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7 July 2009 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit Past highlights are accessible as well.

Early Releases:

1. Travel Associated With Three-Fold Increase in Risk for Venous Thromboembolism

Hundreds of millions of people will embark on long-distance journeys this summer. With long-distance travel comes an increased risk for travel-related venous thrombeoembolism (VTE). VTE is a serious, potentially deadly condition where blood cells form a clot within a vein. While the relationship between travel and VTE is often discussed, results of prior studies are conflicting. To demonstrate the presence and magnitude of the association between long-distance travel and VTE, researchers studied reports investigating the association between travel and VTE for subjects using any mode of transportation and having non-travelling subjects for comparison. These reports included 4,055 cases of VTE. They found that travel is associated with a nearly three-fold higher risk of VTE, with a dose-response of 18 percent higher risk for each two-hour increase in travel duration. Researchers conclude that physicians should investigate the use of low-cost, low-risk interventions such as increased hydration and ambulation for all long-distance travelers. Additional interventions and therapies should be evaluated for higher risk subgroups.

2. Stepped Dosing May Help HIV Patients Suffering from Severe Side Effects of Efavirenz

Efavirenz is a proven antiretroviral therapy for HIV prescribed at a fixed dose of 600 mg/d. However, more than half of patients who start efavirenz treatment develop neuropsychiatric adverse events (NPAEs) such as dizziness, feelings of drunkenness or “hangover,” nightmares, and sleep disorders. Likewise, impaired concentration, mood changes, or severe psychiatric symptoms such as depression, suicidal thoughts, aggressive behavior, delirium, and paranoia, have also been reported. These side effects eventually subside, but some patients cannot tolerate the effects and have to stop taking the drug. In a randomized, double-blind, controlled trial, researchers studied 114 HIV-infected patients to determine if a stepwise dose of efavirenz could decrease the incidence and severity of NPAEs while maintaining virologic efficacy. Researchers found that stepped-dose administration of efavirenz over two weeks significantly decreases the incidence and severity of NPAEs while appearing to maintain the same efficacy over the short term as the standard schedule.


1. Poor Working Conditions May Affect Size of Primary Care Workforce, Patient Care

Studies suggest that adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care. However, little research has been done to assess how or if poor work conditions and adverse physician reactions (stress, burnout, and intent to leave) affect quality of patient care. Researchers studied 422 family practitioners and general internists at 119 clinics. Among the clinics studied, poor work conditions such as chaotic work pace, lack of control over work, and poor organizational culture were strongly associated with adverse physician reactions. However, adverse physician reactions to these conditions were not associated with worse quality patient care. The authors suggest that current practice redesign projects, such as those focusing on the patient-centered medical home, could be an opportunity to create healthier work environments for primary care physicians. Hospitals and clinics that focus on quality of work conditions may be better able to recruit and retain primary care physicians. More research is needed to determine if better work conditions could improve the quality of patient care and reduce medical errors.

2. Physicians Often Miss Abnormal Test Results on Patient Records

Studies have shown that physicians may not recognize up to 30 percent of abnormal test results in a timely manner. Missed test results can delay treatment, threaten patient safety, and lead to malpractice lawsuits. Despite evidence that missed test results are common, little research has been done to measure the effect. Researchers studied the electronic health records of 91 patients with newly diagnosed abdominal aortic dilation observed on computed tomography (CT). Using a comment on the medical record as evidence, the authors found that the clinical care team had not noticed the dilation in 58 percent of cases within three months of CT. In 18 percent of the cases, the dilations were never documented during an average follow-up of more than three years. According to the researchers, these delays and failures did not lead to patient complications or mortalities. The researchers conclude that their findings highlight the need for innovative solutions to ensure that physician awareness of abnormal test results is consistently documented in the medical record.

3. Sox Farewell Editorial: Funding for Medical Journals: Who Should Pay?

In his final editorial as editor of Annals of Internal Medicine , Harold C. Sox, MD, MACP expresses concern about the source of funding for medical journals. According to Dr. Sox, medical journals provide a unique public service because they play a pivotal role in linking research to better medical practice. However, good journal editing is very expensive, and resources to support it are shrinking. Dr. Sox asks, “Who shall pay for good editorial practices?” Should advertisers pay? Or would physicians be willing to pay higher membership dues or subscription fees to support good editing? As for the public, Dr. Sox suggests that because good journal editing benefits everyone, perhaps the public should pay part of the costs.

Angela Collom
Office: 215-351-2653
Mobile: 856-759-7157

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