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Agency for Health Care Policy and Research (US). AHCPR Quick Reference Guides. Rockville (MD): Agency for Health Care Policy and Research (US); 1992-1996.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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4Cataract in Adults: Management of Functional Impairment

Quick Reference Guideline Number 4

Created: .

Attention Clinicians

The Clinical Practice Guideline on which this Quick Reference Guide for Clinicians is based was developed by an interdisciplinary, non-Federal panel comprised of health care professionals and a consumer representative. Panel members were:

  • Denis M. O'Day, MD, FACS, Chair
  • Anthony J. Adams, OD, PhD
  • Edwin H. Cassem, MD, FACP
  • John V. Donlon, Jr., MD
  • Donald J. Doughman, MD, FACS
  • Dagmar B. Friedman, MPH, LICSW
  • Catherine Glynn-Milley, RN, CRNO
  • Harry L. Knopf, MD
  • Ernest L. Mazzaferri, MD, FACP
  • Steven A. Obstbaum, MD
  • Charles J. Pappas, OD
  • Eva N. Skinner, RN
  • Alfred Sommer, MD, MHS
  • Arlo C. Terry, MD
  • Linda A. Vader, RN, CRNO
  • James R. Weber, MD
  • Von Best Whitaker, PhD, RN, C
  • Ira G. Wong, MD

For a description of the guideline development process and information about the sponsoring agency (Agency for Health Care Policy and Research), see the Clinical Practice Guideline, Cataract in Adults: Management of Functional Impairment (AHCPR Publication No. 93-0542), Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1993. A patient booklet (AHCPR Publication No. 93-0544) also is available. To order guideline products, call toll free 800-358-9295 or write the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

AHCPR invites comments and suggestions from users for consideration in development and updating of guidelines. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Executive Office Center, Suite 401, 2101 East Jefferson Street, Rockville, MD 20852.

Note: Clinicians should not rely on this Quick Reference Guide alone. Refer to the complete Clinical Practice Guideline for a more detailed analysis and discussion of the available research, critical evaluation of the assumptions and knowledge of the field, considerations for patients with special needs, and references. The full Guideline Report has a more complete discussion of relevant research.

Purpose and Scope

A cataract can cause a decrease in visual function, which in turn can be classified as a visual disability. Thus, a cataract can be defined in three ways. The first definition is an objective lens change. The second is a lens opacity that is associated with a defined level of visual acuity loss. The third relates to the functional consequences of lens opacification. This guideline focuses on the last definition. It deals with care of the patient with functional impairment due to cataract and improvement in function as a result of treatment for the condition.

The purpose of the guideline is to help ensure quality care for individual patients. Practitioners are encouraged to use the information provided here, but the recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendations must be made by the practitioner in light of available resources and the circumstances presented by individual patients.

Functional impairment due to cataract refers to lost or diminished ability to do any of the following:

  • Perform everyday activities -- Bathing, dressing, eating, using the toilet, walking, preparing meals, doing housework, doing laundry, shopping, taking medicine, getting around outside, driving or using other transportation, managing money, and using the telephone.
  • Participate in hobbies or other leisure-time activities -- Reading, watching television, etc.
  • Work in one's occupation.
It is important to recognize the impact of this disability on the individual's ability to function autonomously. The goal of cataract treatment is to maintain or restore autonomy through appropriate treatment to remove the disability.

Functional impairment due to cataract in the adult is prevalent in the U.S. population. Cataract extraction is the therapeutic surgical procedure performed most frequently on Americans age 65 and over. About 1.35 million extractions are performed annually in the United States.

Currently, there is no medical treatment to prevent the formation or progression of cataract in the otherwise healthy adult eye.

Multiple factors influence the risk of cataract: ultraviolet-B radiation, diabetes, drugs, smoking, diarrhea, alcohol, and low antioxidant vitamin status. Different risk factors are associated with different types of opacities. There are insufficient data to provide management guidelines on reducing the risk of cataract.

