American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News
for the Week of 8-10-10

Highlights

  • Over 40% of all doctors get sued during their careers
  • After miscarriage, women shouldn't delay trying again

Test yourself

  • MKSAP Quiz: three-month history of sweating, appetite and weight loss

Heart failure

Drug risks

  • Meds donít increase suicide risk for epileptics, but may for depressed

FDA update

  • FDA approves vaccines for next flu season

Funding opportunities

  • Cancer control career development awards for primary care physicians

From the College

  • Hospitalists wanted for survey and program development
  • ACP's international newsletter is now online

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Over 40% of all doctors get sued during their careers

Ninety-five medical liability claims are filed for every 100 physicians, according to a report by the American Medical Association (AMA).

Medical liability claim frequency by physician specialty, 2007-2008

Physician type % ever sued % sued 2+ times % sued in last 12 months # of claims per 100
General and family practice 38.9 22.2 3.1 80
General internal medicine 34.0 12.5 4.4 58
Internal medicine subspecialties 40.2 21.3 3.6 86

Other highlights in the report include:

  • 5% of doctors are sued in any given year.
  • General surgeons and obstetricians/gynecologists get sued five times as often as pediatricians and psychiatrists. Nearly half of OB/GYNs are sued by the age of 40.
  • 90% of general surgeons age 55 and over have been sued.
  • 65% of claims were dropped, dismissed or withdrawn; 25.7% were settled; 4.5% were decided by alternative dispute mechanism; and 5% went to trial.
  • Physicians win 90% of cases that go to trial.
  • Average defense costs per claim were $40,649, ranging from a low of $22,163 among claims that were dropped, dismissed or withdrawn to a high of over $100,000 for tried cases.
  • Median paid claims were $200,000 for settled claims and $375,000 for tried claims.
  • Men were sued twice as much, likely because they are concentrated in high-exposure fields such as surgery compared to women, who concentrate in lower-risk fields. Also, men work on average longer and more hours per week, and they're more likely to be practice owners, who get sued more often.
  • Approximately 45% of solo physicians had been sued, compared to 37% of physicians who provided care in multispecialty groups and 40% of those in hospitals.

The AMA report called for tort reform. The data are from the American Medical Associationís 2007-2008 Physician Practice Information survey, which is used primarily for developing practice expense relative value units for the Medicare Physician Fee Schedule but also collected information on a number of other topics. It was jointly funded by the AMA and over 40 national medical specialty associations.

A stratified sample was drawn from the AMA Masterfile across 42 Medicare specialties and had a final size of 5,825 doctors who worked at least 20 hours in their most recent week of practice.

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After miscarriage, women shouldn't delay trying again

Women who conceive within six months of an initial miscarriage have the best chance of having a healthy pregnancy with the lowest complication rates, according to a study.

Researchers conducted a retrospective cohort study of 30,937 women who attended Scottish hospitals between 1981 and 2000. The participants all had a miscarriage in their first pregnancy and subsequently had another pregnancy. Results were published Aug. 5 by BMJ.

Compared with women with an interpregnancy interval of six to 12 months, those who conceived again within six months were less likely to have another miscarriage (adjusted odds ratio [OR], 0.66; 95% CI, 0.57 to 0.77), termination (OR, 0.43; 95% CI, 0.33 to 0.57) or ectopic pregnancy (OR, 0.48; 95% CI, 0.34 to 0.69). Women with an interpregnancy interval of more than 24 months were more likely to have an ectopic second pregnancy (OR, 1.97; 95% CI, 1.42 to 2.72) or termination (OR, 2.40; 95% CI, 1.91 to 3.01).

Compared with women with an interpregnancy interval of six to 12 months, women who conceived again within six months and went on to have a live birth in the second pregnancy were less likely to have a caesarean section (OR, 0.90; 95% CI, 0.83 to 0.98), preterm delivery (OR, 0.89; 95% CI, 0.81 to 0.98) or infant of low birth weight (OR, 0.84; 95% CI, 0.71 to 0.89) but were more likely to have an induced labor (OR, 1.08; 95% CI, 1.02 to 1.23).

"Women wanting to become pregnant soon after a miscarriage should not be discouraged," the authors wrote. "There may be cases where a delay is desirable, for example if there are signs of infection, and women should be advised appropriately."

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Test yourself

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MKSAP Quiz: three-month history of sweating, appetite and weight loss

A 38-year-old woman is evaluated for a 3-month history of increased sweating, increased appetite, and a 7.3-kg (16-lb) weight loss. The patient also reports a 4-month history of amenorrhea, before which time she felt ďcompletely healthy.Ē Medical history is otherwise unremarkable, and she takes no medications.

