The reversal of established medical practice is common and occurs across all classes of medical practice. This investigation sheds light on low-value practices and patterns of medical research.

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The Frequency of Medical Reversal W e use the term reversal to signify the phenomenon of a new trial-superior to predecessors because of better design, increased power, or more appropriate controls-contradicting current clinical practice. In recent years, a number of such reversals have occurred. Use of hormone therapy, 1 the class 1C antiarrhythmic agents, 2 and the pulmonary artery catheter 3 have decreased when trials demonstrated that they are either less effective than previously thought or harmful. Reversal not only affects medications and diagnostic tests. Previously accepted indications for surgical and medical procedures have also been contradicted. In 2007, the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) 4 trial found no benefit to support percutaneous coronary intervention (vs optimal medical therapy) in many patients with stable coronary artery disease, an indication that was previously accepted. The implications of reversal are notable. Reversal implies error or harm to patients who underwent the practice in question, during the years it was considered effective. Reversal also undermines trust in the medical system. We sought to estimate the frequency of reversal by examining 1 year of original publications in the New England Journal of Medicine. Other researchers have studied the rate of reversal in medical research. 5 Studies of medical interventions are often followed by studies that either reach the opposite result or suggest the magnitude of effect was initially overestimated. Among high-citation count publications, Ioannidis 5 found that 16% were contradicted by future studies, and another 16% were found to have smaller effects than initially thought. Herein, we focused on existing practices that were contradicted in a given period in highimpact literature. Knowing the rate of, and predisposing factors for, reversal may have implications for the approval of medical therapies. Methods. We reviewed all Original Articles in the New England Journal of Medicine in 2009 (the last complete year of the publication at the time of our investigation).

The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity Institution authorized to provide research, educational information and other services only to individuals and institutions that function with non-discrimination with respect to race, creed, color, religion, age, disability, sex, sexual orientation, marital status, national origin, political opinions or affiliations.

Osteoporosis is defined by a fragility fracture or hip BMD T score of -2.5 or lower. 1 Osteoporosis is a major health problem that affects 200 million people worldwide and 54 million older adults in the United States. 1,2 Half of all postmenopausal women have an osteoporosis-related fracture during their lifetime, 25% develop a vertebral deformity, and 15% experience a hip fracture. 1 Characteristics of the Guideline SourceThis guideline was developed by the ACP's Clinical Guidelines Committee (Table ), 3 composed of internists who specialize in primary care, health care administration, and medical and health services research. This committee oversees the development and evaluation of evidence-based guidelines published by the ACP. The recommen-dations were based on a systematic review sponsored by the Agency for Healthcare Research and Quality. 4 A conflict of interest disclosure was completed by task force members prior to each meeting. The recommendations were evaluated using the ACP's guideline grading system. 5 The guideline underwent a peer review process through the ACP's journal and was posted online for comments from ACP members and leadership.

The ability to identify medical reversals and other low-value medical practices is an essential prerequisite for efforts to reduce spending on such practices. Through an analysis of more than 3000 randomized controlled trials (RCTs) published in three leading medical journals (the Journal of the American Medical Association, the Lancet, and the New England Journal of Medicine), we have identified 396 medical reversals. Most of the studies (92%) were conducted on populations in high-income counties, cardiovascular disease was the most common medical category (20%), and medication was the most common type of intervention (33%).

Clostridium difficile is a common health care-associated infection in the United States with an increasing incidence of communityacquired disease that can be very severe and has a significant risk of mortality. Recurrent CDI is increasing disproportionately to primary CDI. 1 Management of CDI is determined by disease severity, history of CDI, and a patient's risk of recurrence. 2 Characteristics of the Guideline Source Clinical Review & Education JAMA Clinical Guidelines Synopsis

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