurements accurately predict short-term fracture risk and that treating asymptomatic women with osteoporosis reduces fracture risk.

According to this report, a reasonable recommendation is to screen all women older than 65 years and postmenopausal women younger than 65 years who have low weight (or body mass index) or who have never used hormone replacement therapy.¹

The US Preventive Services Task Force noted that the optimal screening frequency has not been studied, but suggested a frequency of not more than every 2 years for older women or every 5 years for younger postmenopausal women. Also of note: other sources, notably the bisphosphonates package labeling, advise against monitoring therapy with repeated dual-energy x-ray absorptiometry or other methods.

Despite lack of research on the effectiveness of osteoporosis screening to reduce fractures, there is sufficient evidence that bone density measurements accurately predict short-term fracture risk and that treating asymptomatic women with osteoporosis reduces fracture risk.

According to this report, a reasonable recommendation is to screen all women older than 65 years and postmenopausal women younger than 65 years who have low weight (or body mass index) or who have never used hormone replacement therapy.¹

The US Preventive Services Task Force noted that the optimal screening frequency has not been studied, but suggested a frequency of not more than every 2 years for older women or every 5 years for younger postmenopausal women. Also of note: other sources, notably the bisphosphonates package labeling, advise against monitoring therapy with repeated dual-energy x-ray absorptiometry or other methods.

The herpes simplex virus (HSV) type-2 vaccine studied here prevented genital herpes only in women who were seronegative for HSV-1 and HSV-2 at baseline. Ten of these women would need to be vaccinated to prevent 1 case of genital herpes. The vaccine did not prevent infection with HSV-2 in these women. It did not prevent genital herpes in women with other HSV serologic status or in men.

The usefulness of this vaccine is limited by the small subgroup in which it is efficacious. Determining which women fall into this subgroup could prove costly. It is possible that asymptomatic infected persons may spread HSV more readily. Emphasis on the use of condoms and antiviral agents should still be the first line in preventing the spread of genital herpes.

The herpes simplex virus (HSV) type-2 vaccine studied here prevented genital herpes only in women who were seronegative for HSV-1 and HSV-2 at baseline. Ten of these women would need to be vaccinated to prevent 1 case of genital herpes. The vaccine did not prevent infection with HSV-2 in these women. It did not prevent genital herpes in women with other HSV serologic status or in men.

The usefulness of this vaccine is limited by the small subgroup in which it is efficacious. Determining which women fall into this subgroup could prove costly. It is possible that asymptomatic infected persons may spread HSV more readily. Emphasis on the use of condoms and antiviral agents should still be the first line in preventing the spread of genital herpes.

The herpes simplex virus (HSV) type-2 vaccine studied here prevented genital herpes only in women who were seronegative for HSV-1 and HSV-2 at baseline. Ten of these women would need to be vaccinated to prevent 1 case of genital herpes. The vaccine did not prevent infection with HSV-2 in these women. It did not prevent genital herpes in women with other HSV serologic status or in men.

The usefulness of this vaccine is limited by the small subgroup in which it is efficacious. Determining which women fall into this subgroup could prove costly. It is possible that asymptomatic infected persons may spread HSV more readily. Emphasis on the use of condoms and antiviral agents should still be the first line in preventing the spread of genital herpes.

In patients with unstable angina and non–ST segment myocardial infarction treated with aspirin, heparin, and tirofiban, an early invasive strategy with routine angiography and appropriate revascularization has better clinical outcomes, at a relatively minimal increase in cost.

In patients with unstable angina and non–ST segment myocardial infarction treated with aspirin, heparin, and tirofiban, an early invasive strategy with routine angiography and appropriate revascularization has better clinical outcomes, at a relatively minimal increase in cost.

In patients with unstable angina and non–ST segment myocardial infarction treated with aspirin, heparin, and tirofiban, an early invasive strategy with routine angiography and appropriate revascularization has better clinical outcomes, at a relatively minimal increase in cost.

Hand lacerations less than 2 cm long without tendon, joint, fracture, or nerve complications and not involving the nail bed can be cleaned and dressed without suturing, with similar cosmetic results and time to resume normal activities. Moreover, managing these uncomplicated hand lacerations conservatively could result in better use of medical resources and improved patient satisfaction due to less pain and less time spent in the emergency department.