Physical examination shows a thin, restless woman with smooth, fine, moist skin and fine hair. Blood pressure is 108/60 mm Hg, pulse rate is 96/min, respiration rate is 14/min, and BMI is 18.1. Mild lid lag is noted, but no proptosis, diplopia, or conjunctival injection is detected. Her thyroid gland is soft and enlarged approximately twofold. There is a mild, fine tremor of the outstretched hands. Reflexes are brisk.

Laboratory studies:

Thyroid-stimulating hormone 2.4 ĶU/mL (2.4 mU/L)
Thyroxine (T4), free 2.7 ng/dL (34.8 pmol/L)
Triiodothyronine (T3), total 387 ng/dL (5.96 nmol/L)

Which of the following is the most appropriate next test to perform on this patient?

A) MRI of the pituitary gland
B) Thyroid antiĖperoxidase antibody test
C) Thyroid radioactive iodine uptake determination
D) Thyroid scan
E) Thyroid-stimulating immunoglobulin measurement

Click here or scroll to the bottom of the page for the answer and critique.

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Heart failure

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Meta-analysis finds telemonitoring beneficial

Telephone and telemonitoring programs reduced mortality and hospitalizations for patients with heart failure, a new Cochrane review found.

The review included 25 studies comparing remote disease management to usual care, 16 of which included structured telephone support and 11 of which included telemonitoring (two studies used both technologies). All-cause mortality was significantly reduced in the patients receiving telemonitoring (risk ratio, 0.66; 95% CI, 0.54 to 0.81) and positively, although nonsignificantly, affected by the telephone programs (RR, 0.88; 95% CI, 0.67 to 0.94).

Both interventions significantly reduced heart failure-related hospitalizations, and some studies found that the programs improved quality of life, reduced health care costs and were acceptable to patients. There were also improvements in prescribing, patient knowledge and self-care compared to usual treatment. Based on the findings, review authors concluded that such programs are beneficial and may play a significant role in heart failure care for specific patients.

An accompanying editorial was less positive, however. The editorialists said that lack of follow-up in the studies made it difficult to calculate the number needed to treat, and there was some evidence of small study bias. They called for additional trials, noting that few of the studies included in the review measured quality-of-life outcomes and cost or assessed the risk of adverse events from telephone support or telemonitoring.

The authors of the review agreed that more work is required to establish cost-effective means of applying this technology. However, they concluded that no further trials comparing telephone and telemonitoring programs to usual heart failure care are needed. Instead, researchers should focus their work on tailoring these programs to best benefit specific patient groups, the authors said.

An article in the March ACP Internist assessed the potential of remote monitoring.

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Drug risks

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Meds donít increase suicide risk for epileptics, but may for depressed

Taking antiepileptic drugs does not increase epilepsy patientsí risk of suicide, according to a new analysis.

Researchers used a database of 5 million patients in the United Kingdom to assess the risk of attempting or committing suicide. Patients who didnít take antiepileptic drugs and hadnít been diagnosed with epilepsy, depression, or bipolar disorder had a suicide risk of 15.0 per 100,000 patient-years. Epilepsy patients who werenít on the drugs had a rate of 38.2 per 100,000, compared to 48.2 for epileptic patients who did take the drugs. However, once researchers adjusted for age, coexisting conditions and other risk factors, the patients with epilepsy taking drugs were no more likely to have attempted suicide than those who didnít take the medication.

The drugs were not associated with higher risk in bipolar patients, either. But there was a significantly increased risk of suicide in drug-taking patients who had depression or hadnít been diagnosed with epilepsy, depression or bipolar disorder. Researchers noted that at least some of these patients may have been taking the drugs because of pain, and that pain has previously been associated with suicide risk. The cause for the higher risk in depression patients is also uncertain, the study authors said. For example, they speculated that use of the drugs may be a marker of severe depression.

The results conflict with those of an FDA meta-analysis of controlled trials of antiepileptic drugs, the authors noted. Other recent research on the topic has looked at differences in risk among specific antiepileptic medications, but wide confidence intervals prevented this study from coming to precise conclusions on that issue. This study population overall also had a lower than average suicide rate because patients at high risk for suicide, such as those who had a history of attempts, were excluded.

In conclusion, the researchers found no support for an association between antiepileptic drugs and suicide in patients who are taking the medications for epilepsy. They concluded that illness, rather than drug use, is a more important factor in suicide risk. The study was published in the Aug. 5 New England Journal of Medicine.

