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

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ACP InternistWeekly



In the News for the Week of 8-23-11




Highlights

Most doctors sued for malpractice never pay a claim

While most physicians are sued for malpractice at least once during their careers, the vast majority will never have to make an indemnity payment. More...

Physicians do too many Pap tests

Most physicians continue to recommend annual cervical cancer screening, despite guidelines recommending that low-risk women be tested less frequently. More...


Test yourself

MKSAP Quiz: 12-hour history of fever, myalgia, headache, and a rash

A 20-year-old female college student is evaluated in December because of a 12-hour history of fever, myalgia, headache, and a rash. Temperature is 38.8 °C (101.8 °F), blood pressure is 90/45 mm Hg, pulse rate is 112/min, and respiration rate is 24/min. A petechial rash most prominent on the lower extremities is present. What is the most likely diagnosis? More...


Venous thromboembolism

New model predicts future risk of VTE

Researchers have devised a new algorithm to predict a patient's risk of developing venous thromboembolism in the next five years, based on simple clinical variables. More...


Gout

Pegloticase effective in treatment refractory patients

The drug pegloticase successfully treated gout in patients who had been refractory to conventional treatment. More...


From the College

Updated Medical Home Builder debuts

The new Medical Home Builder is an online community that can help ambulatory care practices with any combination of quality improvement, practice efficiency, and medical home recognition preparation. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Patrick Alguire, FACP




Highlights


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Most doctors sued for malpractice never pay a claim

While most physicians are sued for malpractice at least once during their careers, the vast majority will never have to make an indemnity payment, a new study found.

Researchers analyzed malpractice data from 1991 through 2005 for all physicians covered by a single large professional liability insurer with a nationwide client base. The study covered nearly 41,000 physicians and nearly 234,000 physician-years. Because the study relied on one insurer's results, researchers compared their data to similar figures in the National Practitioner Data Bank. Results appeared in the Aug. 18 issue of the New England Journal of Medicine.

By the age of 65 years, 75% of physicians in low-risk specialties had faced a malpractice claim, compared with 99% of physicians in high-risk specialties. Roughly 55% of physicians in internal medicine and its subspecialties were projected to face a malpractice claim by the age of 45 years. This contrasts with projections of 80% of physicians in surgical specialties, including general surgery, and 74% of physicians in obstetrics and gynecology. Among physicians in internal medicine, 89% were projected to face a malpractice claim by the age of 65 years.

Each year, an average of 7.4% of physicians had a malpractice claim filed against them. But only 1.6% of the physicians had to make an indemnity payment, so 78% of all claims did not result in payments. Annual rates of malpractice claims ranged from the top three specialties (19.1% in neurosurgery, 18.9% in thoracic-cardiovascular surgery, and 15.3% in general surgery) to the bottom three (5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry). Internal medicine was only slightly higher than the average among physician specialties for frequency of claims made and claims resulting in payment.

The authors wrote that, "Our projections suggest that nearly all physicians in high-risk specialties will face at least one claim during their career; however, a substantial minority will not have to make an indemnity payment."

Overall, the mean indemnity payment was $274,887, and the median was $111,749. Mean payments ranged from $117,832 for dermatology to $520,923 for pediatrics, which was by far the largest mean payment among all specialties. Pediatrics' mean payment was more than $100,000 more than the second-highest specialty of pathology, which was $383,509. There was little correlation between mean payments and rates of being sued. For example, the average payment for neurosurgeons was only $344,811, but neurosurgeons were the most likely to face a claim in a year.

Authors used their conclusions to interpret physicians' concerns about malpractice risk. "Although the frequency and average size of paid claims may not fully explain perceptions among physicians, one may speculate that the large number of claims that do not lead to payment may shape perceived malpractice risk. Physicians can insure against indemnity payments through malpractice insurance, but they cannot insure against the indirect costs of litigation, such as time, stress, added work, and reputational damage."

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Physicians do too many Pap tests

Most physicians continue to recommend annual cervical cancer screening, despite guidelines recommending that low-risk women be tested less frequently, a survey found.

Researchers from the Centers for Disease Control and Prevention gave clinicians three clinical vignettes. The vignettes describe a woman between the ages of 30 and 60 years of age with a current normal Pap test and: 1) no current human papillomavirus (HPV) test results and history of 2 consecutive normal Pap test results, or 2) a current negative HPV test result and a history of 2 consecutive normal Pap test results, or 3) a current negative HPV test result and no history of Pap tests.

In all three cases, guidelines would support extending the screening interval up to three years. Yet two-thirds or more of the physicians (who were divided into categories by specialty and office or hospital-based practice) recommended a next screening in one year. Less than 15% of them recommended waiting for three years. Specialists in obstetrics/gynecology were no more likely to recommend the longer interval than generalist physicians. The survey also asked clinicians about their use of the HPV co-test and found that about half were using it. Results were published online by the American Journal of Obstetrics and Gynecology on Aug. 18.

