1. Medical Malpractice News Volume 5 Issue 1 Client Characteristics

2. Medical Litigation News Volume 2 Issue 1 Supplement Evidence Based Medicine - Entrenched Traditions

3. Unique Identifier 99358218
Author Elstein AS
Institution Department of Medical Education, University of Illinois College of Medicine at Chicago 60612-7309, USA. aelstein@uic.edu.
Title Heuristics and biases: selected errors in clinical reasoning.
Source Acad Med 1999 Jul;74(7): p791-4
ISSN 1040-2446
Abstract

Many clinical decisions are made in uncertainty. When the diagnosis is uncertain, the goal is to establish a diagnosis or to treat even if the diagnosis remains unknown. If the diagnosis is known (e.g., breast cancer or prostate cancer) but the treatment is risky and its outcome uncertain, still a choice must be made. In researching the psychology of clinical judgment and decision making, the major strategy is to compare observed clinical judgments and decisions with the normative model established by statistical decision theory. In this framework, the process of diagnosing is conceptualized as using imperfect information to revise opinions; Bayes' theorem is the formal rule for updating a diagnosis as new data are available. Treatment decisions should be made so as to maximize expected value. This essay uses Bayes' theorem and concepts from decision theory to describe and explain some well-documented errors in clinical reasoning. Heuristics and biases are the cognitive factors that produce these errors.

4. Unique Identifier 68398183
Author Dudley HA
Title Pay-off, heuristics, and pattern recognition in the diagnostic process.
Source Lancet 1968 Sep 28;2(7570): p723-6
ISSN 0140-6736


5. Medical Litigation News Volume 3 Issue 9 Burying Mistakes

6. Unique Identifier 98205043
Author Feske SK
Institution Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. skfeske@bics.bwh.harvard.edu.
Title Coma and confusional states: emergency diagnosis and management.
Source Neurol Clin 1998 May;16(2): p237-56
ISSN 0733-8619
Abstract

Coma and confusion signal a failure of brain function with many possible causes. Since many of the potential causes may quickly lead to death or severe disability, it is important to develop a focused and ordered approach to facilitate the rapid diagnosis and early institution of proper therapies. This requires an understanding of the localizing features of the neurologic examination and of the syndromes likely to cause coma and confusion, a predetermined plan for empiric therapies in certain cases of doubt when diagnostic confirmation will be delayed, and a careful consideration of cases when the diagnosis is not revealed by the initial neuroimaging, lumbar puncture, or EEG.

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7. Medical Litigation News Volume 3 Issue 3 Coronary Prevention

8. Unique Identifier 98368376
Author Goldberg RJ; O'Donnell C; Yarzebski J; Bigelow C; Savageau J; Gore JM
Institution Department of Medicine, Division of Cardiovascular Medicine, University of Massachusetts Medical Center, Worcester, USA.
Title Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective [see comments]
Source Am Heart J 1998 Aug;136(2): p189-95
ISSN 0002-8703
Abstract

OBJECTIVES: To describe sex differences in symptom presentation after acute myocardial infarction (AMI) while controlling for differences in age and other potentially confounding factors. BACKGROUND: Although several studies have examined sex differences in diagnosis, management, and survival after AMI, limited data exist about possible sex differences in symptom presentation in the setting of AMI. METHODS: Community-based study of patients hospitalized with confirmed AMI in all 16 metropolitan Worcester, Mass., hospitals (1990 census population = 437,000). Men (n = 810) and women (n = 550) hospitalized with validated AMI in 1986 and 1988 comprised the study sample. RESULTS: After simultaneously controlling for age, medical history, and AMI characteristics through regression modeling, men were significantly less likely to complain of neck pain (adjusted odds ratio (OR) = 0.52; 95% CI: 0.35, 0.78), back pain (OR = 0.38; 95% CI: 0.26, 0.56), jaw pain (OR = 0.50; 95% CI: 0.31, 0.81), and nausea (O.R. = 0.58; 95% CI: 0.45, 0.75) than women. Conversely, men were significantly more likely to report diaphoresis (OR = 1.27; 95% CI: 1.00, 1.61) than women. There were no statistically significant sex differences in complaints of chest pain though men were more likely to complain of this symptom. CONCLUSIONS: The results of this population-based observational study suggest differences in symptom presentation in men and women hospitalized with AMI. These findings have implications for public and health care provider education concerning recognition of sex differences in AMI-related symptoms and health care seeking behaviors.