Highlights of Patient Management

Referral Pathways and Access to Care

The process of caring for a patient with functional impairment due to cataract should start when a disability is recognized. A diagnosis of cataract can be made by any of a number of health care providers, including ophthalmologists, optometrists, family physicians, and internists. However, in order to decide whether to have the cataract removed, a patient must understand the likely benefits and potential risks of undergoing cataract surgery. Such an understanding of the risks and benefits comes from a discussion with the ophthalmologist who might perform the surgery. The surgeon is responsible for ensuring that the patient understands the likely benefits and potential risks of cataract surgery in his or her case before making a decision about whether or not to proceed with surgery.

Setting and Providers of Care

Cataract surgery should be performed where the patient can receive quality care in a safe environment -- close to home, if at all possible, or close to the best social support system of family and friends. Outpatient surgery can be performed in a hospital or an independent surgery center. The selection of the site is the responsibility of the ophthalmologist who performs the surgery. It is preferable that the perioperative care and surgery be performed in the same community.

The ophthalmologist who performs the surgery has the responsibility and ethical obligation to the patient for care during the postoperative period. The surgeon must examine the patient the day following surgery, initiate appropriate postoperative treatment, monitor the patient's recovery from the surgery, diagnose and treat postoperative complications (or refer the patient to an ophthalmologist better able to deal with those complications), and perform surgical revision when appropriate. In order to fulfill these responsibilities, the surgeon must examine the patient periodically until he or she is confident that the patient has fully recovered from surgery, a process that usually takes 6-12 weeks.

The surgeon cannot abrogate his or her responsibility for the patient's postoperative care. However, certain components of postoperative care can be delegated to one or more members of a team of appropriately trained professionals, including optometrists, community health nurses, social workers, and other health care professionals.

If anyone other than the operating ophthalmologist is to provide all or most of the postoperative care, then the operating ophthalmologist has an obligation to inform the patient prior to surgery of the arrangements and of the relative qualifications of the postoperative caregiver.

If the patient with cataract is seeking surgery by an ophthalmologist located far from home, so that provision of postoperative care by that ophthalmologist is impractical, the surgeon should educate the patient about the importance of the continuum of the care process involved in cataract surgery. This includes the preoperative phase, the surgical procedure, and the period of postoperative care.

Diagnosis and Preoperative Ophthalmologic Testing

1. The decision to perform cataract surgery is generally made after judging the effect of the cataract on the patient's visual and overall function, after assessing the patient's visual needs, and after a thorough consideration of the potential risks associated with surgery.

2. Management decisions should be made primarily on the basis of a complete patient history and ocular examination.

3. Special preoperative tests are rarely of assistance in deciding whether to recommend cataract surgery.

  • Contrast sensitivity testing: At this time there is inadequate scientific evidence that contrast sensitivity testing provides information that is useful for determining whether a patient would benefit from cataract surgery beyond that obtained by history and ocular examination.
  • Glare testing: In general, there is inadequate evidence that glare testing provides useful information beyond that obtained by history and ocular examination. However, it may be useful for corroborating glare symptoms in a small percentage of cataract patients who complain of glare yet measure good Snellen acuity in office testing. Even in these patients, a positive glare test does not determine whether surgery should be recommended.
  • Potential vision testing: Adequate evidence is lacking to determine whether tests of potential vision assist the ophthalmologist in predicting the outcome of cataract surgery. Available data suggest that these tests may not be useful. There are no data to substantiate the value of potential vision testing in situations in which it is uncertain whether other diseases, particularly mild to moderate atrophic macular degeneration, might limit postoperative visual rehabilitation.
  • Specular photographic microscopy: There is currently no evidence or rationale to support routine use of specular microscopy in order to predict the response of the cornea to cataract surgery.

Treatment

Functional rehabilitation as a result of visual improvement is possible in the vast majority of patients and should be the goal at each stage of treatment.

Nonsurgical Management

1. Patients developing cataract should be educated and reassured about the cause of visual disability and the prognosis.

2. During early cataract development, visual impairment can often be reduced by nonsurgical means (changing the distance spectacle lens prescription; use of strong bifocals, magnification, or other visual aids; and appropriate illumination). Pupillary dilation may help patients with a posterior subcapsular cataract. However, the glare caused by such a cataract may be unacceptable, particularly when the intensity of ambient light is high or when facing high-intensity light, as in night driving.

