John R. Bell

BALTIMORE — When deciding which drug to prescribe for a patient with restless legs syndrome, the frequency and painfulness of symptoms are crucial to making the correct choice, Dr. Christopher J. Earley said at a neurology meeting sponsored by Johns Hopkins University.

“For [75%]–80%, depending on the population that you deal with, pain is not what they experience,” said Dr. Earley, a neurologist at Johns Hopkins. A far greater portion instead describe their RLS as uncomfortable, he said. But for those with painful RLS, that pain must be treated. “So I tend to use the antiseizure medications [e.g., gabapentin, lamotrigine, pregabalin] or the opiates as my first line of treatment, as opposed to the dopamine [DA] agents, when I'm dealing with painful symptoms,” he said. If it's partially responsive … then I will consider the dopamine agonists. If I really get desperate … I might consider sedation.”

For painless nightly RLS, he advises a DA agonist as first-line therapy, opiates as a second-line choice, and sedatives as third-line treatment. Frequent painless RLS (2–3 nights per week) warrants a sedative first, followed by opiates and, if those fail, levodopa. For occasional RLS (less than twice per week), he advises either a half or whole tablet of carbidopa 25 mg/levodopa 100 mg (available as Sinemet and Parcopa brands) as needed for first-line therapy. “This is going to be effective in 99.9% of patients, barring side effects like nausea,” he said.

He recommends a DA agonist and a sedative as second- and third-line treatment, respectively. Drugs that can aggravate RLS include neuroleptics and antiemetics, as well as SSRIs and tricyclic antidepressants (except for bupropion and trazodone) and antihistamines.

A disadvantage of the DA agonists is that they take 2 hours to reach peak dose effect (3 hours if taken with a meal or after symptom onset), compared with 30–60 minutes for opiates. Thus dopamine agonists are most useful for situations such as airplane flights, he said, but less practical for nighttime RLS. Dr. Earley favors levodopa for occasional nonpainful RLS. “If you have any doubts about whether this is RLS or not RLS, you can use the levodopa”-carbidopa combination (carbidopa 25 mg/levodopa 100 mg) of half to 1 1/2 tablets for 3 days. “If they get no real benefits from that, this is not RLS—at least not the RLS that I know.”

The DA agonists do have other disadvantages besides their delayed effect, Dr. Earley noted. They can cause compulsive behaviors. They also can cause hypersomnia. “It's almost like narcolepsy,” he said. Moreover, DA agonists risk the phenomenon of augmentation, whereby an increase in dosage leads to an increase in symptoms, so that a patient is treated effectively for a time period in which RLS occurs (e.g., bedtime), but then the RLS begins to occur either before or after the treated period. “Augmentation is the single biggest reason why you have to stop this drug.” He advised that when patients taking a DA agonist for sleep complain of RLS symptoms before or after bedtime, the physician should not prescribe additional drugs.

Notably, opiates do not pose augmentation risk, he said. With opiates, “you're going to get about 85% of them up walking away relatively happy.”

Iron deficiency has been implicated as a possible cause of RLS, he noted. “I check ferritins in everybody,” he said.

BALTIMORE — When deciding which drug to prescribe for a patient with restless legs syndrome, the frequency and painfulness of symptoms are crucial to making the correct choice, Dr. Christopher J. Earley said at a neurology meeting sponsored by Johns Hopkins University.

“For [75%]–80%, depending on the population that you deal with, pain is not what they experience,” said Dr. Earley, a neurologist at Johns Hopkins. A far greater portion instead describe their RLS as uncomfortable, he said. But for those with painful RLS, that pain must be treated. “So I tend to use the antiseizure medications [e.g., gabapentin, lamotrigine, pregabalin] or the opiates as my first line of treatment, as opposed to the dopamine [DA] agents, when I'm dealing with painful symptoms,” he said. If it's partially responsive … then I will consider the dopamine agonists. If I really get desperate … I might consider sedation.”

For painless nightly RLS, he advises a DA agonist as first-line therapy, opiates as a second-line choice, and sedatives as third-line treatment. Frequent painless RLS (2–3 nights per week) warrants a sedative first, followed by opiates and, if those fail, levodopa. For occasional RLS (less than twice per week), he advises either a half or whole tablet of carbidopa 25 mg/levodopa 100 mg (available as Sinemet and Parcopa brands) as needed for first-line therapy. “This is going to be effective in 99.9% of patients, barring side effects like nausea,” he said.

He recommends a DA agonist and a sedative as second- and third-line treatment, respectively. Drugs that can aggravate RLS include neuroleptics and antiemetics, as well as SSRIs and tricyclic antidepressants (except for bupropion and trazodone) and antihistamines.

A disadvantage of the DA agonists is that they take 2 hours to reach peak dose effect (3 hours if taken with a meal or after symptom onset), compared with 30–60 minutes for opiates. Thus dopamine agonists are most useful for situations such as airplane flights, he said, but less practical for nighttime RLS. Dr. Earley favors levodopa for occasional nonpainful RLS. “If you have any doubts about whether this is RLS or not RLS, you can use the levodopa”-carbidopa combination (carbidopa 25 mg/levodopa 100 mg) of half to 1 1/2 tablets for 3 days. “If they get no real benefits from that, this is not RLS—at least not the RLS that I know.”