Given that the study data was collected in 2006, the limited uptake of the HPV test is understandable, since it was only FDA-approved and guideline-recommended in 2003, the study authors said. However, the recommendation for longer screening intervals predates the HPV test and therefore, providers' lack of adoption of that guideline is more concerning. Overtesting increases patients' pain, inconvenience, morbidity and general health care costs, the authors said. They recommended continued surveillance and data collection on this question as well as promotion of evidence-based screening policies.

ACP is developing recommendations for the appropriate use of testing in a wide variety of clinical scenarios as part of its High-Value, Cost-Conscious Care Initiative, which will assess benefits, harms, and costs of diagnostic tests and treatments for various diseases to determine whether they provide medical benefits that are commensurate with their costs and outweigh any harms.

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Test yourself


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MKSAP Quiz: 12-hour history of fever, myalgia, headache, and a rash

A 20-year-old female college student is evaluated in December because of a 12-hour history of fever, myalgia, headache, and a rash. Her only medication is an oral contraceptive agent.

On physical examination, the patient appears ill. Temperature is 38.8 °C (101.8 °F), blood pressure is 90/45 mm Hg, pulse rate is 112/min, and respiration rate is 24/min. A petechial rash most prominent on the lower extremities is present. Passive neck flexion causes discomfort.

Laboratory studies:

Leukocyte count 10,500/µL (10.5 × 109/L) with 80% polymorphonuclear cells (PMNs) and 20% band forms
Platelet count 105,000/µL (105 × 109/L)
Blood urea nitrogen 30 mg/dL (10.7 mmol/L)
Creatinine 2.5 mg/dL (221 µmol/L)
Bicarbonate 15 meq/L (15 mmol/L)

Lumbar puncture is performed. Opening pressure is 300 mm H2O. Cerebrospinal fluid leukocyte count is 1250/µL (1250 × 106/L) with 95% PMNs. Protein is 100 mg/dL (1000 mg/L). Gram stain shows numerous PMNs; no organisms are seen.

Which of the following is the most likely diagnosis?

A) Listeria monocytogenes meningitis
B) Neisseria meningitidis meningitis
C) Rocky Mountain spotted fever
D) Viral meningitis

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

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Venous thromboembolism


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New model predicts future risk of VTE

Researchers have devised a new algorithm to predict a patient's risk of developing venous thromboembolism (VTE) in the next five years, based on simple clinical variables.

Researchers in the England and Wales conducted a prospective open cohort study of primary care patients in 564 general practices, using data that is routinely collected in practice. Participants were aged 25 to 84 years, had no record of pregnancy in the last year or of any VTE, and were not taking oral anticoagulation. There were 2,314,701 patients in the derivation cohort and 1,240,602 in the validation cohort. The main outcome was incident cases of VTE (either deep vein thrombosis [DVT] or pulmonary embolism [PE]) as recorded in primary care records or cause-of-death records. Cox proportional hazards models were used in the derivation cohort to create risk equations at one and five years from baseline. Researchers examined 21 prediction variables based on established risk factors for VTE, specifically those that are recorded in a patient's record and that patients are likely to know. The study was published online Aug. 16 in BMJ.

The VTE rate was 14.6 per 10,000 person years in the derivation cohort and 14.9 per 10,000 person years in the validation cohort. The predictor variables in the final simplified models for both sexes included: smoking status (smoker or non-smoker, and heavy/moderate/light smoker); history of varicose veins, heart failure and chronic kidney disease, any cancer, chronic obstructive pulmonary disease, inflammatory bowel disease, and hospital admission in the past six months; and current use of antipsychotics. For women, current use of tamoxifen, oral contraceptives and hormone replacement therapy were also included in the final model. Variables that didn't change risk, and weren't included in the models, were: current antiplatelet therapy, asthma, cardiovascular disease, atrial fibrillation, and family history of VTE.

The algorithm, embedded in a clinical risk calculator, could be useful in several clinical situations, such as to identify increased VTE risk on or before hospital admission, or before long flights, the authors said. In such cases, prophylaxis could be considered. The algorithm could also be used when considering whether to prescribe medications, such as oral contraceptives, that might increase VTE risk, as well as to identify high risk groups of patients who might need more testing, monitoring or preventive treatment, the authors noted. They cautioned, however, that the model is meant to identify patients at risk of VTE who might require prophylaxis before a medical procedure or other event, not to diagnose symptomatic patients or estimate changing risk during a hospital episode.

A guideline on the issue, "Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline from the American College of Physicians," will appear in an upcoming issue of Annals of Internal Medicine.

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Gout


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Pegloticase effective in treatment refractory patients

The drug pegloticase successfully treated gout in patients who had been refractory to conventional treatment, according to a new manufacturer-sponsored study.