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9. Unique Identifier 95225518
Author Green LA; Yates JF
Institution Department of Family Practice, University of Michigan Medical School, Ann Arbor.
Title Influence of pseudodiagnostic information on the evaluation of ischemic heart disease.
Source Ann Emerg Med 1995 Apr;25(4): p451-7
ISSN 0196-0644
Abstract

STUDY OBJECTIVES: To measure the influence of classic epidemiologic risk factors (as recorded on the chart) on physicians' admission decisionmaking for patients with suspected acute cardiac ischemia and to compare the influence of those risk factors, which are of limited predictive utility, to the influence of predictively useful information. DESIGN: Retrospective chart review. SETTING: Emergency departments of two community hospitals. PARTICIPANTS: Seven hundred eighty-seven patients evaluated for suspected acute cardiac ischemia, whether admitted or not. RESULTS: Logistic regression revealed that the effect of a recorded history of hypertension on the admission decision (OR, 7.89; 95% CI, 4.57 to 13.58) was greater than that for ST-segment changes on the ECG (OR, 3.98; 95% CI, 2.56 to 6.18) or history of infarction (OR, 2.36; 95% CI, 1.53 to 3.62). A recorded history of diabetes had a small effect (OR, 1.84; 95% CI, 1.01 to 3.36), whereas Q waves and T-wave changes were not statistically significant. CONCLUSION: Physicians' admission decisions appeared to be more heavily influenced by pseudodiagnostic information than by information of objective predictive power. Physicians do not appear to distinguish risk factors from diagnostic information; education may be directed at this distinction.

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10. Unique Identifier 87295752
Author Lee TH, Rouan GW, Weisberg MC, Brand DA, Acampora D, Stasiulewicz C, Walshon J, Terranova G, Gottlieb L, Goldstein-Wayne B, et al
Title Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room.
Source Am J Cardiol 1987 Aug 1;60(4):219-24
ISSN 0002-9149
Abstract

In a prospective multicenter investigation of emergency room patients with acute chest pain, physicians admitted 96% of patients with acute myocardial infarction (AMI) and discharged 4%. Of 35 patients who were sent home with AMI, only 11 (31%) returned to the same hospital because of persistent symptoms. Compared with a control group of 105 randomly selected patients with AMI who were admitted from the emergency room, patients in whom AMI was missed were significantly younger, had less typical symptoms and were less likely to to have had prior AMI or angina or to have electrocardiographic evidence of ischemia or infarction not known to be old. Despite the less typical presentations of patients in whom AMI was missed, after controlling for age and sex, the short-term mortality rate was significantly higher among patients in whom AMI was missed but in whom it was detected through our follow-up procedures than in admitted AMI patients. As determined by independent reviewers, 49% of the missed AMIs could have been diagnosed through improved electrocardiographic reading skills or by admission of patients with recognized ischemic pain at rest or ischemic electrocardiographic changes not known to be old.

11. Medical Litigation News Volume 2 Issue 7 Bacterial Endocarditis

12. Medical Litigation News Volume 2 Issue 8 Bacterial Meningitis

13. Unique Identifier 99282741
Author Shetty AK; Desselle BC; Craver RD; Steele RW
Institution Department of Pediatrics, Louisiana State University Medical Center, Children's Hospital, New Orleans, LA 70118, USA. avishetty@pol.net.
Title Fatal cerebral herniation after lumbar puncture in a patient with a normal computed tomography scan.
Source Pediatrics 1999 Jun;103(6 Pt 1): p1284-7
ISSN 0031-4005

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14. Medical Litigation News Volume 2 Issue 4 Missed Appendicitis

15. Unique Identifier 97213891
Author Hale DA; Molloy M; Pearl RH; Schutt DC; Jaques DP
Institution Quality Assurance Office, Assistant Secretary of Defense (Health Affairs), Washington, D.C., USA.
Title Appendectomy: a contemporary appraisal.
Source Ann Surg 1997 Mar;225(3): p252-61
ISSN 0003-4932
Abstract