The DA agonists do have other disadvantages besides their delayed effect, Dr. Earley noted. They can cause compulsive behaviors. They also can cause hypersomnia. “It's almost like narcolepsy,” he said. Moreover, DA agonists risk the phenomenon of augmentation, whereby an increase in dosage leads to an increase in symptoms, so that a patient is treated effectively for a time period in which RLS occurs (e.g., bedtime), but then the RLS begins to occur either before or after the treated period. “Augmentation is the single biggest reason why you have to stop this drug.” He advised that when patients taking a DA agonist for sleep complain of RLS symptoms before or after bedtime, the physician should not prescribe additional drugs.

Notably, opiates do not pose augmentation risk, he said. With opiates, “you're going to get about 85% of them up walking away relatively happy.”

Iron deficiency has been implicated as a possible cause of RLS, he noted. “I check ferritins in everybody,” he said.

BALTIMORE — When deciding which drug to prescribe for a patient with restless legs syndrome, the frequency and painfulness of symptoms are crucial to making the correct choice, Dr. Christopher J. Earley said at a neurology meeting sponsored by Johns Hopkins University.

“For [75%]–80%, depending on the population that you deal with, pain is not what they experience,” said Dr. Earley, a neurologist at Johns Hopkins. A far greater portion instead describe their RLS as uncomfortable, he said. But for those with painful RLS, that pain must be treated. “So I tend to use the antiseizure medications [e.g., gabapentin, lamotrigine, pregabalin] or the opiates as my first line of treatment, as opposed to the dopamine [DA] agents, when I'm dealing with painful symptoms,” he said. If it's partially responsive … then I will consider the dopamine agonists. If I really get desperate … I might consider sedation.”

For painless nightly RLS, he advises a DA agonist as first-line therapy, opiates as a second-line choice, and sedatives as third-line treatment. Frequent painless RLS (2–3 nights per week) warrants a sedative first, followed by opiates and, if those fail, levodopa. For occasional RLS (less than twice per week), he advises either a half or whole tablet of carbidopa 25 mg/levodopa 100 mg (available as Sinemet and Parcopa brands) as needed for first-line therapy. “This is going to be effective in 99.9% of patients, barring side effects like nausea,” he said.

He recommends a DA agonist and a sedative as second- and third-line treatment, respectively. Drugs that can aggravate RLS include neuroleptics and antiemetics, as well as SSRIs and tricyclic antidepressants (except for bupropion and trazodone) and antihistamines.

A disadvantage of the DA agonists is that they take 2 hours to reach peak dose effect (3 hours if taken with a meal or after symptom onset), compared with 30–60 minutes for opiates. Thus dopamine agonists are most useful for situations such as airplane flights, he said, but less practical for nighttime RLS. Dr. Earley favors levodopa for occasional nonpainful RLS. “If you have any doubts about whether this is RLS or not RLS, you can use the levodopa”-carbidopa combination (carbidopa 25 mg/levodopa 100 mg) of half to 1 1/2 tablets for 3 days. “If they get no real benefits from that, this is not RLS—at least not the RLS that I know.”

The DA agonists do have other disadvantages besides their delayed effect, Dr. Earley noted. They can cause compulsive behaviors. They also can cause hypersomnia. “It's almost like narcolepsy,” he said. Moreover, DA agonists risk the phenomenon of augmentation, whereby an increase in dosage leads to an increase in symptoms, so that a patient is treated effectively for a time period in which RLS occurs (e.g., bedtime), but then the RLS begins to occur either before or after the treated period. “Augmentation is the single biggest reason why you have to stop this drug.” He advised that when patients taking a DA agonist for sleep complain of RLS symptoms before or after bedtime, the physician should not prescribe additional drugs.

Notably, opiates do not pose augmentation risk, he said. With opiates, “you're going to get about 85% of them up walking away relatively happy.”

Iron deficiency has been implicated as a possible cause of RLS, he noted. “I check ferritins in everybody,” he said.

Colonoscopy detects cancers and advanced neoplasia at a higher rate in men than in women, according to a cross-sectional analysis of more than 50,000 participants in a Polish national colon cancer screening program.

The findings suggest that screening guidelines should include male sex as a risk factor.

Dr. Jaroslaw Regula of the Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, and colleagues analyzed data from 43,042 people aged 50–66 years and 7,106 people aged 40–49 years who had reported a family history of any type of cancer. Participants had been referred by general or family physicians at any of 40 sites in Poland and were excluded if they had colon cancer or clinical signs thereof, or a colonoscopy within the last 10 years.

In the younger cohort, colonoscopy detected 124 advanced neoplasias (ANS) in 2.8% of women and 4.5% of men. Similarly, in patients aged 50 years or older, colonoscopy detected AN in 4.5% of women and 8.5% of men (N. Engl. J. Med. 2006;355:1863–72).

The number needed to screen to detect AN in the large bowel was lower for men than for women in all age groups: 30 vs. 52, respectively, in the 40- to 49-year-old age group, 18 vs. 31 in the 50–54 group, 12 vs. 23 in those 55–59 years old, and 10 vs. 19 in those aged 60–66 years.

“We identified male sex as an independent predictor of advanced neoplasia,” Dr. Regula and colleagues wrote. “This finding suggests that the screening recommendations should be modified in order to ensure the maximal diagnostic yield of the screening and the optimal use of resources.” Current screening guidelines, such as those from the American College of Gastroenterology and the U.S. Preventive Services Task Force, call for colonoscopy screening to begin at age 50 and do not make specific recommendations according to sex.