The study included two double-blind trials of patients with severe gout, allopurinol intolerance or refractoriness and serum uric acid concentration of 8.0 mg/dL or greater. The 225 participating patients from 56 practices all received 12 biweekly intravenous infusions, but were randomized to one of three treatment courses: 8 mg of pegloticase every time (biweekly group), pegloticase alternating with placebo (monthly group) or placebo every time. The trials were published in the Aug. 17 Journal of the American Medical Association.

The primary endpoint of the study was a plasma uric acid level of less than 6.0 mg/dL at months 3 and 6. In a pooled analysis of the two trials, 42% (36 of 85) of biweekly patients achieved the endpoint, compared to 35% (29 of 84) of the monthly patients and 0% (0 of 43) of the placebo group (P<0.001 for each comparison). Secondary endpoints included physical function and quality of life, which were significantly improved in both active treatment groups compared to placebo. Patient-reported pain was also significantly less in the biweekly group than the placebo group.

These effects are noteworthy because typically impairments resulting from gout have been difficult to separate from effects of patients' other comorbidities, the study authors said. They also pointed out that the effectiveness of the drug within six months makes it unique among urate-lowering agents.

A number of adverse effects were found in the study. Infusion-related reactions were the most common, occurring in 26%, 42% and 5% of the biweekly, monthly and placebo groups respectively. All of the studied patients received routine prophylaxis for infusion reactions, and all of the reactions resolved promptly.

Researchers noted that most reactions occurred after loss of response to pegloticase. There were also three cardiovascular events in active treatment patients. Based on these adverse events, study authors recommended that physicians maintain infusion reaction prophylaxis in all patients during treatment and stabilize cardiovascular comorbidities prior to treatment in any patients with cardiovascular risk factors.

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From the College


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Updated Medical Home Builder debuts

The new Medical Home Builder (MHB) has debuted. It is an online community that can help ambulatory care practices with any combination of quality improvement, practice efficiency, and medical home recognition preparation.

The website provides self-paced, team-oriented, practice assessment modules (Practice Biopsies), access to pertinent resources including customizable documents and templates, and peer-to-peer/practice-to-practice links for sharing ideas and asking questions of others working through similar issues.

The MHB website has more details on the updated tool. Free webinar demonstrations are available online.

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Cartoon caption contest


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And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20110823-cartoon.jpg

"You say niacin gives you a flushing problem?"

This issue's winning cartoon caption was submitted by David S Borislow, ACP Member. Readers cast 88 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 63.6% of the votes.

The runners-up were:

"I'm not sure there's a CPT code for this, but here goes ...."

"Of course, the informed consent form is a little longer if you want me to use this one ...."

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MKSAP Answer and Critique



The correct answer is B) Neisseria meningitidis meningitis. This item is available to MKSAP 15 subscribers as item 54 in the Infectious Disease section. More information about MKSAP 15 is available online.

This patient's illness is most consistent with meningococcal infection, which is characterized by the sudden onset of fever, myalgia, headache, and rash in a previously healthy patient. Early in its course, meningococcal disease may be indistinguishable from other common viral illnesses; however the rapidity with which the disease worsens (often over hours) and progresses to septic shock differentiates it from these other illnesses. A petechial rash is most common and may coalesce to form purpuric lesions.

The diagnosis is established based on clinical presentation and confirmed with blood and cerebrospinal fluid (CSF) cultures. It is likely that this student received meningococcal vaccine because it is recommended for all adolescents aged 11 to 18 years and frequently is administered before entrance to college. The current vaccines are immunogenic and effective at preventing disease due to serogroups A, C, Y, and W-135. Unfortunately, none of the current vaccines is effective against serogroup B, which is also a common cause of disease occurring in the United States.

Meningitis caused by Listeria monocytogenes is associated with extremes of age (neonates and persons age >50 years), alcoholism, malignancy, immunosuppression, diabetes mellitus, hepatic failure, renal failure, iron overload, collagen vascular disorders, and HIV infection. The clinical presentation of Listeria meningoencephalitis ranges from a mild illness with fever and mental status changes to a fulminant course with coma.

The classic presentation of Rocky Mountain spotted fever is a severe headache, fever, myalgia, and arthralgia. Thrombocytopenia and acute kidney injury can occur. A maculopapular rash develops 3 to 5 days later (hardly ever on the first day of illness, as in this patient). It begins on the wrists and ankles and may involve the palms and soles. Rocky Mountain spotted fever is transmitted by the American dog tick in the spring and early summer, which is inconsistent with the timing of this patient's presentation.

Viral (aseptic) meningitis can present similarly to bacterial meningitis with the classic findings of fever, headache and stiff neck, and photophobia and may be associated with a maculopapular eruption. However, acute viral meningitis is rarely associated with the combination of findings indicating early organ dysfunction such as metabolic acidosis and acute kidney injury.

Key Point

  • Meningococcal infection should be considered in the differential diagnosis of any previously healthy patient who presents with acute-onset fever, headache, and myalgia.

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Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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