American Academy of Family unit Physicians

Twenty Things Physicians and Patients Should Question

Released April iv, 2012 (i–v), February 21, 2013 (6–10), September 24, 2013 (11–xv) and August 8, 2018 (16–20); #2, 11 and 13 updated and #fourteen withdrawn July 18, 2018; #7 withdrawn Oct 11, 2019 ; #10 withdrawn February eighteen, 2021; Last reviewed 2021

  1. i

    Don't do imaging for low dorsum pain inside the first vi weeks, unless red flags are nowadays.

    Red flags include, just are not express to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine earlier half-dozen weeks does non ameliorate outcomes, but does increase costs. Low dorsum pain is the 5th most common reason for all doc visits.

  2. 2

    Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms final for x or more days, or symptoms worsen after initial clinical improvement.

    Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the convalescent setting is due to a viral infection that will resolve on its ain. Despite consistent recommendations to the opposite, antibiotics are prescribed in more than 80 per centum of outpatient visits for acute sinusitis. Sinusitis accounts for xvi million office visits and $5.8 billion in annual health care costs.

  3. three

  4. iv

    Don't order annual electrocardiograms (EKGs) or any other cardiac screening for low-take a chance patients without symptoms.

    There is footling testify that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart affliction improves health outcomes. Fake-positive tests are likely to pb to damage through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.

  5. five

    Don't perform Pap smears on women younger than 21 or who accept had a hysterectomy for not-cancer affliction.

    Almost observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age grouping can lead to unnecessary anxiety, additional testing and price. Pap smears are not helpful in women afterward hysterectomy (for non-cancer disease) and there is little prove for improved outcomes.

  6. vi

    Don't schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational historic period.

    Delivery prior to 39 weeks, 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increment in morbidity and mortality. There are articulate medical indications for delivery prior to 39 weeks and 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

  7. 7

    Due to recently published evidence related to induction of labor between 39 and 41 weeks gestation, the AAFP has withdrawn this recommendation.

  8. 8

    Don't screen for carotid avenue stenosis (CAS) in asymptomatic adult patients.

    There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to not-indicated surgeries that result in serious harms, including decease, stroke and myocardial infarction.

  9. ix

    Don't screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are non otherwise at high gamble for cervical cancer.

    At that place is acceptable prove that screening women older than 65 years of age for cervical cancer who accept had adequate prior screening and are non otherwise at high take a chance provides little to no do good.

  10. ten

    Due to recently-published evidence related to screening for cervical cancer in women nether 30, the AAFP has withdrawn this recommendation. The AAFP supports the recommendation from the U.S. Preventive Services Job Strength in back up of screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years.

  11. eleven

    Don't routinely prescribe antibiotics for otitis media in children aged two-12 years with not-severe symptoms where the observation choice is reasonable.

    The "observation selection" refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting direction to symptomatic relief. The decision to find or care for is based on the child'due south age, diagnostic certainty and illness severity. To find a child without initial antibacterial therapy, information technology is important that the parent or caregiver has a set means of communicating with the clinician. There also must be a system in identify that permits reevaluation of the kid.

  12. 12

    Don't perform voiding cystourethrogram (VCUG) routinely in first delirious urinary tract infection (UTI) in children anile 2 -24 months.

    The risks associated with radiation (plus the discomfort and expense of the process) outweigh the risk of delaying the detection of the few children with correctable genitourinary abnormalities until their second UTI.

  13. 13

    Do non routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam. For men who desire PSA screening, it should only be performed after engaging in shared controlling.

    Screening for prostate cancer using PSA may prevent mortality from prostate cancer for a pocket-sized number of men, while putting many men at take chances for long term harms, such as urinary incontinence and erectile dysfunction. Whether this potentially modest benefit in mortality outweighs the potential harms is dependent on the values and preferences of individual men. Therefore, for men who express a want for prostate cancer screening, it should simply be performed post-obit a discussion of the potential benefits and harms. Routine screening for prostate cancer should not be done. PSA-based prostate cancer screening should not be performed in men over 70 years of age.

  14. 14

    Due to recently published evidence related to screening adolescents for scoliosis, the AAFP has withdrawn this recommendation.

  15. 15

    Don't require a pelvic test or other concrete exam to prescribe oral contraceptive medications.

    Hormonal contraceptives are safe, effective and well-tolerated for almost women. Information do not support the necessity of performing a pelvic or breast examination to prescribe oral contraceptive medications. Hormonal contraception can be safely provided on the basis of medical history and blood pressure measurement.

