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

Advertisement

ACP InternistWeekly



In the News for the Week of March 5, 2013




Highlights

Tests do little to reassure patients who likely didn't need them

Patients who receive diagnostic tests for the purpose of reassurance don't feel less worried in either the short or long term, a meta-analysis found. More...

Afib associated with cognitive impairment, dementia regardless of stroke history

Atrial fibrillation (AF) was associated with a higher risk for cognitive impairment and dementia, with or without a history of clinical stroke, a meta-analysis found. More...


Test yourself

MKSAP Quiz: 2-year history of daytime somnolence, snoring, and apnea

A 65-year-old man is evaluated for a 2-year history of daytime somnolence, snoring, and apneic episodes during the night as witnessed by his wife. He does not have blurred vision, tinnitus, or headache. He has no cardiopulmonary symptoms and does not smoke cigarettes. The patient has hypertension for which he takes lisinopril and atenolol. Following a physical exam and lab studies, what is the most appropriate management? More...


Quality of care

Study analyzes diagnostic errors in primary care

Diagnostic errors in primary care are often related to process breakdowns during the clinical encounter, according to a new study. More...


Cardiology

Increased walking impairment linked to higher mortality risk in PAD

Patients with peripheral arterial disease (PAD) whose walking ability decreased over a two-year period had a higher risk for death, a new study found. More...


FDA update

Peginesatide pulled from the market

All lots of the injectable anemia drug peginesatide (Omontys) have been recalled, due to new postmarketing reports of serious hypersensitivity reactions, some fatal. More...


From Annals of Internal Medicine

CME credits available in patient safety supplement

A supplement to the March 5 Annals of Internal Medicine, which offers 11 CME credits, focuses on a recent Agency for Healthcare Research and Quality–funded project, "Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices." More...


Internal Medicine 2013

ACP to conduct Annual Business Meeting

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2013. Current College Officers will retire from office and incoming Officers, new Regents and Governors-elect will be introduced. More...


From the College

ACP and MGMA-ACMPE collaborate on online cost survey

ACP and MGMA-ACMPE are working together to provide physicians an opportunity to participate in an exciting new streamlined MGMA 2013 Cost Survey. More...


Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner. More...


Physician editor: Philip Masters, MD, FACP



Highlights


.
Tests do little to reassure patients who likely didn't need them

Patients who receive diagnostic tests for the purpose of reassurance don't feel less worried in either the short or long term, a meta-analysis found.

To study the effect of diagnostic tests on worry about illness, anxiety, symptom persistence, and subsequent use of health care resources in patients with a low pretest probability of serious illness, researchers conducted a systematic review and meta-analysis of 14 randomized, controlled trials that included 3,828 patients.

Results appeared online at JAMA Internal Medicine on Feb. 25.

Three trials showed no overall effect of diagnostic tests on illness worry (odds ratio [OR], 0.87; 95% CI, 0.55 to 1.39), and two showed no effect on nonspecific anxiety (standardized mean difference, 0.06; 95% CI, −0.16 to 0.28). Ten trials showed no overall long-term effect on continuation of symptoms (odds ratio, 0.99; 95% CI, 0.85 to 1.15). After excluding outliers, the authors found the suggestion of a reduction in visits after conducting tests (OR, 0.77; 95% CI, 0.62 to 0.96). Researchers noted that the number of patients needed to test to avoid one subsequent visit varied from 16 to 26, depending on the symptom.

They concluded, "In the context of widespread belief that diagnostic testing reassures patients, these findings suggest that physicians overestimate the value of testing when the probability of serious disease is low." They added that the reassurance of a negative test offers comfort that can last as little as a few hours—"a fleeting sense of relief"—instead of long-term assurance.

An editorial noted that if it requires testing 16 to 26 patients to avoid one repeat visit, and the tests cost $250 to $500 per test, then the health care system is spending between $4,000 and $16,000 to prevent a $100 primary care visit.

