In the News for the Week of 11-2-04
- Studies: Shorter shifts reduce resident errors
Clinical news in the headlines
- CDC creates ethics panel to guide flu vaccine decisions
Medication error alert
- Drug company warns about Reminyl/Amaryl errors
- ACP expands content integration of College resources
- College Governor receives national rheumatology award
Two studies released last week found that residents were more alert and made fewer mistakes under restricted work hours that allowed them to get more sleep.
One study, which looked at the effect of shorter shifts on reducing serious medical errors, found that first-year residents working in ICUs made 36% fewer errors working 16-hour shifts, compared to those working traditional shifts of 24 hours or more. A second study found that interns working less than 80 hours a week had less than half the rate of attentional failures as those working more than 80 hours. Both studies appeared in the Oct. 28 New England Journal of Medicine (NEJM).
On longer shifts, residents made significantly more medication and diagnostic errors, the authors reported. According to the Oct. 28 Washington Post, mistakes included misdiagnoses, orders for the wrong medication or dose, incorrect interpretations of test results, and mistakes during procedures. No one died as a result of the errors, many of which were caught by supervising doctors.
The authors noted that, with many interns regularly working 30-hour shifts, further modifications are needed to the work hour standards set in 2003 by the Accreditation Council for Graduate Medical Education. Those standards limit work hours for U.S. medical residents to 80 hours a week averaged over four weeks, with up to 32 additional hours per month for requested exceptions or extra programs; and to continuous shifts of up to 24 hours, plus an additional six hours for hand-offs or educational obligations.
The current standards do not take into account actual hours of work and sleep, the authors continued. With traditional shifts, interns often got less than two hours of sleep before a 24-hour-plus shift, whereas they slept longer and were less tired working shorter shifts.
The NEJM abstracts are online.
The Washington Post is online.
Clinical news in the headlines
The following articles appear in this week's Annals of Internal Medicine. Full text is available to College members and subscribers online.
Treating atrial fibrillation: control heart rate or heart rhythm? A study of two common therapies for atrial fibrillation found that using drugs to slow heart rate (rate control) was more cost-effective than medicating to restore normal heart rhythm (rhythm control).
An accompanying editorial noted, however, that although heart rate control is safe, cheaper and the preferred first-line treatment for atrial fibrillation, rhythm control works for some people. The editorial also said that emerging non-drug therapies, such as catheter ablation, are also effective. The study is online.
United States faces severe physician shortage. A new study examining long-term economic and demographic trends found that the United States will need 200,000 more physicians by 2020 to keep up with population growth. That looming shortage has been masked, researchers said, by the growth in the number of nonphysician clinicians, international medical graduates and osteopathic physicians.
According to an accompanying editorial, however, the future need for physicians is unpredictable and could be affected by several variables. Those factors include whether older patients are healthier and need fewer services; new technologies prevent subsequent illness and disability; and higher insurance deductibles cause patients to be more concerned about price when seeking care. More.
Commonly-used heartburn and ulcer drugs, especially powerful proton pump inhibitors, may make patients more susceptible to pneumonia, according to a study released last week.
The risk of developing pneumonia among the more than 364,600 people in a Dutch study nearly doubled for those taking proton pump inhibitors compared to non-users, a study in the Oct. 27 Journal of the American Medical Association (JAMA) found. Users of H2-receptor antagonists had a 1.63-fold increased risk of pneumonia.
H2-receptor antagonists and proton pump inhibitors increase susceptibility to infections by increasing gastric acid, the authors noted. In general, the benefit of acid-suppressing drugs outweighs the relatively low overall risk of developing community-acquired pneumonia, but the higher risk could be a problem for patients at increased risk for infection.
For those patients—including the elderly, children and people with asthma or chronic obstructive lung disease, or immunosuppressive diseases—the authors recommended acid-suppressing treatment only when necessary and at the lowest possible dose.
The JAMA article is online.
The CDC last week announced that it has established a permanent ethics panel to help decide how to allocate flu vaccine during a shortage and how the government should respond to future pandemics.