Surgical Management

1. Cataract surgery is generally a nonemergency procedure.

2. Clinical judgment combined with Snellen acuity remains the best general guide to the appropriateness of surgery.

3. Individual functional and visual needs, environment, and risks may vary widely and must be taken into account. The likely degree of visual improvement and its impact on the quality of life must be weighed against the risk and cost of surgery.

Indications for Surgery

1. Cataract surgery is indicated when the cataract reduces visual function to a level that interferes with everyday activities of the patient.

2. Surgery is not necessary solely because the cataract is present.

3. The patient should make the decision to proceed with surgery after careful consideration of the ophthalmologist's recommendation and after considering subjective, objective, and educational criteria for various levels of visual impairment.

  • Visual disability with Snellen acuity of 20/50 or worse.
    • Subjective:
    • The ability to carry out needed or desired activities is impaired.
    • Objective:
    • Ocular examination confirms that the best correctable visual acuity in the affected eye is 20/50 or worse and that the cataract is responsible for this.
    • Educational:
    • After the ophthalmologist educates the patient about likely benefits and risks of surgery, including alternatives to surgery, the patient decides that expected improvement in function outweighs the potential risk, cost, and inconvenience of surgery.
  • Visual disability with Snellen acuity of 20/40 or better.
    • For patients with Snellen acuity of 20/40 or better, the indicators are the same as for patients with Snellen acuity of 20/50 or worse. However, it is especially important to document visual impairment for any of the following reasons:
    • Visual function fluctuates because of glare or dim illumination.
    • Patient complains of monocular diplopia or polyopia.
    • Visual disparity exists between the two eyes.
    • Patient needs but cannot obtain an unrestricted driving license.
  • Visual disability of the one-eyed patient.
    • A one-eyed patient with cataract is defined as a patient with a cataract in one eye and permanent legal blindness in the other eye. The indications for surgery for the one-eyed patient are the same as those for the two-eyed patient, except that the ophthalmologist should emphasize the risk of total blindness.

4. There are two other indications for cataract removal.

  • Lens-induced disease: Phacomorphic glaucoma, phacolytic glaucoma, and other lens-induced diseases may require cataract surgery, and the need for extraction may be urgent.
  • Concomitant ocular disease that requires clear media: Cataract extraction may be required to adequately diagnose or treat other ocular conditions, such as diabetic retinopathy.

Contraindications for Surgery

Surgery should not be performed solely to improve vision under the following circumstances:

  • The patient does not desire surgery.
  • Glasses or visual aids provide satisfactory functional vision.
  • The patient's lifestyle is not compromised.
  • The patient is medically unfit.

Preoperative Medical Evaluation

1. The primary purpose of the preoperative medical evaluation is to ensure a safe perioperative course for the patient. It also provides an opportunity to evaluate many patients who may not be receiving regular medical care.

2. The preoperative medical evaluation and appropriate testing should be done on all patients undergoing cataract surgery.

3. Preoperative medical management should be guided by consideration of the patient's age, the presence of concurrent medical illnesses, the patient's use of medicine, and the patient's proximity to the location where surgery is to be performed.

4. The preoperative medical evaluation should include screening for functional or emotional disability. Elderly patients should receive special screening of functional status, and particular attention should be given to the psychosocial and economic problems imposed by aging.

5. Prior to surgery, areas of special importance to the individual, such as cultural, ethical, and spiritual values, should be taken into consideration. The patient's own assessment of the quality of his or her life also should be considered to optimally prepare him or her for surgery and recovery.

Anesthesia

1. Anesthesia for cataract surgery can be either general or local.

2. General anesthesia is preferred in the following situations:

  • The patient has extreme anxiety that does not respond to counseling or sedation.
  • The patient is unable to cooperate with the surgical team.
  • Satisfactory local anesthesia cannot be provided.
  • The patient has a known allergy to local anesthetic medications.
  • Disorders are present that are best managed under general anesthesia (e.g., severe back pain or postural problems).

3. Monitored anesthesia care by an anesthesiologist or anesthetist is strongly preferred. Monitored anesthesia care includes physiologic monitoring with life-support systems available. It should include use of electrocardiogram, pulse oximetry, blood pressure, and respiration monitoring techniques.