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FDA update

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FDA approves vaccines for next flu season

Vaccines have been approved for the 2010-2011 influenza season, the FDA announced last week.

The agency chose the strains for the new vaccine based on the viruses that have been circulating in the Southern hemisphere. Three strains were included:

  • A/California/7/09 (H1N1)-like virus (the pandemic 2009 influenza virus),
  • A/Perth /16/2009 (H3N2)-like virus and
  • B/Brisbane/60/2008-like virus.

The labeling for one vaccine, CSL Limitedís Afluria, has undergone changes this season to inform clinicians about an increased incidence of fever and febrile seizure, which was seen in children, mainly those younger than 5 years, following administration of the vaccine in the Southern hemisphere.

This flu season will also be the first in which government recommendations call for vaccinating an expanded population: all people age 6 months or older. The recommendations were published by the CDC and are available online.

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Funding opportunities

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Cancer control career development awards for primary care physicians

Applications are currently being accepted for grants from the American Cancer Society.

These awards are made to support primary care physicians with a rank of instructor to assistant professor who are pursuing an academic career with an emphasis on cancer control. Awards are for three years and for up to $100,000 per year. A maximum of $10,000 per year for mentors may be included in the budget.

The application deadline is Oct. 15 and application information is online.

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From the College

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Hospitalists wanted for survey and program development

ACP would like to work with practicing hospitalists to develop innovative programs, products and services to better meet the needs of physicians working in inpatient settings. If you are currently a practicing hospitalist, and would like to be involved in this important College activity, please click here to take a survey.

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ACP's international newsletter is now online

The current issue of ACP International Newsletter includes a global perspective on internal medicine from Somwang Danchaivijitr, FACP (Hon), immediate past president of the Royal College of Physicians of Thailand, and a profile of Norman Wilder, MACP, MBA, past governor of the ACP Alaska Chapter, discussing his recent ACP ambassador travel to Venezuela.

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Cartoon caption contest

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Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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MKSAP answer and critique

The correct answer is A) MRI of the pituitary gland. This item is available to online to MKSAP 15 subscribers as item 41 in the Endocrinology and Metabolism module.

This patient should undergo MRI of the pituitary gland to detect a possible thyroid-stimulating hormone (TSH)Ėsecreting tumor. This patient clinically has hyperthyroidism, and testing shows clearly elevated levels of free thyroxine (T4) and total triiodothyronine (T3). However, her serum TSH level is not suppressed, as it is in almost all causes of hyperthyroidism. This incongruity raises the possibility of a TSH-secreting pituitary adenoma as the cause of her hyperthyroidism.

Antiperoxidase antibodies are usually present in patients with autoimmune thyroid disease, such as Hashimoto disease. The presence or absence of such antibodies in this patient with a probable TSH-secreting pituitary adenoma, however, would not be diagnostically helpful.

A determination of thyroid radioactive iodine uptake helps to quantitate hyperactivity in the thyroid gland and may help differentiate thyroiditis from Graves disease. In this patient, the uptake would not be useful in the differential diagnosis because the patient most likely has a TSH-secreting pituitary adenoma and not a primary thyroid gland disorder.

A thyroid scan is useful in showing functional morphology of a gland. Although a thyroid scan is likely to show diffuse hyperfunction in this patient, it would not be useful in the differential diagnosis because the most likely cause of this patientís symptoms is not primary thyroid disease but a TSH-secreting pituitary adenoma.

Patients with Graves disease have an unregulated production of T4 and T3 because of the presence of autoantibodies, such as thyroid-stimulating immunoglobulin, against the TSH receptor, but these autoantibodies are not always present at all time points. In this patient, the titer of such antibodies is likely to be low because the cause of this patientís hyperthyroidism is not likely to be Graves disease.

Key point

  • In a patient with hyperthyroidism, the finding of an inappropriately normal level of thyroid-stimulating hormone suggests a pituitary cause of the hyperthyroidism.

Click here to return to the rest of ACP InternistWeekly.

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About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2010 by the American College of Physicians.

Test yourself

A 19-year-old man is evaluated for a sore throat, daily fever, frontal headache, myalgia, and arthralgia of 5 days' duration. He also has severe discomfort in the lower spine and a rash on his trunk and extremities. He returned from a 7-day trip to the Caribbean 8 days ago. The remainder of the history is noncontributory. Following a physical exam and lab studies, what is the most likely diagnosis?

Find the answer

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