The editorial offered five suggestions:

  • Order diagnostic tests based on greater anxiety, symptom persistence or complexity;
  • Don't assume patients want more testing;
  • Offer reassurance through written or verbal information on the meaning of normal results;
  • Develop evidence-based guidelines for diagnostic testing for common conditions; and
  • Address reasonable physician concerns about malpractice.

.
Afib associated with cognitive impairment, dementia regardless of stroke history

Atrial fibrillation (AF) was associated with a higher risk for cognitive impairment and dementia, with or without a history of clinical stroke, a meta-analysis found.

annals.jpg

Twenty-one studies were included in the meta-analysis, seven that looked at the association of AF with cognitive impairment or dementia after stroke and 14 that examined the association between AF and cognitive impairment or dementia in a broader population, including patients with or without a history of stroke.

The review appeared in the March 5 Annals of Internal Medicine.

In a combined analysis, AF was significantly associated with cognitive impairment (relative risk [RR], 1.40; 95% CI, 1.19 to 1.64). There was significant heterogeneity among studies, mainly from variability among prospective studies and possibly due to variances in outcome measures. So researchers incorporated a random-effects model and did several sensitivity analyses and found that pooled estimates were virtually the same for prospective and cross-sectional studies. Restricting the analysis to studies of dementia, which is more reliably diagnosed than cognitive impairment, eliminated the significant heterogeneity without changing the pooled estimate substantially (RR, 1.38; 95% CI, 1.22 to 1.56).

Limiting the analysis to the eight studies that defined cognitive impairment as a mini-mental state exam (MMSE) score of 24 or less or cognitive decline as a reduction in MMSE score of 3 points or more did not appreciably change the results (RR, 1.38; 95% CI, 1.11 to 1.71). Investigating subtypes of dementia did not reveal any significant association between AF and Alzheimer's disease (RR, 1.22; 95% CI, 0.96 to 1.56); however, the association was significant for vascular dementia (RR, 1.72; 95% CI, 1.27 to 2.32).

Limiting the analysis to participants without a history of stroke and studies that adjusted for stroke in multivariate analyses did not appreciably affect the primary results (RR, 1.34; 95% CI, 1.13 to 1.58), nor did restricting the analysis to studies that specifically excluded patients with a history of stroke (RR, 1.37; 95% CI, 1.08 to 1.73).

Seven studies reported an association between AF and cognitive impairment or dementia after stroke (RR, 2.70; 95% CI, 1.82 to 4.00). Although prospective and cross-sectional studies showed overlapping risk estimates, the association was stronger in prospective studies (RR, 3.01; 95% CI, 1.96 to 4.61).

The researchers wrote, "On the basis of this systematic review and meta-analysis of all available data, future research should carefully distinguish between types of dementia, and investigators should consider cognitive function as a new outcome to be assessed in interventional studies for the treatment of AF."



Test yourself


.
MKSAP Quiz: 2-year history of daytime somnolence, snoring, and apnea

A 65-year-old man is evaluated for a 2-year history of daytime somnolence, snoring, and apneic episodes during the night as witnessed by his wife. He does not have blurred vision, tinnitus, or headache. He has no cardiopulmonary symptoms and does not smoke cigarettes. The patient has hypertension for which he takes lisinopril and atenolol.

mksap.gif

On physical examination, temperature is normal, blood pressure is 170/98 mm Hg, pulse rate is 72/min, and respiration rate is 18/min. BMI is 44. Oxygen saturation is 95% with the patient breathing ambient air and does not decrease with modest exertion. The patient's face is erythematous, and his neck is thick. Hepatosplenomegaly is absent.

Laboratory studies:

Hemoglobin 17.5 g/dL (175 g/L)
Leukocyte count 5000/µL (5.0 × 109/L)
Platelet count 225,000/µL (225 × 109/L)
Erythropoietin 35 mU/mL (35 units/L)

Which of the following is the most appropriate management?