OBJECTIVE: The authors present an accurate and comprehensive snapshot of appendicitis and the practice of appendectomy in the 1990s. METHODS: Appendectomies were performed on 4950 patients in 147 Department of Defense hospitals worldwide over a 12-month period ending January 31, 1993. RESULTS: The median age was 23 years (range, 6 months to 82 years) with 64% males and 36% females. The patients were assigned a diagnosis of normal appendix in 632 (13%) cases, acute appendicitis in 3286 (66%) cases, and perforated appendicitis in 1032 (21%) cases. There were no differences in perforation and normal appendix rates between those operations performed in teaching hospitals versus community hospitals or between high-volume hospitals (> or = 100 appendectomies/year) versus low-volume hospitals. Both a preoperative temperature > or = 100.5 and a preoperative leukocyte count > or = 10,000 were incapable of discriminating between patients with appendicitis and those with a normal appendix. Multivariate analysis showed a significantly increased risk of perforation associated with age younger than or equal to 8 years (38% vs. 18%) and age older than or equal to 45 years (49% vs. 18%). Females had a significantly higher rate of normal appendices (19% vs. 9%) and a lower rate of perforation (18% vs. 23%). The complication rates to include reoperation and intraabdominal sepsis were markedly increased in those patients with perforation. There were four deaths in this series (0.08%). CONCLUSIONS: Despite a marked decline in associated mortality over the past 50 years, rates of perforation and negative appendectomy remain unchanged because they are influenced strongly by factors untouched by the intervening technologic advances.

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16. Medical Malpractice News Volume 4 Issue 4 Pap Smear Revisited

17. Unique Identifier 88080793
Author Simon JB
Institution Department of Medicine, Queen's University, Kingston, Ontario, Canada.
Title The pros and cons of fecal occult blood testing for colorectal neoplasms.
Source Cancer Metastasis Rev 1987;6(3): p397-411
ISSN 0891-9992
Abstract

Testing feces for occult blood is widely recommended as a means of detecting subclinical colorectal tumors. Guaiac tests such as Hemoccult are the most widely used, but chemical sensitivity is relatively low and the tests are affected by dietary peroxidases, the state of fecal hydration, and certain drugs. The newly devised HemoQuant and immunologic techniques appear more sensitive and specific, but they require further evaluation before widespread clinical usage can be recommended. Occult blood screening has both merits and weaknesses. Testing does uncover subclinical colorectal cancer, often at a relatively early stage, but whether this actually improves the prognosis remains to be proven. Benign neoplastic polyps are also detected, although it is debatable whether this is a valid rationale for screening. Test sensitivity for malignancy varies from good to moderate, but is poor for benign polyps. Specificity is usually around 97%-98%, yet the predictive value of a positive test for cancer is only about 10%; hence most test-positive individuals are needlessly subjected to invasive colonic investigations. Reported figures on public compliance with occult blood testing vary widely from excellent to poor. Published costs of screening are usually quite low, but these overlook important indirect and hidden expenses and are therefore misleading. On balance, the problems of occult blood testing currently appear to outweight the merits. This could change, however, with the newer testing techniques and with awaited mortality data from controlled clinical trials now underway.

18. Unique Identifier 97320779
Author Khullar SK; Di Sario JA
Institution Division of Gastroenterology, University of Utah School of Medicine and Health Sciences Center, Salt Lake City, Utah 84132, USA.
Title Colon cancer screening. Sigmoidoscopy or colonoscopy.
Source Gastrointest Endosc Clin N Am 1997 Jul;7(3): p365-86
ISSN 1052-5157
Abstract

Colorectal cancer is a common neoplasia with high morbidity and mortality. With endoscopy it is possible to identify its precursor lesion, the adenoma, and early localized cancer. Early detection and removal of adenomas can reduce the incidence and mortality of this disease. Studies using fecal occult blood testing (FOBT) and sigmoidoscopy for screening asymptomatic patients demonstrate a reduction in mortality from colorectal cancer. Colonoscopy, however, has the highest yield for detecting polyps. Most authorities and organizations now recommend screening the asymptomatic population over age 50 for colorectal neoplasia. The estimated cost of colon cancer screening is well within the benchmark figure of $40,000 per year of life saved, which is considered by the government to be cost effective. Controversies still exist regarding which colon cancer screening strategy is the most sensitive, specific, acceptable to the population, and cost effective. The American Cancer Society recommends a combination of FOBT and flexible sigmoidoscopy, but some experts believe that a one-time colonoscopy at age 60 may be a more cost-effective method. If the costs of colonoscopy are reduced, it is more cost effective than other techniques. Colonoscopy also may help to stratify at-risk patients, and those with negative initial colonoscopy may not need further screening. Advances in molecular biology may provide markers for screening or identifying people who are at high risk for colorectal neoplasia. This development may allow screening to be directed at high-risk groups.

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