  16. xvi

    Don't perform pelvic exams on asymptomatic nonpregnant women, unless necessary for guideline-appropriate screening for cervical cancer.

    Screening pelvic examinations, except for the purpose of performing cervical cancer screening at recommended intervals, have not led to reduction in bloodshed or morbidity, and betrayal asymptomatic women to unnecessary invasive testing. Noninvasive options to screen for sexually-transmitted infections are at present available every bit alternatives to endocervical cultures. Screening pelvic examinations also add unnecessary costs to the health care system, included expenses from evaluations of simulated-positive findings. These pelvic exams can fifty-fifty lead to unnecessary surgery.

  17. 17

    Don't routinely recommend daily home glucose monitoring for patients who have Type 2 diabetes mellitus and are not using insulin.

    Cocky-monitoring of blood glucose (SMBG) is an integral part of patient cocky-management in maintaining safety and target-driven glucose control in type 1 diabetes mellitus. Nevertheless, daily finger glucose testing has no benefit in patients with type 2 diabetes mellitus who are not on insulin or medications associated with hypoglycemia, and small, but significant, patient harms are associated with daily glucose testing. SMBG should exist reserved for patients during the titration of their medication doses or during periods of changes in patients' nutrition and do routines.

  18. 18

    Don't screen for genital herpes simplex virus infection (HSV) in asymptomatic adults, including pregnant women.

    Serologic testing for HSV infection has low specificity and a high simulated-positive rate, and no confirmatory examination is currently available. The serologic tests cannot determine site of infection. Given the prevalence of the infection in the United States, positive predictive value of the test is estimated at near 50%. A positive exam tin can crusade considerable anxiety and disruption of personal relationships.

  19. xix

    Don't screen for testicular cancer in asymptomatic adolescent and developed males.

    There is no do good to screening for testicular cancer due to the low incidence of illness and high cure rates of treatment, even in patients who have advanced disease. At that place are potential harms associated with screening, which include faux-positive results, anxiety, and harms from diagnostic tests or procedures.

  20. xx

    Don't transfuse more than the minimum of ruby-red claret prison cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to eight m/dL in stable patients).

    Unnecessary transfusion exposes patients to potential adverse effects without whatever likelihood of benefit and generates boosted costs. Transfusion decisions should exist influenced by a person'south symptoms and hemoglobin concentration.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this listing or their individual situation should consult their md.

Founded in 1947, the American University of Family Physicians (AAFP) represents 105,900 physicians and medical students nationwide. It is the only medical society devoted solely to primary care. Approximately one in four of all doctor'due south office visits are made to family physicians. Family medicine's cornerstone is an ongoing, personal patient-dr. relationship focused on integrated care.

For information about health care, health atmospheric condition, and health, please visit the AAFP's award-winning consumer website, familydoctor.org.

How This List Was Created

i–5: The American Academy of Family Physicians (AAFP) list is an endorsement of the 5 recommendations for Family unit Medicine previously proposed by the National Physicians Brotherhood (NPA) and published in the Archives of Internal Medicine, equally part of its Less is More™ series. The goal was to place items common in master care do, strongly supported by the evidence and literature, that would atomic number 82 to significant health benefits, reduce risks and harm, and reduce costs. A working grouping was assembled for each of the three primary intendance specialties; family medicine, pediatrics and internal medicine. The original list was adult using a modification of the nominal group process, with online voting. The literature was and so searched to provide supporting evidence or refute the activities. The listing was modified and a 2nd circular of field testing was conducted. The field testing with family unit physicians showed support for the final recommendations, the potential positive touch on on quality and cost, and the ease with which the recommendations could be implemented.

More detail on the study and methodology tin be constitute in the Archives of Internal Medicine article: The "Meridian v" Lists in Primary Care.

half dozen–10: The American Academy of Family unit Physicians (AAFP) has identified this listing of clinical recommendations for the second phase of theChoosing Wisely entrada. The goal was to place items mutual in the practice of family medicine supported past a review of the evidence that would pb to significant health benefits, reduce risks, harms and costs. For each particular, bear witness was reviewed from appropriate sources such as evidence reviews from the Cochrane Collaboration, and the Bureau for Healthcare Research and Quality. The AAFP's Committee on Health of the Public and Science and Chair of the Lath of Directors reviewed and approved the recommendations.