A) Initiate hydroxyurea
B) Order sleep study
C) Perform bone marrow biopsy
D) Perform phlebotomy

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


.

Quality of care


.
Study analyzes diagnostic errors in primary care

Diagnostic errors in primary care are often related to process breakdowns during the clinical encounter, according to a new study.

Researchers reviewed medical records of diagnostic errors at two sites, an urban Veterans Affairs facility and an integrated private health care system. The errors were detected by triggers in the electronic health record due to unexpected return visits after a first primary care visit between Oct. 1, 2006, and Sept. 30, 2007. The study's objective was to examine the diseases, diagnostic processes, and contributing factors involved in the errors. Main outcome measures were presenting symptoms at the initial visit, types of missed diagnoses, process breakdowns, possible contributing factors and potential harm. Results were published online Feb. 25 by JAMA Internal Medicine.

One hundred ninety unique diagnostic errors, defined as missed, delayed, or wrong diagnoses, were detected during the study period. Of these, 68 were unique missed diagnoses, including pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), primary cancer (5.3), and urinary tract infections or pyelonephritis (4.8%).

Process breakdowns were most common during the clinical encounter between the patient and the clinician providing primary care (78.9%) but were also seen in the referral process to other clinicians (19.5%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%); patient-related factors, such as provision of inaccurate medical information or problems with effective communication, were involved in 16.3%. More than one of these types of breakdowns was involved in 43.7% of the errors. Breakdowns during the clinical encounter most commonly occurred during the history taking (56.3%), examination (47.4%), or process of ordering further diagnostic tests (57.4%). In addition, 81.1% of cases had no differential diagnosis noted at the initial visit, and previous progress notes were copied and pasted into the index visit notes in 7.4% of cases. Moderate to severe harm was considered possible as a result of most of the errors.

The authors noted that their study was retrospective and that their results may not apply to primary care practices outside integrated health systems, among other limitations. However, they concluded that diagnostic errors in the primary care setting affected a variety of common diseases and could cause significant harm. They pointed out that most of the breakdowns occurred during the clinical encounter, when clinicians have increasingly become more and more pressed for time.

"Our findings highlight the need to focus on basic clinical skills and related cognitive processes (eg, data gathering within the medical history and physical examination and synthesis of data) in the age of increasing reliance on technology and team-based care to improve the health care system," they wrote. They called for preventive interventions that target common contributing factors, including data gathering and synthesis during the clinical encounter.

An accompanying editorial noted that while important lessons have been learned about diagnostic errors, it is difficult to determine effective solutions. The editorialists noted that generic strategies to reduce errors have not successfully improved patient outcomes. Hybrid fixes may be the best goal, they said, including modifying electronic health record systems so that they can continuously monitor diagnostic performance and provide timely, specific feedback.

"One critical step toward this last approach would be mandatory, structured recording and coding of presenting symptoms, rather than simply diagnoses, in our electronic health record systems," the editorialists wrote. "This step alone, if consistently performed, would radically transform our ability to track and reduce diagnostic errors." The editorialists called for all stakeholders to commit to improving diagnostic safety and quality as a top priority.



Cardiology


.
Increased walking impairment linked to higher mortality risk in PAD

Patients with peripheral arterial disease (PAD) whose walking ability decreased over a two-year period had a higher risk for death, a new study found.

Researchers asked men and women with PAD to complete the Walking Impairment Questionnaire (WIQ), a self-administered questionnaire specific to PAD, at baseline and again at two-year follow-up. The study aimed to determine whether increased decline in WIQ stair-climbing, distance or speed scores was associated with increased all-cause and cardiovascular disease mortality rates. Data on two-year changes in these variables were examined using Cox proportional hazards models and were adjusted for covariates including age, sex, race, ankle brachial index, body mass index, smoking and comorbid conditions. The study results were published March 5 by the Journal of the American College of Cardiology.