4. Either peribulbar or retrobulbar injection is acceptable. The injection should be administered by an ophthalmologist or by an appropriately trained and qualified professional who has demonstrated competence in these techniques.

5. Peribulbar and retrobulbar anesthesia should be administered to properly monitored patients with intravenous access established. There should be access to oxygen with assisted respirations via mask ventilation apparatus.

Surgical Techniques and Complications

1. Phacoemulsification and extracapsular surgery appear to be equally effective in restoring vision. Inadequate data are available to determine if one technique is more effective than the other in reducing or eliminating functional impairment due to cataract.

2. It cannot be determined from existing data whether the smaller wound incision needed for phacoemulsification leads to more enhanced safety and more rapid postoperative rehabilitation than with extracapsular surgery.

3. Ophthalmologists should use their best judgment in selecting surgical techniques for individual patients after discussing the alternatives with the patient.

4. The ophthalmologist who is to perform the surgery is responsible for the following:

  • Ensuring that the patient has had an appropriate general medical history and physical examination.
  • If an intraocular lens is to be implanted, ensuring that the appropriate keratometry and A-scan measurements have been performed.
  • If an intraocular lens is to be implanted, selecting the appropriate intraocular lens power after discussion with the patient.
  • Reviewing the results of presurgical and diagnostic patient evaluations and discussing the findings with the patient or, in appropriate cases, with another responsible adult acting for the patient.

Second Eye Surgery

1. Indications for second eye surgery are the same as for first eye surgery.

2. In no case should surgery be done on both eyes at the same time. The time interval should be based on the following factors:

  • The patient is able to provide informed consent for surgery on the second eye after evaluating the visual results and postoperative course of surgery on the first eye.
  • Adequate time has passed to detect and treat the most immediate vision-threatening complications of cataract surgery.
  • Vision in the operated eye has recovered sufficiently that the patient is not at risk of injury due to functional impairment during second eye cataract surgery and the immediate postoperative period.
  • In the event that vision has not recovered or is not recoverable, there is time to arrange for adequate assistance so that the patient is not at risk of injury due to functional impairment following second eye cataract surgery.

3. Surgery in the second eye is justified and appropriate when the subjective, objective, and educational criteria outlined under "Indications for Surgery" are met. An exception is the special case in which the opposite eye has no useful vision. In this case, the decision for surgery is determined by the degree of vision reduction at the time the patient enters into the evaluation process. In some cases, surgery may be delayed because of the greater potential for total blindness in the event of a serious complication of surgery. It is then the obligation of the ophthalmologist to inform and educate the patient about the potential risk of total blindness. Although the decreased visual acuity and level of disability may fall well within the guidelines for cataract surgery, the worse the vision is in the fellow eye, the greater the need is for caution in considering cataract surgery in a patient's only seeing eye.

Postoperative Care

Patient Education

The ophthalmologist who performs the surgery has an obligation to educate and instruct the patient about appropriate signs or symptoms of possible complications, as well as eye protection, level of activity permitted, medications, required visits, and details concerning access to emergency care. The patient likewise has an obligation during the postoperative phase to follow the advice and instructions of the surgeon and to notify the surgeon promptly if problems occur.

Patient's Condition at Discharge

Criteria for discharge after ambulatory surgery include:

  • Stable vital signs.
  • Return to preoperative mental state.
  • Absence of nausea.
  • Absence of significant pain.
  • Availability of an escort.
  • Review with the patient or escort of postsurgical care until the first postoperative visit on the day following surgery, including relief of pain, activity level permitted, and access to emergency care if needed.
  • Prearranged followup appointment.
  • Written postoperative instructions.
  • Suitable home environment.
  • Adequate home care support.

Unplanned Postoperative Hospitalization

1. Operative complications of an ocular or medical nature are possible indications for unplanned postoperative hospitalization.

2. Ocular complications can include hyphema, infection, wound dehiscence, endophthalmitis, uncontrolled elevated intraocular pressure, threatened or actual expulsive hemorrhage, retrobulbar hemorrhage, severe pain, or other ocular problems requiring acute management or careful observation.