In the case of the kickoff two items on our list – "Don't schedule constituent, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age" and "Don't schedule constituent, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable" – we collaborated with the American College of Obstetricians and Gynecologists in developing the final language.

eleven–15:The American Academy of Family Physicians (AAFP) has identified this list of clinical recommendations for the tertiary stage of the Choosing Wisely® campaign. The goal was to identify items common in the practise of family unit medicine supported by a review of the evidence that would pb to significant health benefits, reduce risks, harms and costs. For each item, evidence was reviewed from appropriate sources such every bit the Cochrane Collaboration, the Agency for Healthcare Research and Quality and other sources. The AAFP's Commission on Health of the Public and Science and Board of Directors reviewed and approved the recommendations.

16-20: The American Academy of Family unit Physicians (AAFP) has identified this listing of clinical recommendations for the quaternary phase of the Choosing Wisely entrada. Three recommendations were derived from AAFP Preventive Services Recommendations and two were based on other medical societies' Choosing Wisely recommendations.

The goal was to identify items common in the practice of family medicine supported by a review of the prove that would lead to significant health benefits, reduce risks, harms and costs. For each particular, evidence was reviewed from appropriate sources such equally the Cochrane Collaboration, the Agency for Healthcare Research and Quality and other sources. The AAFP'southward Commission on Health of the Public and Science and Lath of Directors reviewed and canonical the recommendations.

AAFP'south disclosure and disharmonize of involvement policy can be found at www.aafp.org.

Sources

  1. Bureau for Health Care Enquiry and Policy (AIICPR), Cochrane Reviews.

  2. Centers for Disease Control and Prevention (CDC), Cochrane, and Register of Internal Medicine.

  3. U.S. Preventive Services Task Force (USPSTF), American Association of Clinical Endocrinology (AACE), American College of Preventive Medicine (ACPM), National Osteoporosis Foundation (NOF).

  4. U.S. Preventive Services Task Force (USPSTF).

  5. U.S. Preventive Services Task Strength (USPSTF) (for hysterectomy), American Higher of Obstetrics and Gynecology (ACOG) (for age).

  6. Main Due east, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, Kowalewski L (California Maternal Quality Care Collaborative). Elimination of not-medically indicated (elective) deliveries before 39 weeks gestational age. California: March of Dimes; Commencement edition July 2010. California Department of Public Health; Maternal, Child and Boyish Wellness Division; Contract No: 08-85012.

  7. "Labor Induction versus Expectant Management in Depression-Risk Nulliparous Women," N Engl J Med 2018; 379:513-523
    https://www.nejm.org/doi/full/ten.1056/NEJMoa1800566

  8. American Academy of Family unit Physicians. Carotid Artery Stenosis [Internet]. 2007[cited 2012 Oct 10]. Available from: www.aafp.org/online/en/habitation/clinical/exam/carotidartery.html

    U.Southward. Preventive Services Task Force. Screening for Carotid Artery Stenosis [Internet]. 2007 Dec. [Cited 2012 Oct 10]. Bachelor from: www.uspreventiveservicestaskforce.org/uspstf/uspsacas.htm

    Wolff T, Guirguis-Blake J, Miller T, et al. Screening For Asymptomatic Carotid Artery Stenosis [Internet]. Rockville (MD): Agency for Healthcare Enquiry and Quality (United states); 2007 Dec. (Testify Syntheses, No. 50). Bachelor from: www.ncbi.nlm.nih.gov/books/NBK33504/

  9. American University of Family Physicians. Cervical Cancer [Internet]. 2012 [cited 2012 Oct 10]. http://www.aafp.org/patient-care/clinical-recommendations/all/cervical-cancer.html

    U.S. Preventive Services Task Strength. Screening for Cervical Cancer. 2012 Mar. [cited 2012 Oct 10]. Bachelor from: www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm

    Vesco KK, Whitlock EP, Eder G, et al. Screening for Cervical Cancer: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Bureau for Healthcare Enquiry and Quality (United states of america); 2011 May. (Evidence Syntheses, No. 86.) Available from: preview.ncbi.nlm.nih.gov/bookshelf/booktest/br.fcgi?book=es86

  10. American Academy of Family Physicians. Cervical Cancer [Internet]. 2012 [cited 2012 Oct 10]. www.aafp.org/online/en/home/clinical/exam/cervicalcancer.html

    U.South. Preventive Services Task Force. Screening for Cervical Cancer. 2012 Mar. [cited 2012 Oct 10]. Available from: world wide web.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm

    Vesco KK, Whitlock EP, Eder Thou, et al. Screening for Cervical Cancer: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Cyberspace]. Rockville (Physician): Agency for Healthcare Enquiry and Quality (US); 2011 May. (Prove Syntheses, No. 86.) Bachelor from: preview.ncbi.nlm.nih.gov/bookshelf/booktest/br.fcgi?volume=es86

  11. Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, Joffe MD, Miller DT, Rosenfeld RM, Sevilla XD, Schwartz RH, Thomas PA, Tunkel DE, American Academy of Pediatrics, American Academy of Family Physicians. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar;131(3):e964–99.

    Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2013 January 31;one:CD000219.

  12. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical do guideline for the diagnosis and management of the initial UTI in delirious infants and children ii to 24 months. Pediatrics. 2011 Sep;128(3):595–610.

    American College of Radiology (ACR), Society for Pediatric Radiology (SPR), Guild of Nuclear Medicine (SNM). ACR-SPR-SNM practice guideline for the performance of developed and pediatric radionuclide cystography [Cyberspace]. Reston (VA): American College of Radiology (ACR); 2010. five p.

    National Institute for Wellness and Clinical Excellence, National Collaborating Centre for Women's and Children's Health (UK). Urinary tract infection in children: diagnosis, treatment and long-term direction. London: RCOG Press; August 2007. 429 p.

    Westwood ME, Whiting PF, Cooper J, Watt IS, Kleijnen J. Further investigation of confirmed urinary tract infection (UTI) in children under v years: a systematic review. BMC Pediatrics. 2005 Mar 15;5:ii.

  13. American University of Family Physicians. Prostate cancer [Cyberspace]. Leawood (KS): American Academy of Family Physicians; 2012 [cited 2013 Jul 23]. Available from: www.aafp.org/patient-care/clinical-recommendations/all/prostate-cancer.html

    U.S. Preventive Services Task Force. Screening for prostate cancer. Rockville (MD): U.S. Preventive Services Task Force. 2012 May. 16 p.

  14. U.S. Preventive Services Task Force. Final Update Summary: Adolescent Idiopathic Scoliosis: Screening. Rockville (Dr.) 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/adolescent-idiopathic-scoliosis-screening1

  15. Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, Trussell J. Clinical breast and pelvic test requirements for hormonal contraception: current practise vs testify. JAMA. 2001 May 2;285(17):2232–nine.

    Henderson JT, Sawaya GF, Blum One thousand, Stratton L, Harper CC. Pelvic examinations and admission to oral hormonal contraception. Obstet Gynecol. 2010 Dec;116(half-dozen):1257–64.

    Committee on Gynecologic Practice. Committee opinion no. 534: well-woman visit.Obstet Gynecol. 2012 Aug;120(2 Pt 1):421–4.

  16. AAFP Clinical Preventive Service Recommendation: The AAFP recommends against screening pelvic exams in asymptomatic women. (2017) http://www.aafp.org/patient-care/clinicalrecommendations/all/screening-pelvic-exam.html

    Annals of Internal Medicine: Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline from the American Higher of Physicians (Endorsed by the AAFP) http://annals.org/aim/fullarticle/1884537/screening-pelvic-examination-adult-women-clinical-practice-guideline-from-american

  17. JAMA: More Evidence That Glucose Self-Monitoring May Non Improve Outcomes in Non- Insulin Dependent Type ii Diabetes http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2630691

    Society for Internal Medicine Choosing Wisely Recommendation: Don't recommend daily dwelling house finger glucose testing in patients with Type ii diabetes mellitus not using insulin. http://www.choosingwisely.org/clinician-lists/guild-general-internal-medicine-daily-home-finger-glucose-testing-blazon-2-diabetes-mellitus/

    American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2013;36 Suppl1:S11-66.

    Karter AJ, Parker MM, Moffet HH, Spence MM, Chan J, Ettner SL, Selby JV. Longitudinal study of new and prevalent use of self-monitoring of blood glucose. Diabetes Care. 2006;29:1757-63.

    Harris MI. Frequency of claret glucose monitoring in relation to glycemic control in patients with blazon 2 diabetes. Diabetes Intendance. 2001;24:979-82.

    Malanda UL, Welschen LMC, Riphagen II, Dekker JM, Nijpels M, Bot SDM. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are non using insulin. Cochrane Database of Systematic Reviews 2012;1:ane-88.

    O'Kane MJ, Bunting B, Copeland Grand, Coates VE; ESMON study group. Efficacy of self-monitoring of claret glucose in patients with newly diagnosed type ii diabetes (ESMON study): randomized controlled trial. BMJ. 2008;336:1174-vii.

    Pare Due east, Douglas G, Lawton J. Cocky-monitoring of blood glucose in type2 diabetes: longitudinal qualitative report of patients' perspectives. BMJ. 2007;335:493-8.