Colonoscopy detects cancers and advanced neoplasia at a higher rate in men than in women, according to a cross-sectional analysis of more than 50,000 participants in a Polish national colon cancer screening program.

The findings suggest that screening guidelines should include male sex as a risk factor.

Dr. Jaroslaw Regula of the Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, and colleagues analyzed data from 43,042 people aged 50–66 years and 7,106 people aged 40–49 years who had reported a family history of any type of cancer. Participants had been referred by general or family physicians at any of 40 sites in Poland and were excluded if they had colon cancer or clinical signs thereof, or a colonoscopy within the last 10 years.

In the younger cohort, colonoscopy detected 124 advanced neoplasias (ANS) in 2.8% of women and 4.5% of men. Similarly, in patients aged 50 years or older, colonoscopy detected AN in 4.5% of women and 8.5% of men (N. Engl. J. Med. 2006;355:1863–72).

The number needed to screen to detect AN in the large bowel was lower for men than for women in all age groups: 30 vs. 52, respectively, in the 40- to 49-year-old age group, 18 vs. 31 in the 50–54 group, 12 vs. 23 in those 55–59 years old, and 10 vs. 19 in those aged 60–66 years.

“We identified male sex as an independent predictor of advanced neoplasia,” Dr. Regula and colleagues wrote. “This finding suggests that the screening recommendations should be modified in order to ensure the maximal diagnostic yield of the screening and the optimal use of resources.” Current screening guidelines, such as those from the American College of Gastroenterology and the U.S. Preventive Services Task Force, call for colonoscopy screening to begin at age 50 and do not make specific recommendations according to sex.

Colonoscopy detects cancers and advanced neoplasia at a higher rate in men than in women, according to a cross-sectional analysis of more than 50,000 participants in a Polish national colon cancer screening program.

The findings suggest that screening guidelines should include male sex as a risk factor.

Dr. Jaroslaw Regula of the Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, and colleagues analyzed data from 43,042 people aged 50–66 years and 7,106 people aged 40–49 years who had reported a family history of any type of cancer. Participants had been referred by general or family physicians at any of 40 sites in Poland and were excluded if they had colon cancer or clinical signs thereof, or a colonoscopy within the last 10 years.

In the younger cohort, colonoscopy detected 124 advanced neoplasias (ANS) in 2.8% of women and 4.5% of men. Similarly, in patients aged 50 years or older, colonoscopy detected AN in 4.5% of women and 8.5% of men (N. Engl. J. Med. 2006;355:1863–72).

The number needed to screen to detect AN in the large bowel was lower for men than for women in all age groups: 30 vs. 52, respectively, in the 40- to 49-year-old age group, 18 vs. 31 in the 50–54 group, 12 vs. 23 in those 55–59 years old, and 10 vs. 19 in those aged 60–66 years.

“We identified male sex as an independent predictor of advanced neoplasia,” Dr. Regula and colleagues wrote. “This finding suggests that the screening recommendations should be modified in order to ensure the maximal diagnostic yield of the screening and the optimal use of resources.” Current screening guidelines, such as those from the American College of Gastroenterology and the U.S. Preventive Services Task Force, call for colonoscopy screening to begin at age 50 and do not make specific recommendations according to sex.

WASHINGTON — Much of the public harbors misperceptions about influenza and vaccination against it, according to data from a nationwide survey presented at a press briefing sponsored by the National Foundation for Infectious Diseases.

In the Public Perception of Influenza, Vaccination and Treatment Options Survey, randomly administered via telephone to more than 1,000 adults in all 50 states, only 48% of the respondents said they planned to be immunized this year.

Reasons given for not seeking immunization included the belief that influenza is not a serious enough disease to warrant vaccination (43%), that they were personally not at risk (38%), that they previously contracted the flu even after being vaccinated (23%), and that vaccination in a prior influenza season would offer protection against current infection (15%).

Overall, 46% of respondents believed influenza vaccine can cause influenza. Also, 30% said the vaccine is not worthwhile because it protects against only three strains of influenza. Many said vaccination in December or later was too late to be effective.

These findings underscore the need for physicians to recommend vaccination to their patients, said Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases. A direct recommendation from a health care provider “was one of the major drivers for individuals getting influenza vaccine,” she said.

“The medical community must also reinforce the public health benefits of vaccination in the later season,” Dr. Rehm said, “by educating patients throughout the winter months … about the benefits of the vaccine, even if disease has already begun to be seen in their area.”

Also of concern: Only 49% of respondents knew annual influenza vaccination is recommended for pregnant women.

WASHINGTON — Much of the public harbors misperceptions about influenza and vaccination against it, according to data from a nationwide survey presented at a press briefing sponsored by the National Foundation for Infectious Diseases.

In the Public Perception of Influenza, Vaccination and Treatment Options Survey, randomly administered via telephone to more than 1,000 adults in all 50 states, only 48% of the respondents said they planned to be immunized this year.

Reasons given for not seeking immunization included the belief that influenza is not a serious enough disease to warrant vaccination (43%), that they were personally not at risk (38%), that they previously contracted the flu even after being vaccinated (23%), and that vaccination in a prior influenza season would offer protection against current infection (15%).