3. Medical complications can include cardiac instability, respiratory instability, a cerebrovascular episode, diabetes mellitus requiring acute management, uncontrolled nausea or vomiting, acute urinary retention, acute psychiatric disorientation, or other medical conditions requiring acute management or careful monitoring.

Planned Postoperative Hospitalization

Indications for planned postoperative hospitalization are as follows:

  • Medical conditions are present that require prolonged postoperative observation by a nurse or skilled personnel.
  • Best correctable vision in the unoperated eye is 20/200 or worse.
  • Patient is mentally debilitated, diagnosed as mentally ill, or functionally incapacitated so that a risk of injury exists in the immediate postoperative period.
  • Physical disability prevents satisfactory immediate postoperative care.

Postoperative Visits

1. The frequency of examination during the postoperative period is based on the need to:

  • Diagnose and provide the most efficient treatment for complications when they arise.
  • Provide routine postoperative care as healing proceeds.
  • Educate and support the patient during the postoperative period.

2. The frequency of normal followup for a patient without signs or symptoms of possible complications is as follows:

  • The day following surgery.
  • Approximately 1 week, 3 weeks, and 6-8 weeks following surgery.
  • More frequently if unusual findings or complications occur.

Postoperative Examinations

1. The components of postoperative examinations include:

  • Visual acuity measurement each visit.
  • Intraocular pressure measurement each visit.
  • External examination each visit.
  • Slit lamp examination each visit.
  • Patient counseling and education each visit unless the patient's condition does not allow it. This should include medication instructions and information about progress toward healing, level of activity permitted, symptoms requiring emergency care, and access to emergency care.
  • Ophthalmoscopy. A dilated fundus exam to include the peripheral retina should be done at least once during this postoperative period.

2. The timing and frequency of refraction will depend on patient needs, the amount of astigmatism, and the stability of the measurement. Sutures may be cut or removed by the ophthalmologist to reduce astigmatism. Usually, optical correction can be prescribed 6-12 weeks after surgery.

Long-Term Followup

Patients should be informed of the need for periodic eye examinations and of the possible need for YAG capsulotomy if a posterior capsular opacification develops.

Rehabilitation

1. Overall supervision of planning for postoperative rehabilitation is the responsibility of the surgeon. Appropriate planning for postoperative care and rehabilitation can be accomplished by office personnel interacting with the family and patient preoperatively and postoperatively or through a multidisciplinary approach utilizing optometrists, registered nurses, and/or social workers.

2. Successful rehabilitation involves numerous factors:

  • Physician instructions: The patient should understand and comply with physician instructions.
  • Patient education: Careful preoperative assessment of the abilities of the patient and family to understand and comply with instructions is critical to ensuring adequate postoperative care. Referral to a home health care agency can be appropriate for further education and to evaluate a patient's ability to follow discharge instructions.
  • Timely management of postoperative complications: Postoperative complications can occur unpredictably as a result of coexisting medical problems, physical limitations from a preexisting condition, difficulty in identifying labels on medications because of altered visual status, adverse systemic reactions from mixing medications by patients concurrently treated with other drug therapy, and premature discharge of a patient with delayed postanesthetic recovery or with unrecognized or delayed postanesthetic complications. Immediate intervention is necessary, particularly for the patient living alone.
  • Economic factors: Attention should be given to the possible adverse economic impact of cataract on patients and their families.
  • Environmental factors: The patient's home environment may pose safety risks that can profoundly influence rehabilitation.
  • Cultural and ethnic factors: Recognizing the mores and belief systems of patients of diverse cultural and ethnic backgrounds aids in developing an appropriate plan for care. Non-English-speaking or deaf patients require the efforts of interpreters to ensure effective communication.
  • Psychosocial factors: Learning how elderly people function in their daily lives is essential to understanding and caring for them. Referral for counseling should be made when indicated. When cataract patients who are considering surgery have the responsibility of being the primary caretaker for another individual, they should be referred to a home health care agency or family service agency for help in obtaining interim assistance in fulfilling those responsibilities.

Posterior Capsular Opacification and YAG Capsulotomy

1. Opacification of the posterior capsule is a consequence of modern cataract surgery. As the opacification increases, the patient begins to notice a decrease in visual function that can lead to functional impairment.

