Annals of internal medicine
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Comparative Study
A decision analysis of mandatory compared with voluntary HIV testing in pregnant women.
The benefit of antiretroviral therapy in reducing maternal-fetal transmission of HIV during pregnancy has caused a public policy debate about the relative benefits of mandatory HIV screening and voluntary HIV screening in pregnant women. ⋯ The most important variables in the model were voluntary HIV testing, the deterrence rate associated with mandatory testing compared with voluntary testing, and the prevalence of HIV infection in women of child-bearing age. At high levels of acceptance of voluntary HIV testing, the benefits of a policy of mandatory testing are minimal and may create the potential harms of avoiding prenatal care to avoid mandatory testing.
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Transesophageal echocardiography visualizes the left atrium and its appendage, thrombi, and spontaneous echocardiographic contrast. ⋯ In outpatients with atrial fibrillation and without recent stroke, thrombi of the left atrium or left atrial appendage and length and width of the left atrial appendage were associated with stroke or embolism in univariate analysis. In a multivariate analysis, age, hypertension, and previous stroke were risk factors for stroke or embolism, and thrombi of the left atrium or left atrial appendage were possible risk factors. In these patients, history may be more useful than transesophageal echocardiography for the assessment of embolic risk.
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Randomized Controlled Trial Clinical Trial
Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography.
Transesophageal echocardiography (TEE) visualizes potential sources of embolism in patients with atrial fibrillation, but the clinical significance of TEE findings has not been prospectively established. ⋯ In high-risk patients with atrial fibrillation, subsequent rates of thromboembolism are correlated with dense spontaneous echocardiographic contrast, thrombus of the atrial appendage, and aortic plaque. Adjusted-dose warfarin reduces the rate of stroke among patients with dense contrast and complex plaque. In patients with atrial fibrillation, the pathogenesis of stroke is multifactorial, and warfarin seems effective for the diverse mechanisms.
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Patients' loved ones often make end-of-life treatment decisions, but the accuracy of their substituted judgments and the factors associated with accuracy are poorly understood. ⋯ The accuracy of substituted judgments is associated with multiple clinically apparent patient and surrogate factors. This information can help clinicians identify conditions under which substituted judgments are likely to be accurate or inaccurate and can help target populations for education designed to improve the accuracy of surrogate decision making.