Overall, 46% of respondents believed influenza vaccine can cause influenza. Also, 30% said the vaccine is not worthwhile because it protects against only three strains of influenza. Many said vaccination in December or later was too late to be effective.

These findings underscore the need for physicians to recommend vaccination to their patients, said Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases. A direct recommendation from a health care provider “was one of the major drivers for individuals getting influenza vaccine,” she said.

“The medical community must also reinforce the public health benefits of vaccination in the later season,” Dr. Rehm said, “by educating patients throughout the winter months … about the benefits of the vaccine, even if disease has already begun to be seen in their area.”

Also of concern: Only 49% of respondents knew annual influenza vaccination is recommended for pregnant women.

WASHINGTON — Much of the public harbors misperceptions about influenza and vaccination against it, according to data from a nationwide survey presented at a press briefing sponsored by the National Foundation for Infectious Diseases.

In the Public Perception of Influenza, Vaccination and Treatment Options Survey, randomly administered via telephone to more than 1,000 adults in all 50 states, only 48% of the respondents said they planned to be immunized this year.

Reasons given for not seeking immunization included the belief that influenza is not a serious enough disease to warrant vaccination (43%), that they were personally not at risk (38%), that they previously contracted the flu even after being vaccinated (23%), and that vaccination in a prior influenza season would offer protection against current infection (15%).

Overall, 46% of respondents believed influenza vaccine can cause influenza. Also, 30% said the vaccine is not worthwhile because it protects against only three strains of influenza. Many said vaccination in December or later was too late to be effective.

These findings underscore the need for physicians to recommend vaccination to their patients, said Dr. Susan J. Rehm, medical director of the National Foundation for Infectious Diseases. A direct recommendation from a health care provider “was one of the major drivers for individuals getting influenza vaccine,” she said.

“The medical community must also reinforce the public health benefits of vaccination in the later season,” Dr. Rehm said, “by educating patients throughout the winter months … about the benefits of the vaccine, even if disease has already begun to be seen in their area.”

Also of concern: Only 49% of respondents knew annual influenza vaccination is recommended for pregnant women.

Leaders of academic internal medicine are developing plans to reform training so residents can spend more time in ambulatory settings and programs can promote residents on the basis of their mastery of certain skills.

The recently convened Education Redesign Task Force of the Alliance for Academic Internal Medicine (AAIM) is expected to issue its final report in the first half of 2007.

The task force recommendations are likely to guide those of the Residency Review Committee for Internal Medicine of the Accreditation Council for Graduate Medical Education, which updates its requirements every 3 years, according to Dr. Barbara Schuster, president of the Association of Professors of Medicine, one of the component organizations of the AAIM. (The other four AAIM organizations are the Association of Program Directors in Internal Medicine, the Association of Specialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine.)

The task force, which met in October in New Orleans during an AAIM meeting that was closed to the press, focused its efforts on defining the core curriculum of internal medicine residency, identifying resources needed in residency programs, and assessing ways to evaluate residents, Dr. Schuster said in an interview.

The committee also discussed basing training and progress within residency on demonstration of the specific ACGME competencies, rather than gauging progress by the clock, she said. Those competencies are patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.

Giving residents more training in ambulatory care was of great interest, Dr. Schuster said. One option discussed by the task force, she said, was having residents spend 3 months in ambulatory care and then rotate back to the hospital, instead of spending a half day in ambulatory care every week. Educators are concerned that having residents spend a half day each week is not effective, and that residents sometimes can't come into the ambulatory clinic “because they've been on call the night before.”

That sentiment was shared by two internists from the University of California-Davis Medical Center in Sacramento who attended the meeting.

“One criticism is that we have residents spend too much time in the hospital,” said Dr. Craig R. Keenan, director of the primary care residency program. But a change would require reforms in funding of residency programs, he said, given that teaching hospitals and university medical schools are funded in large part based on the number of patients who receive treatment from residents in the hospital.

Another potential obstacle is the integral role that teaching hospitals—and by extension, their residents—play in caring for the uninsured and underinsured, said Dr. Mark C. Henderson, vice chair for education in the internal medicine department. “Teaching hospitals bear the largest share of uncompensated care,” he said. “So most of the underinsured are taken care of by residents in the large urban centers. To take residents away to offices, where they can get better training, could worsen the crisis of care for the uninsured and underinsured.”

Thus “the stewards of the teaching programs … have to advocate to disentangle our residents from the financial and service needs of their teaching hospitals,” he said.

Promotion within residency is an area that many IM educators consider to be in need of change, Dr. Henderson said. “People are promoted from the first year to the second year to the third year based on how much time they've spent in the program,” he said.

“The problem is that in that 1 year, two residents may have a very different actual clinical experience. One resident may see twice as many patients as another resident. So the question becomes, why do you promote people within the 3 years simply based on the amount of time they've spent?

Wouldn't it be better to promote them based on the acquisition of certain required skills or competencies?”

But such an approach would require more intense supervision of each resident, he noted.

Residency reform is needed to address the dearth of IM residents, Dr. Henderson added. “Fewer students are choosing internal medicine as a career—and this has implications not only for the quality of individuals who go into internal medicine but also for the workforce.”

Given the aging U.S. population, this shortage could lead to a national crisis in primary care.

