This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.

Purpose: Lung cancer is a leading cause of cancer death worldwide. Although smoking remains the predominant cause of lung cancer, lung cancer in never smokers is an increasingly prominent public health issue. However, data on this topic, particularly lung cancer incidence rates in never smokers, are limited.

Methods: We reviewed the existing literature on lung cancer incidence and mortality rates among never smokers and present new data regarding rates in never smokers from the following large, prospective cohorts: Nurses' Health Study; Health Professionals Follow-Up Study; California Teachers Study; Multiethnic Cohort Study; Swedish Lung Cancer Register in the Uppsala/Orebro region; and First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study.

Results: Truncated age-adjusted incidence rates of lung cancer among never smokers age 40 to 79 years in these six cohorts ranged from 14.4 to 20.8 per 100,000 person-years in women and 4.8 to 13.7 per 100,000 person-years in men, supporting earlier observations that women are more likely than men to have non-smoking-associated lung cancer. The distinct biology of lung cancer in never smokers is apparent in differential responses to epidermal growth factor receptor inhibitors and an increased prevalence of adenocarcinoma histology in never smokers.

Conclusion: Lung cancer in never smokers is an important public health issue, and further exploration of its incidence patterns, etiology, and biology is needed.

Aim: This study compared matched samples of substance use disorder (SUD) patients in Swiss and United States (US) residential treatment programs and examined the relationship of program characteristics to patients' substance use and psychosocial functioning at a 1-year follow-up.

Design and Setting: The study used a prospective, naturalistic design and a sample of 10 public programs in the German-speaking part of Switzerland and 15 US public treatment programs.

Participants: A total of 358 male patients in Swiss programs were matched on age, marital status and education with 358 male patients in US programs. A total of 160 Swiss and 329 US patient care staff members also participated.

Measurement: Patients completed comparable inventories at admission, discharge and 1-year follow-up to assess their substance use and psychological functioning and receipt of continuing care. Staff members reported on program characteristics and their beliefs about substance use.

Findings: Compared to Swiss patients, US patients had more severe substance use and psychological problems at intake and although they did not differ on abstinence and remission at follow-up, had somewhat poorer outcomes in other areas of functioning. Swiss programs were longer and included more individual treatment sessions; US programs included more group sessions and were more oriented toward a disease model of treatment. Overall, length of program, treatment intensity and 12-step orientation were associated with better 1-year outcomes for patients in both Swiss and US programs.

Conclusions: The sample of Swiss and US programs studied here differed in patient and treatment characteristics; however, in general, there were comparable associations between program characteristics and patients' 1-year outcomes. These findings suggest that associations between treatment processes and patients' outcomes may generalize from one cultural context to another.

Although the quality of health care would logically seem to be a universal concept, this study hypothesized that physicians and their patients could differ in their perceptions of high-quality care and that those beliefs might vary by country. Such a mismatch in beliefs may be especially important as clinical practice guidelines developed in the United States are globalized.

A survey of 20 statements describing various components of health care delivery and quality was sent to pediatric cardiologists in 33 countries, who ranked the statements in order of priority for ideal health care. Each participating physician administered the questionnaire to the parents of children with congenital heart disease; 554 questionnaires were received and analyzed. A subanalysis of 9 countries with the largest number of responses was done (Canada, the Czech Republic, France, Germany, Italy, The Netherlands, Sweden, the United Kingdom, and the United States). Doctors and parents rated the same 4 statements among the top 5: the doctor is skillful and knowledgeable; the doctor explains health problems, tests, and treatments in a way the patient can understand; a basic level of healthcare is available to all citizens regardless of their ability to pay; and treatment causes the patient to feel physically well.

Overall, parents' responses differed more among countries than those of physicians; the magnitude of the difference between parents and physicians varied by country. This discrepancy highlights a potential mismatch between patients' and physicians' views about the desired components of health care delivery, in particular the application of American quality standards for health care to systems in other countries.

With continuing emigration from endemic countries, screening for parasitic infections remains a priority in U.S. communities serving refugee and immigrant populations. We report the prevalence of helminths and protozoa as well as demographic risk factors associated with these infections among 533 refugees seen at the Santa Clara County, California, Refugee Clinic between October 2001 and January 2004. Stool parasites were identified from 14% of refugees, including 9% found to have one or more protozoa and 6% found to have at least one helminth. Most common protozoan infections were Giardia lamblia (6%) and Dientamoeba fragilis (3%), and for helminths, hookworm (2%). Protozoa were more frequent in refugees 18 years of age (OR: 2.2 [1.2-4.2]), whereas helminths were more common in refugees from South Central Asia (OR: 8.0 [2.3-27.7]) and Africa (OR: 5.9 [1.6-21.6]) when compared with refugees from Eastern Europe and the Middle East. Among helminths, Ascaris lumbricoides and hookworm were concentrated among South Central Asians (6 of 7 and 10 of 11 cases, respectively), whereas Strongyloides stercoralis was predominantly found in Africans (5 of 7 cases). Although predeparture empirical treatment programs in Saharan Africa may have helped to reduce prevalence among arriving refugees from this region, parasitic infection is still common among refugees to the United States with helminth infections found in more specific populations. As refugees represent only a fraction of recent immigrants from endemic countries, current studies in nonrefugee groups are also needed.