Hand lacerations less than 2 cm long without tendon, joint, fracture, or nerve complications and not involving the nail bed can be cleaned and dressed without suturing, with similar cosmetic results and time to resume normal activities. Moreover, managing these uncomplicated hand lacerations conservatively could result in better use of medical resources and improved patient satisfaction due to less pain and less time spent in the emergency department.

Hand lacerations less than 2 cm long without tendon, joint, fracture, or nerve complications and not involving the nail bed can be cleaned and dressed without suturing, with similar cosmetic results and time to resume normal activities. Moreover, managing these uncomplicated hand lacerations conservatively could result in better use of medical resources and improved patient satisfaction due to less pain and less time spent in the emergency department.

For now, a reasonable strategy is to consider watchful waiting as an acceptable alternative to radical prostatectomy for patients with early prostate cancer and a lifespan of less than 10 years. For other patients, discuss the benefits and risks of the treatment options, balancing expected side effects of the operation and the impact of other illnesses on survival with the possible benefit of the operation or other kinds of treatment.

We still lack sufficient evidence whether early detection by PSA screening can reduce morbidity or mortality.

In this study, radical prostatectomy for early prostate cancer decreased disease-specific mortality, but did not improve overall mortality. A companion study¹ showed that non–nerve-sparing radical prostatectomy yielded no difference in subjective quality of life, although clinically important increases in erectile dysfunction (number needed to harm [NNH]=3) and urinary leakage (NNH=4) did occur, compared with watchful waiting.

Clinicians should understand that these results might not apply to patients with highly undifferentiated cancer; patients identified by screening to have elevated prostate-specific antigen (PSA) concentrations and no clinically symptomatic disease; or patients with significant comorbidities.

For now, a reasonable strategy is to consider watchful waiting as an acceptable alternative to radical prostatectomy for patients with early prostate cancer and a lifespan of less than 10 years. For other patients, discuss the benefits and risks of the treatment options, balancing expected side effects of the operation and the impact of other illnesses on survival with the possible benefit of the operation or other kinds of treatment.

We still lack sufficient evidence whether early detection by PSA screening can reduce morbidity or mortality.

In this study, radical prostatectomy for early prostate cancer decreased disease-specific mortality, but did not improve overall mortality. A companion study¹ showed that non–nerve-sparing radical prostatectomy yielded no difference in subjective quality of life, although clinically important increases in erectile dysfunction (number needed to harm [NNH]=3) and urinary leakage (NNH=4) did occur, compared with watchful waiting.

Clinicians should understand that these results might not apply to patients with highly undifferentiated cancer; patients identified by screening to have elevated prostate-specific antigen (PSA) concentrations and no clinically symptomatic disease; or patients with significant comorbidities.

For now, a reasonable strategy is to consider watchful waiting as an acceptable alternative to radical prostatectomy for patients with early prostate cancer and a lifespan of less than 10 years. For other patients, discuss the benefits and risks of the treatment options, balancing expected side effects of the operation and the impact of other illnesses on survival with the possible benefit of the operation or other kinds of treatment.

We still lack sufficient evidence whether early detection by PSA screening can reduce morbidity or mortality.

In this study, radical prostatectomy for early prostate cancer decreased disease-specific mortality, but did not improve overall mortality. A companion study¹ showed that non–nerve-sparing radical prostatectomy yielded no difference in subjective quality of life, although clinically important increases in erectile dysfunction (number needed to harm [NNH]=3) and urinary leakage (NNH=4) did occur, compared with watchful waiting.

Clinicians should understand that these results might not apply to patients with highly undifferentiated cancer; patients identified by screening to have elevated prostate-specific antigen (PSA) concentrations and no clinically symptomatic disease; or patients with significant comorbidities.

Empiric treatment of women with minimally abnormal Papanicolaou smears (limited by inflammation, benign, or reactive cellular changes) with 0.75% metronidazole vaginal gel is ineffective in yielding a higher rate of reversion to normal cytology when compared with no treatment.

Empiric treatment of women with minimally abnormal Papanicolaou smears (limited by inflammation, benign, or reactive cellular changes) with 0.75% metronidazole vaginal gel is ineffective in yielding a higher rate of reversion to normal cytology when compared with no treatment.

Empiric treatment of women with minimally abnormal Papanicolaou smears (limited by inflammation, benign, or reactive cellular changes) with 0.75% metronidazole vaginal gel is ineffective in yielding a higher rate of reversion to normal cytology when compared with no treatment.