Recruitment to internal medicine, particularly general internal medicine, may be stymied by value differences between two generations—physicians in current practice and those now going into resident training.

One option is to have residents spend 3 months in ambulatory care and then rotate back to the hospital. DR. SCHUSTER

Leaders of academic internal medicine are developing plans to reform training so residents can spend more time in ambulatory settings and programs can promote residents on the basis of their mastery of certain skills.

The recently convened Education Redesign Task Force of the Alliance for Academic Internal Medicine (AAIM) is expected to issue its final report in the first half of 2007.

The task force recommendations are likely to guide those of the Residency Review Committee for Internal Medicine of the Accreditation Council for Graduate Medical Education, which updates its requirements every 3 years, according to Dr. Barbara Schuster, president of the Association of Professors of Medicine, one of the component organizations of the AAIM. (The other four AAIM organizations are the Association of Program Directors in Internal Medicine, the Association of Specialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine.)

The task force, which met in October in New Orleans during an AAIM meeting that was closed to the press, focused its efforts on defining the core curriculum of internal medicine residency, identifying resources needed in residency programs, and assessing ways to evaluate residents, Dr. Schuster said in an interview.

The committee also discussed basing training and progress within residency on demonstration of the specific ACGME competencies, rather than gauging progress by the clock, she said. Those competencies are patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.

Giving residents more training in ambulatory care was of great interest, Dr. Schuster said. One option discussed by the task force, she said, was having residents spend 3 months in ambulatory care and then rotate back to the hospital, instead of spending a half day in ambulatory care every week. Educators are concerned that having residents spend a half day each week is not effective, and that residents sometimes can't come into the ambulatory clinic “because they've been on call the night before.”

That sentiment was shared by two internists from the University of California-Davis Medical Center in Sacramento who attended the meeting.

“One criticism is that we have residents spend too much time in the hospital,” said Dr. Craig R. Keenan, director of the primary care residency program. But a change would require reforms in funding of residency programs, he said, given that teaching hospitals and university medical schools are funded in large part based on the number of patients who receive treatment from residents in the hospital.

Another potential obstacle is the integral role that teaching hospitals—and by extension, their residents—play in caring for the uninsured and underinsured, said Dr. Mark C. Henderson, vice chair for education in the internal medicine department. “Teaching hospitals bear the largest share of uncompensated care,” he said. “So most of the underinsured are taken care of by residents in the large urban centers. To take residents away to offices, where they can get better training, could worsen the crisis of care for the uninsured and underinsured.”

Thus “the stewards of the teaching programs … have to advocate to disentangle our residents from the financial and service needs of their teaching hospitals,” he said.

Promotion within residency is an area that many IM educators consider to be in need of change, Dr. Henderson said. “People are promoted from the first year to the second year to the third year based on how much time they've spent in the program,” he said.

“The problem is that in that 1 year, two residents may have a very different actual clinical experience. One resident may see twice as many patients as another resident. So the question becomes, why do you promote people within the 3 years simply based on the amount of time they've spent?

Wouldn't it be better to promote them based on the acquisition of certain required skills or competencies?”

But such an approach would require more intense supervision of each resident, he noted.

Residency reform is needed to address the dearth of IM residents, Dr. Henderson added. “Fewer students are choosing internal medicine as a career—and this has implications not only for the quality of individuals who go into internal medicine but also for the workforce.”

Given the aging U.S. population, this shortage could lead to a national crisis in primary care.

Recruitment to internal medicine, particularly general internal medicine, may be stymied by value differences between two generations—physicians in current practice and those now going into resident training.

One option is to have residents spend 3 months in ambulatory care and then rotate back to the hospital. DR. SCHUSTER

Leaders of academic internal medicine are developing plans to reform training so residents can spend more time in ambulatory settings and programs can promote residents on the basis of their mastery of certain skills.

The recently convened Education Redesign Task Force of the Alliance for Academic Internal Medicine (AAIM) is expected to issue its final report in the first half of 2007.

The task force recommendations are likely to guide those of the Residency Review Committee for Internal Medicine of the Accreditation Council for Graduate Medical Education, which updates its requirements every 3 years, according to Dr. Barbara Schuster, president of the Association of Professors of Medicine, one of the component organizations of the AAIM. (The other four AAIM organizations are the Association of Program Directors in Internal Medicine, the Association of Specialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine.)

The task force, which met in October in New Orleans during an AAIM meeting that was closed to the press, focused its efforts on defining the core curriculum of internal medicine residency, identifying resources needed in residency programs, and assessing ways to evaluate residents, Dr. Schuster said in an interview.

The committee also discussed basing training and progress within residency on demonstration of the specific ACGME competencies, rather than gauging progress by the clock, she said. Those competencies are patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.

Giving residents more training in ambulatory care was of great interest, Dr. Schuster said. One option discussed by the task force, she said, was having residents spend 3 months in ambulatory care and then rotate back to the hospital, instead of spending a half day in ambulatory care every week. Educators are concerned that having residents spend a half day each week is not effective, and that residents sometimes can't come into the ambulatory clinic “because they've been on call the night before.”

That sentiment was shared by two internists from the University of California-Davis Medical Center in Sacramento who attended the meeting.