BACKGROUND: Cervical-cancer screening strategies that involve the use of conventional cytology and require multiple visits have been impractical in developing countries. METHODS: We used computer-based models to assess the cost-effectiveness of a variety of cervical-cancer screening strategies in India, Kenya, Peru, South Africa, and Thailand. Primary data were combined with data from the literature to estimate age-specific incidence and mortality rates for cancer and the effectiveness of screening for and treatment of precancerous lesions. We assessed the direct medical, time, and program-related costs of strategies that differed according to screening test, targeted age and frequency, and number of clinic visits required. Single-visit strategies involved the assumption that screening and treatment could be provided in the same day. Outcomes included the lifetime risk of cancer, years of life saved, lifetime costs, and cost-effectiveness ratios (cost per year of life saved). RESULTS: The most cost-effective strategies were those that required the fewest visits, resulting in improved follow-up testing and treatment. Screening women once in their lifetime, at the age of 35 years, with a one-visit or two-visit screening strategy involving visual inspection of the cervix with acetic acid or DNA testing for human papillomavirus (HPV) in cervical cell samples, reduced the lifetime risk of cancer by approximately 25 to 36 percent, and cost less than 500 dollars per year of life saved. Relative cancer risk declined by an additional 40 percent with two screenings (at 35 and 40 years of age), resulting in a cost per year of life saved that was less than each country's per capita gross domestic product--a very cost-effective result, according to the Commission on Macroeconomics and Health. CONCLUSIONS: Cervical-cancer screening strategies incorporating visual inspection of the cervix with acetic acid or DNA testing for HPV in one or two clinical visits are cost-effective alternatives to conventional three-visit cytology-based screening programs in resource-poor settings.

Background:

Eight randomized trials have evaluated whether the prophylactic use of an implantable cardioverter-defibrillator (ICD) improves survival among patients who are at risk for sudden death due to left ventricular systolic dysfunction but who have not had a life-threatening ventricular arrhythmia. We assessed the cost-effectiveness of the ICD in the populations represented in these primary-prevention trials.

Methods:

We developed a Markov model of the cost, quality of life, survival, and incremental cost-effectiveness of the prophylactic implantation of an ICD, as compared with control therapy, among patients with survival and mortality rates similar to those in each of the clinical trials. We modeled the efficacy of the ICD as a reduction in the relative risk of death on the basis of the hazard ratios reported in the individual clinical trials.

Results:

Use of the ICD increased lifetime costs in every trial. Two trials - the Coronary Artery Bypass Graft (CABG) Patch Trial and the Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) - found that the prophylactic implantation of an ICD did not reduce the risk of death and thus was both more expensive and less effective than control therapy. For the other six trials - the Multicenter Automatic Defibrillator Implantation Trial (MADIT) I, MADIT II, the Multicenter Unsustained Tachycardia Trial (MUSTT), the Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) trial, the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial, and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)- the use of an ICD was projected to add between 1.01 and 2.99 quality-adjusted life-years (QALY) and between $68,300 and $101,500 in cost. Using base-case assumptions, we found that the cost-effectiveness of the ICD as compared with control therapy in these six populations ranged from $34,000 to $70,200 per QALY gained. Sensitivity analyses showed that this cost-effectiveness ratio would remain below $100,000 per QALY as long as the ICD reduced mortality for seven or more years.

Conclusions:

Prophylactic implantation of an ICD has a cost-effectiveness ratio below $100,000 per QALY gained in populations in which a significant device-related reduction in mortality has been demonstrated.

Adherence to (or compliance with) a medication regimen is generally defined as the extent to which patients take medications as prescribed by their health care providers. The word "adherence" is preferred by many health care providers, because "compliance" suggests that the patient is passively following the doctor's orders and that the treatment plan is not based on a therapeutic alliance or contract established between the patient and the physician. Both terms are imperfect and uninformative descriptions of medication-taking behavior. Unfortunately, applying these terms to patients who do not consume every pill at the desired time can stigmatize these patients in their future relationships with health care providers. The language used to describe how patients take their medications needs to be reassessed, but these terms are still commonly used.1 Regardless of which word is preferred, it is clear that the full benefit of the many effective medications that are available will be achieved only if patients follow prescribed treatment regimens reasonably closely.