    Cameron C, Coyle D, Ur Due east, Klarenback S. Cost-effectiveness of self-monitoring of blood glucose in patients with type two diabetes mellitus managed without insulin. CMAJ. 2010;182(one):28-34.

    Canada's Choosing Wisely Recommendation: Don't recommend routine or multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that practise not cause hypoglycemia. https://choosingwiselycanada.org/endocrinology-and-metabolism

    Canadian Diabetes Clan Clinical Practice Guidelines Good Commission, et al. Monitoring glycemic control. Tin can J Diabetes. 2013 April;37 Suppl 1:S35-9.
    PMID: 24070960.

    Davidson MB, et al. The upshot of self monitoring of blood glucose concentrations on glycated hemoglobin levels in diabetic patients not taking insulin: a blinded, randomized trial. Am J Med. 2005 April;118(4):422-v. PMID: 15808142.

    Farmer A, et al. Touch of self monitoring of blood glucose in the management of patients with not-insulin treated diabetes: open parallel grouping randomised trial. BMJ. 2007 Jul 21;335(7611):132. PMID: 17591623.

    O'Kane MJ, et al. Efficacy of self monitoring of claret glucose in patients with newly diagnosed blazon ii diabetes (ESMON written report): randomised controlled trial. BMJ. 2008 May 24;336(7654):1174-7. PMID: 18420662.

  18. American Academy of Family Physicians Clinical Preventive Services Recommendation: The AAFP recommends against routine serological screening for genital canker simplex virus (HSV) infection in asymptomatic adolescents and adults, including those who are pregnant. (2016) http://www.aafp.org/patient-intendance/clinical-recommendations/all/genital-herpes.html

    Serologic Screening for Genital Herpes: An Updated Evidence Report and Systematic Review for the United states Preventive Services Task Force. Feltner C, Grodensky C, Ebel C, Middleton JC, Harris RP, Ashok M, Jonas DE JAMA. 2016;316(23):2531.

  19. American Academy of Family Physicians Clinical Preventive Services Recommendation: The AAFP recommends against screening for testicular cancer in asymptomatic adolescent or adult males (2011) http://world wide web.aafp.org/patient-care/clinical-recommendations/all/testicular-cancer.html

    U.S. Preventive Services Chore Strength. Concluding Recommendation Statement: Testicular Cancer: Screening. Rockville (MD): U.S. Preventive Services Task Strength. 2011.

  20. American Society of Hematology Choosing Wisely Recommendation: Don't transfuse more than the minimum number of blood-red claret cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a condom hemoglobin range (7 to 8 g/dL in stable, non-cardiac in-patients).
    http://www.choosingwisely.org/societies/american-gild-of-hematology

    Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA,Weinstein R, Swinton McLaughlin LG, Djulbegovic B; Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012 Jul 3;157(1):49–58.

    Retter A, Wyncoll D, Pearse R, Carson D, McKechnie South, Stanworth Due south, Allard Due south, Thomas D, Walsh T; British Commission for Standards in Hematology. Guidelines on the management of anaemia and cherry cell transfusion in developed critically sick patients. Br J Haematol. 2013 Feb;160(4):445–64.

    American Association of Blood Banks Choosing Wisely recommendation: Don't transfuse more units of blood than absolutely necessary http://www.choosingwisely.org/societies/american-association-of-blood-banks

    Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B; Clinical Transfusion Medicine Commission of the AABB. Red claret cell transfusion: a clinical exercise guideline from the AABB. AnnIntern Med. 2012 Jul 3;157(1):49–58.

    Canada'due south Choosing Wisely Recommendation: Don't transfuse patients based solely on an capricious hemoglobin threshold. https://choosingwiselycanada.org/hematology/

    Callum J, et al. Bloody easy 3, blood transfusions, blood alternatives and transfusion reactions, a guide to transfusion medicine. tertiary ed. Toronto (ON): Sunnybrook and Women's College Wellness Sciences Centre; 2011. PMID: 22751760.

    Choosing Wisely Canada. Canadian Society of Internal Medicine: 5 Things Physicians and Patients Should Question [Internet]. 2014 [cited 2014 Aug 26].

    Carson JL, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann. Intern. Med. Jul 3 2012;157(i):49-58. PMID: 22751760.

    Hebert PC, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in disquisitional care. Transfusion Requirements in Disquisitional Care Investigators, Canadian Critical Care Trials Group. N. Engl. J. Med. Feb eleven 1999;340(6):409-417. PMID: 9971864.

    Hicks LK, et al. The ASH Choosing Wisely(R) entrada: v hematologic tests and treatments to question. Blood. Dec 5 2013;122(24):3879-3883. PMID: 24307720.