“One criticism is that we have residents spend too much time in the hospital,” said Dr. Craig R. Keenan, director of the primary care residency program. But a change would require reforms in funding of residency programs, he said, given that teaching hospitals and university medical schools are funded in large part based on the number of patients who receive treatment from residents in the hospital.

Another potential obstacle is the integral role that teaching hospitals—and by extension, their residents—play in caring for the uninsured and underinsured, said Dr. Mark C. Henderson, vice chair for education in the internal medicine department. “Teaching hospitals bear the largest share of uncompensated care,” he said. “So most of the underinsured are taken care of by residents in the large urban centers. To take residents away to offices, where they can get better training, could worsen the crisis of care for the uninsured and underinsured.”

Thus “the stewards of the teaching programs … have to advocate to disentangle our residents from the financial and service needs of their teaching hospitals,” he said.

Promotion within residency is an area that many IM educators consider to be in need of change, Dr. Henderson said. “People are promoted from the first year to the second year to the third year based on how much time they've spent in the program,” he said.

“The problem is that in that 1 year, two residents may have a very different actual clinical experience. One resident may see twice as many patients as another resident. So the question becomes, why do you promote people within the 3 years simply based on the amount of time they've spent?

Wouldn't it be better to promote them based on the acquisition of certain required skills or competencies?”

But such an approach would require more intense supervision of each resident, he noted.

Residency reform is needed to address the dearth of IM residents, Dr. Henderson added. “Fewer students are choosing internal medicine as a career—and this has implications not only for the quality of individuals who go into internal medicine but also for the workforce.”

Given the aging U.S. population, this shortage could lead to a national crisis in primary care.

Recruitment to internal medicine, particularly general internal medicine, may be stymied by value differences between two generations—physicians in current practice and those now going into resident training.

One option is to have residents spend 3 months in ambulatory care and then rotate back to the hospital. DR. SCHUSTER

SAN ANTONIO — Dogs serving as visitation-therapy animals in health care facilities have tested positive for Clostridium difficile and can also harbor Salmonella and methicillin-resistant Staphylococcus aureus, according to new research.

Sandra Lefebvre, D.V.M., and her colleagues of the Ontario Veterinary College at the University of Guelph discussed her group's findings on C. difficile in a poster presentation at a meeting of the Southwest Conference on Diseases in Nature Transmissible to Man.

They collected fecal samples from dogs used in a hospital visitation program in Ontario and used polymerase chain reaction techniques to identify microorganisms in the samples. They found C. difficile in 58 (57%) of the 102 dogs. Of the strains identified, 10% were indistinguishable from human strains.

One dog, a toy poodle, shed an epidemic strain of the bacteria.

The investigators discovered that this healthy animal had previously visited a hospital with documented cases of C. difficile-associated disease. Dr. Lefebvre and her colleagues recently reported these findings in a published letter (Emerg. Infect. Dis. 2006;12:1036–7).

The group is currently conducting a prospective cohort canine study that has revealed perhaps a more ominous discovery.

“We're finding that dogs are picking up MRSA, too,” as well as Salmonella, Dr. Lefebvre said in an interview with PEDIATRIC NEWS.

She noted that the dogs often lick the hand of a patient with the infection and then lick a noninfected patient, risking transmission of the disease. Such findings do not prove that dogs have spread such diseases to humans, her group wrote—but “they certainly support that possibility.”

Furthermore, visitation dogs then return to the home and neighborhood, where they can spread the disease to humans and other dogs, she said at the meeting, held in conjunction with the International Conference on Diseases in Nature Communicable to Man.

Three dogs so far have tested positive for MRSA after visiting hospitals, but one dog with no such exposure has also tested positive.

“These animals are going from patient to patient, getting up onto beds and licking people,” Dr. Lefebvre said. “They also lick and are handled by health care workers, who are notorious for having contaminated hands.”

She added that the MRSA found so far in the dogs is community acquired—an ominous fact, given that this type of bacterium (unlike the less robust hospital-acquired variant) often infects healthy individuals, rather than the elderly and immunocompromised.

Additionally, one-third of the dogs have so far tested positive for Salmonella, she noted, speculating that a diet containing raw meat or poultry (common among visitation dogs) could be the prime source of this bacterium.

Dr. Lefebvre emphasized that, even in light of these findings, she personally supports animal-visitation programs and believes they “spread more good than harm…. But people are being really naive in their approaches, and they need to practice more intact vector control than they are right now.

“A few simple precautions, particularly practicing hand hygiene [before and] after handling the animals, can reduce the potential harms—to both pets and people,” Dr. Lefebvre said.

She also pointed to the dogs' habit of licking as a principal link in the disease-transmission chain.

“I think it's a bad idea to … let dogs lick people and think there are no ramifications for that,” she said.

Dr. Lefebvre also advised that people caring for visitation dogs not feed them raw meat or poultry.

SAN ANTONIO — Dogs serving as visitation-therapy animals in health care facilities have tested positive for Clostridium difficile and can also harbor Salmonella and methicillin-resistant Staphylococcus aureus, according to new research.

Sandra Lefebvre, D.V.M., and her colleagues of the Ontario Veterinary College at the University of Guelph discussed her group's findings on C. difficile in a poster presentation at a meeting of the Southwest Conference on Diseases in Nature Transmissible to Man.