Overall, 442 men and women participated in the study. One hundred twenty-three (27.8%) died during a median of 4.7 years after the two-year follow-up assessment. Of these, 45 (36.6%) died of cardiovascular disease and 11 (8.9%) died of unknown causes. Older age was associated with the greatest decline in the two-year stair-climbing score, while more physical activity at baseline was associated with the greatest decline in distance score. The mean two-year score changes were −0.79, −1.78 and −1.55, respectively, for stair-climbing, distance and speed. Patients were followed for a median of 44.7 months for cardiovascular death.

After the data were adjusted for covariates, all-cause mortality was higher in patients whose WIQ score decreased 20 points or more over two years (hazard ratios, 1.93 [95% CI, 1.01 to 3.68] for stair climbing, 2.34 [95% CI, 1.15 to 4.75] for distance, and 3.55 [95% CI, 1.57 to 8.04] for speed) compared with patients whose score improved by 20 points or more. Patients whose distance score decreased by 20 points or more during the two-year period had higher cardiovascular disease mortality rates than those whose distance scores improved by 20 points or more (hazard ratio, 4.56 [95% CI, 1.30 to 16.01]).

The authors acknowledged that their results may not be generalizable to all patients with PAD and that unidentified characteristics may have affected their findings, among other limitations. However, they concluded that patients whose WIQ scores decrease over time are at greater risk for all-cause mortality. "Further study is needed to determine whether implementing measurement of two-year change in WIQ scores in clinical practice is associated with improved outcomes," they wrote.



FDA update


.
Peginesatide pulled from the market

All lots of the injectable anemia drug peginesatide (Omontys) have been recalled, due to new postmarketing reports of serious hypersensitivity reactions, some fatal.

To date, fatal reactions have been reported in approximately 0.02% of patients following the first dose of intravenous administration, according to an FDA alert. The reported serious hypersensitivity reactions have occurred within 30 minutes after such administration of the drug. There have been no reports of such reactions following subsequent doses or in patients who have completed their dialysis session.

More than 25,000 patients have received the drug, and hypersensitivity reactions have been reported in approximately 0.2%, with about a third of these categorized as serious, including anaphylaxis requiring prompt medical intervention and in some cases hospitalization.

The drug should be returned to the manufacturers, Affymax and Takeda, the FDA said.



From Annals of Internal Medicine


.
CME credits available in patient safety supplement

A supplement to the March 5 Annals of Internal Medicine, which offers 11 CME credits, focuses on a recent Agency for Healthcare Research and Quality–funded project, "Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices."

annals.jpg

The project leaders identified 41 patient safety strategies and conducted reviews of many of them. Ten of the reviews are included in the Annals supplement:

Each review has an accompanying CME quiz, and by completing these quizzes, physicians can earn 11 CME credits that meet professional responsibility and risk management requirements.

In addition, the March 5 issue includes Annals' first article in "graphic novel" format, which also deals with a patient safety issue, a missed diagnosis that haunts a physician throughout his professional life.



Internal Medicine 2013


.
ACP to conduct Annual Business Meeting

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2013. Current College Officers will retire from office and incoming Officers, new Regents and Governors-elect will be introduced.

The meeting will be held at the Moscone Center in San Francisco on Saturday, April 13, from 12:45 p.m. to 1:45 p.m., with outgoing ACP President David L. Bronson, MD, FACP, presiding. Dennis R. Schaberg, MD, MACP, will present the Annual Report of the Treasurer.

A key feature of the meeting is the presentation of ACP's priorities for 2013-14 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, MD, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.



From the College


.
ACP and MGMA-ACMPE collaborate on online cost survey

ACP and MGMA-ACMPE are working together to provide physicians an opportunity to participate in an exciting new streamlined MGMA 2013 Cost Survey.