The panel, which has already begun meeting, will examine such dilemmas as which priority groups should receive vaccine first during severe shortages and whether certain health care professions should have priority in the event of a pandemic, the Oct. 28 New York Times reported. For example, babies, the chronically ill and the elderly are all on the CDC's priority list for flu vaccine, but it may not be possible to get vaccine to everyone in those categories, making it necessary to choose among high-risk groups.
Four people have been named to the panel, including Robert J. Levine, FACP, director of the law, policy and ethics core at Yale University's Center for Interdisciplinary Research on AIDS. A fifth member may be added later.
The panel is expected to be active over the next several weeks as the CDC decides how to allocate the remaining flu vaccine beyond public health agencies to nursing homes, physician offices, veterans' hospitals and convalescent hospitals. Aventis, this season's sole injectable flu vaccine manufacturer, has already shipped 35 million doses and is working with the CDC to deliver 26 million more doses over the next two months.
The New York Times is online.
Medication error alert
A drug company last week issued an alert, saying that physicians and pharmacists have made prescribing and dispensing errors with an Alzheimer's drug and a diabetes medication. Those errors have led to the deaths of two patients.
Janssen Pharmaceutica announced that it has learned of 10 different occasions when the diabetes drug glimepiride (Amaryl), marketed by Aventis, had been prescribed or dispensed to patients instead of Janssen's galantamine hydrobromide (Reminyl), which is used to treat mild to moderate Alzheimer's disease. Giving glimepiride to nondiabetics with Alzheimer's has caused serious adverse events, including severe hypoglycemia and death.
According to reports submitted to the FDA and the U.S. Pharmacopoeia, mix-ups have occurred because prescriptions have been incorrectly written, interpreted, labeled or filled. Galantamine hydrobromide was introduced in 2001.
Janssen is launching an awareness campaign to educate health care professionals about the problem. Efforts include sending letters to physicians and pharmacists, and providing tags for pharmacy shelves.
For more information, call Janssen at 800-526-7736 or go online.
Members now have seamless access to a wide range of College resources, as ACP broadens content integration of its journals and electronic products.
Physicians who use PIER (Physicians' Information and Education Resource), the College's electronic evidence-based clinical decision-support tool, can now access full text of the most recent and relevant Annals of Internal Medicine and ACP Journal Club articles through specially marked links in the "What's New" section of specific PIER modules.
You can find an example of these links in the PIER Chronic Stable Angina module. Links to College resources in PIER modules will eventually move to the "Additional Resources" section of each module, providing easy access to key College content.
Annals.org, the online version of Annals of Internal Medicine, has also added direct links to content from PIER and ACP Journal Club to its interface. Relevant ACP content will now be found in the "Related ACP Content" link in the "Articles" section of the menu bar. An example can be found in the recent Annals article, "Malaria-Related Deaths Among U.S. Travelers, 1963-2001."
Edward D. Harris Jr., FACP, Governor for the College's Northern California Chapter and Vice Chair of the ACP Publications Committee, has received the distinguished rheumatologist award from the American College of Rheumatology (ACR). The award recognizes outstanding contributions in the areas of patient care, clinical scholarship or service to benefit patients with rheumatic diseases.
Dr. Harris was recognized for his research defining tissue destruction mechanisms in rheumatoid arthritis. He helped prove that the rheumatoid pannus works as a locally invasive malignancy, producing large amounts of matrix metalloproteases that can degrade cartilage and other joint components. Dr. Harris received the award, which is given once each year, last month during the ACR's annual meeting.
Between 1987 and 1995, Dr. Harris chaired the department of medicine at Stanford University. Prior to that, he helped produce the first edition of the "Textbook of Rheumatology" in 1979, and is now editor-in-chief of that textbook's seventh edition. He is also editor of The Pharos, the journal of the Alpha Omega Alpha medical society.
Dr. Harris became a Fellow in the College in 1969, and was elected Chapter Governor in 2001. He was also recently elected to fellowship in London's Royal College of Physicians. An ACR press release is online.
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Copyright 2004 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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