They collected fecal samples from dogs used in a hospital visitation program in Ontario and used polymerase chain reaction techniques to identify microorganisms in the samples. They found C. difficile in 58 (57%) of the 102 dogs. Of the strains identified, 10% were indistinguishable from human strains.

One dog, a toy poodle, shed an epidemic strain of the bacteria.

The investigators discovered that this healthy animal had previously visited a hospital with documented cases of C. difficile-associated disease. Dr. Lefebvre and her colleagues recently reported these findings in a published letter (Emerg. Infect. Dis. 2006;12:1036–7).

The group is currently conducting a prospective cohort canine study that has revealed perhaps a more ominous discovery.

“We're finding that dogs are picking up MRSA, too,” as well as Salmonella, Dr. Lefebvre said in an interview with PEDIATRIC NEWS.

She noted that the dogs often lick the hand of a patient with the infection and then lick a noninfected patient, risking transmission of the disease. Such findings do not prove that dogs have spread such diseases to humans, her group wrote—but “they certainly support that possibility.”

Furthermore, visitation dogs then return to the home and neighborhood, where they can spread the disease to humans and other dogs, she said at the meeting, held in conjunction with the International Conference on Diseases in Nature Communicable to Man.

Three dogs so far have tested positive for MRSA after visiting hospitals, but one dog with no such exposure has also tested positive.

“These animals are going from patient to patient, getting up onto beds and licking people,” Dr. Lefebvre said. “They also lick and are handled by health care workers, who are notorious for having contaminated hands.”

She added that the MRSA found so far in the dogs is community acquired—an ominous fact, given that this type of bacterium (unlike the less robust hospital-acquired variant) often infects healthy individuals, rather than the elderly and immunocompromised.

Additionally, one-third of the dogs have so far tested positive for Salmonella, she noted, speculating that a diet containing raw meat or poultry (common among visitation dogs) could be the prime source of this bacterium.

Dr. Lefebvre emphasized that, even in light of these findings, she personally supports animal-visitation programs and believes they “spread more good than harm…. But people are being really naive in their approaches, and they need to practice more intact vector control than they are right now.

“A few simple precautions, particularly practicing hand hygiene [before and] after handling the animals, can reduce the potential harms—to both pets and people,” Dr. Lefebvre said.

She also pointed to the dogs' habit of licking as a principal link in the disease-transmission chain.

“I think it's a bad idea to … let dogs lick people and think there are no ramifications for that,” she said.

Dr. Lefebvre also advised that people caring for visitation dogs not feed them raw meat or poultry.

SAN ANTONIO — Dogs serving as visitation-therapy animals in health care facilities have tested positive for Clostridium difficile and can also harbor Salmonella and methicillin-resistant Staphylococcus aureus, according to new research.

Sandra Lefebvre, D.V.M., and her colleagues of the Ontario Veterinary College at the University of Guelph discussed her group's findings on C. difficile in a poster presentation at a meeting of the Southwest Conference on Diseases in Nature Transmissible to Man.

They collected fecal samples from dogs used in a hospital visitation program in Ontario and used polymerase chain reaction techniques to identify microorganisms in the samples. They found C. difficile in 58 (57%) of the 102 dogs. Of the strains identified, 10% were indistinguishable from human strains.

One dog, a toy poodle, shed an epidemic strain of the bacteria.

The investigators discovered that this healthy animal had previously visited a hospital with documented cases of C. difficile-associated disease. Dr. Lefebvre and her colleagues recently reported these findings in a published letter (Emerg. Infect. Dis. 2006;12:1036–7).

The group is currently conducting a prospective cohort canine study that has revealed perhaps a more ominous discovery.

“We're finding that dogs are picking up MRSA, too,” as well as Salmonella, Dr. Lefebvre said in an interview with PEDIATRIC NEWS.

She noted that the dogs often lick the hand of a patient with the infection and then lick a noninfected patient, risking transmission of the disease. Such findings do not prove that dogs have spread such diseases to humans, her group wrote—but “they certainly support that possibility.”

Furthermore, visitation dogs then return to the home and neighborhood, where they can spread the disease to humans and other dogs, she said at the meeting, held in conjunction with the International Conference on Diseases in Nature Communicable to Man.

Three dogs so far have tested positive for MRSA after visiting hospitals, but one dog with no such exposure has also tested positive.

“These animals are going from patient to patient, getting up onto beds and licking people,” Dr. Lefebvre said. “They also lick and are handled by health care workers, who are notorious for having contaminated hands.”

She added that the MRSA found so far in the dogs is community acquired—an ominous fact, given that this type of bacterium (unlike the less robust hospital-acquired variant) often infects healthy individuals, rather than the elderly and immunocompromised.

Additionally, one-third of the dogs have so far tested positive for Salmonella, she noted, speculating that a diet containing raw meat or poultry (common among visitation dogs) could be the prime source of this bacterium.

Dr. Lefebvre emphasized that, even in light of these findings, she personally supports animal-visitation programs and believes they “spread more good than harm…. But people are being really naive in their approaches, and they need to practice more intact vector control than they are right now.

“A few simple precautions, particularly practicing hand hygiene [before and] after handling the animals, can reduce the potential harms—to both pets and people,” Dr. Lefebvre said.

She also pointed to the dogs' habit of licking as a principal link in the disease-transmission chain.

“I think it's a bad idea to … let dogs lick people and think there are no ramifications for that,” she said.