The survey gathers financial and other data that can help with managing costs, comparing physician and staff compensation, optimizing clinician and office staffing and managing practice finances. Participants in the survey will receive a free report comparing their own practice to benchmarks of their peers.

Your participation in this influential survey will make a difference to your ACP peers and the industry. Historically, internal medicine and small practices have been under-represented, and your participation can help to ensure that reliable benchmarks can be provided. The survey deadline is April 19. To participate, go online.

If you have questions, please contact MGMA's Data Solutions toll-free at 877-275-6462, ext. 1895, or by e-mail.



Cartoon caption contest


.
Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

acpi-20130305-cartoon.jpg

"Are you part of the rabbit response team?"

"I think your problem is carotenemia."

"I'm all ears."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, March 11, with the winner announced in the March 12 issue.


.


MKSAP Answer and Critique



The correct answer is B) Order sleep study. This item is available to MKSAP 16 subscribers as item 25 in the Hematology and Oncology section.

MKSAP 16 released Part A on July 31, 2012, and Part B on Feb. 1, 2013. More information is available online.

This patient requires a sleep study to diagnose obstructive sleep apnea and nocturnal oxygen desaturation as a cause of secondary erythrocytosis. The diagnosis of secondary erythrocytosis is suggested by the elevated hemoglobin concentration and elevated erythropoietin level. In patients with polycythemia vera (PV), the erythropoietin level is suppressed. The most common cause of secondary erythrocytosis is hypoxic pulmonary disease. However, this patient's oxygen saturation is normal at rest and following modest exertion. Nocturnal oxygen desaturation due to obstructive sleep apnea is also a cause of secondary erythrocytosis, and this diagnosis is suggested by his snoring, obesity, and increased neck size, as well as his witnessed apneic episodes. If obstructive sleep apnea is confirmed by polysomnography, the patient's management would include continuous positive airway pressure.

PV is characterized by nonspecific symptoms including tinnitus, blurred vision, headache, and more specific symptoms including generalized pruritus that often worsens after bathing, erythromelalgia (a burning sensation in the palms and soles possibly caused by platelet activation), and splenomegaly, none of which are present in this patient. In addition, his leukocyte and platelet counts are not elevated as they often are in PV, and his elevated erythropoietin level essentially excludes PV. Treatment of PV is directed toward reducing the red blood cell mass and preventing thrombosis. Therapeutic phlebotomy and low-dose aspirin is the primary therapy for most patients. Hydroxyurea is often used in older symptomatic patients whose disorder cannot be controlled with phlebotomy and aspirin alone. Because this patient does not have PV, phlebotomy, low-dose aspirin, and hydroxyurea are not indicated.

An increased number of megakaryocytes and a hypercellular bone marrow are characteristic of PV, but bone marrow findings are not part of the Polycythemia Vera Study Group diagnostic criteria. Furthermore, although a hypercellular bone marrow is likely in a patient with secondary erythrocytosis, this finding does not establish the cause of the condition.

Key Point

  • In patients with confirmed erythrocytosis, an elevated serum erythropoietin level helps exclude polycythemia vera and suggests the presence of secondary erythrocytosis.

Click here to return to the rest of ACP InternistWeekly.

Top




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.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

This week's quiz asks readers to reevaluate a 55-year-old man during a follow-up examination for a wrist fracture and anemia.

Find the answer

ACP JournalWise

Reviews of the World's Top Medical Journals—FREE to ACP Members!

New CME Option: Internal Medicine 2014 RecordingsACP JournalWiseSM is mobile optimized with optional email alerts! Get access to reviews from over 120 of the world’s top medical journals alerting you to the highest quality, most clinically relevant new articles based on your preferred areas of specialty. ACP Members register your FREE account now!

New CME Option: Internal Medicine 2014 Recordings

New CME Package

New CME Option: Internal Medicine 2014 RecordingsIncludes 75 of the most popular sessions in internal medicine and the subspecialties. Stream the sessions, answer brief quizzes and earn CME credit. See details.