2. The most commonly used technique for treating posterior capsular opacification is Nd:YAG capsulotomy, usually referred to as YAG or laser capsulotomy. YAG capsulotomy is performed as an outpatient procedure.

3. The approach to the management of functional impairment due to posterior capsular opacification is similar to that for functional impairment due to cataract.

4. The time of onset of capsular opacification following cataract surgery is variable, as is the frequency with which YAG capsulotomy is performed.

5. Capsular opacification severe enough to require YAG capsulotomy should be a rare occurrence within 3 months of surgery and uncommon in the first 6 months. Data suggest that less than 25 percent of patients undergo YAG capsulotomy within 2 years following surgery. The optimum rate of YAG capsulotomy following cataract surgery is unknown.

Diagnosis

1. The same general approach as outlined for cataract should be followed.

2. Diagnosis of functional impairment due to capsular opacification is based on clinical judgment regarding the following:

  • Visual loss and/or symptoms of glare.
  • Symptoms of decreased contrast.
  • The amount of posterior capsular opacification.
  • Other possible causes of decreased vision following cataract surgery.
  • The degree of functional impairment.

Indications for Surgery

1. Laser capsulotomy is appropriate and justified when the following subjective, objective, and educational criteria are met.

  • Subjective: The ability to carry out needed or desired activities is increasingly impaired.
  • Objective: The eye examination confirms the diagnosis of posterior capsular opacification and excludes other ocular causes of functional impairment.
  • Educational: The patient has been educated about the risks and benefits of surgery.

2. Occasionally, laser capsulotomy is indicated to diagnose and treat retinal detachment, macular disease, or diabetic retinopathy; to evaluate the optic nerve head; or to diagnose posterior pole tumors or other conditions requiring ophthalmological evaluation.

Contraindications for Surgery

1. Laser capsulotomy should never be scheduled at the time cataract surgery is scheduled or performed, and it should never be performed prophylactically because:

  • There is no predictable time at which laser surgery may be required.
  • Laser surgery is seldom indicated before 3 months following surgery.
  • Laser surgery carries its own risks.

2. Justification for performing the procedure should be well documented in the patient's record.

Preoperative Ophthalmic and Medical Evaluation

1. Fluorescein angiography and B-scan ultrasonography may be indicated in certain circumstances.

2. The preoperative ophthalmic evaluation should include a history and complete ocular examination.

3. The ophthalmologist who will perform the laser surgery is responsible for assessing the medical suitability of the patient for the procedure and the perioperative use of vasoactive drugs.

Complications

The major complications of YAG capsulotomy include:

  • Elevated intraocular pressure.
  • Retinal detachment.
  • Cystoid macular edema.
  • Damage to the intraocular lens.
  • Hyphema.
  • Dislocated intraocular lens.
  • Corneal edema.

Postoperative Care

1. The ophthalmologist who performed the laser capsulotomy has an ethical and legal responsibility to provide postoperative care and to provide appropriate care if complications develop. Referral to another ophthalmologist should be made only with the patient's consent.

2. Following capsulotomy, patients must be observed for at least 1 hour for evidence of elevated intraocular pressure. If the pressure is elevated, appropriate treatment must be instituted and the patient followed until the problem is resolved.

3. Within 2 weeks of the procedure, the patient should be reexamined by the ophthalmologist who performed the surgery. The examination should include:

  • Measurement of intraocular pressure.
  • Slit lamp examination of the anterior segment to confirm the adequacy of the capsulotomy and stability of the intraocular lens.
  • Indirect ophthalmoscopy for retinal tears or detachment.
  • Refraction, if necessary.
  • Instruction to patients about the risk and symptoms of retinal detachment, the slight risk of glaucoma and other long-term complications, and the need for periodic eye examinations.

[Suggested Citation]

This document is in the public domain and may be used and reprinted without special permission. AHCPR appreciates citation as to source, and the suggested format is provided below:

Cataract Management Guideline Panel. Management of Cataract in Adults. Clinical Practice Guideline. Quick Reference Guide for Clinicians, Number 4. Rockville, MD. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Pub. No. 93-0543. Feb. 1993.

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AHCPR Publication No. 93-0543.

National Library of Medicine DOCLINE Information: MED/93251255

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