Dr. Lefebvre also advised that people caring for visitation dogs not feed them raw meat or poultry.

Forty-four cases of community-acquired methicillin-resistant Staphylococcus aureus associated with tattoos were reported from June 2004 to August 2005 in Ohio, Kentucky, and Vermont, according to the Centers for Disease Control and Prevention.

The CDC reported 34 primary cases (persons who had recently received a new tattoo) and 10 secondary cases (those who had been in close contact with a recently tattooed person but who had not themselves been recently tattooed) occurring in six unconnected clusters. Time between tattoo and symptom onset ranged from 4 to 22 days for the primary cases, and most infections were mild to moderate, the CDC reported (MMWR 2006;55:677–9).

All primary cases occurred in patients who had been tattooed by unlicensed tattooists, three of whom had been recently incarcerated. The tattooists who could be found and interviewed by health and law enforcement authorities admitted they had not practiced all appropriate hygienic and sterilization measures.

Forty-four cases of community-acquired methicillin-resistant Staphylococcus aureus associated with tattoos were reported from June 2004 to August 2005 in Ohio, Kentucky, and Vermont, according to the Centers for Disease Control and Prevention.

The CDC reported 34 primary cases (persons who had recently received a new tattoo) and 10 secondary cases (those who had been in close contact with a recently tattooed person but who had not themselves been recently tattooed) occurring in six unconnected clusters. Time between tattoo and symptom onset ranged from 4 to 22 days for the primary cases, and most infections were mild to moderate, the CDC reported (MMWR 2006;55:677–9).

All primary cases occurred in patients who had been tattooed by unlicensed tattooists, three of whom had been recently incarcerated. The tattooists who could be found and interviewed by health and law enforcement authorities admitted they had not practiced all appropriate hygienic and sterilization measures.

Forty-four cases of community-acquired methicillin-resistant Staphylococcus aureus associated with tattoos were reported from June 2004 to August 2005 in Ohio, Kentucky, and Vermont, according to the Centers for Disease Control and Prevention.

The CDC reported 34 primary cases (persons who had recently received a new tattoo) and 10 secondary cases (those who had been in close contact with a recently tattooed person but who had not themselves been recently tattooed) occurring in six unconnected clusters. Time between tattoo and symptom onset ranged from 4 to 22 days for the primary cases, and most infections were mild to moderate, the CDC reported (MMWR 2006;55:677–9).

All primary cases occurred in patients who had been tattooed by unlicensed tattooists, three of whom had been recently incarcerated. The tattooists who could be found and interviewed by health and law enforcement authorities admitted they had not practiced all appropriate hygienic and sterilization measures.

Leaders of academic internal medicine are developing plans to reform residency training so residents can spend more time in ambulatory settings and so programs can promote residents on the basis of their mastery of certain skills.

The recently convened Education Redesign Task Force of the Alliance for Academic Internal Medicine (AAIM) is expected to issue its final report during the first 6 months of 2007.

The task force recommendations are likely to guide those of the Residency Review Committee for Internal Medicine of the Accreditation Council for Graduate Medical Education, which updates its requirements every 3 years, according to Dr. Barbara Schuster, president of the Association of Professors of Medicine, one of the component organizations of the AAIM. (The other four AAIM organizations are the Association of Program Directors in Internal Medicine, the Association of Specialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine.)

The task force, which met in October in New Orleans during an AAIM meeting that was closed to the press, focused its efforts on defining the core curriculum of internal medicine residency, identifying resources needed in residency programs, and assessing ways to evaluate residents, Dr. Schuster said in an interview.

The committee also discussed basing training and progress within residency on demonstration of the specific ACGME competencies, rather than gauging progress according to time spent in residency, she said. Those competencies are patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.

Giving residents more training in ambulatory care was of great interest, Dr. Schuster said.

One option discussed by the task force, she said, was having residents spend 3 months in ambulatory care and then rotate back to the hospital, instead of spending a half-day in ambulatory care every week. Educators are concerned that having residents spend a half-day each week is not effective, and that residents sometimes can't come into the ambulatory clinic “because they've been on call the night before or because they're worried about their patient in the ICU.”

That sentiment was shared by two internists from the University of California-Davis Medical Center in Sacramento who attended the meeting.

“One criticism is that we have residents spend way too much time in the hospital,” said Dr. Craig R. Keenan, director of the primary care residency program in the internal medicine department. But a change would require reforms in funding of residency programs, he said, given that teaching hospitals and university medical schools are funded in large part based on the number of patients who receive treatment from residents in the hospital.

Another potential obstacle is the integral role that teaching hospitals—and by extension, their residents—play in caring for uninsured and underinsured patients, said Dr. Mark C. Henderson, who is vice chair for education in the internal medicine department.

“Teaching hospitals bear the largest share of uncompensated care,” he said. “So most of the underinsured are taken care of by residents in the large urban centers. To take residents away to offices, where they can get better training, could worsen the crisis of care for the uninsured and underinsured.”

Thus “the stewards of the teaching programs … have to advocate to disentangle our residents from the financial and service needs of their teaching hospitals,” he said. “We have to somehow protect their education and design their education based on what they need to learn, rather than how many patients the hospital has and the fact that they're overwhelmed and need bodies to provide that service.”

Promotion within residency is an area that many IM educators consider to be in need of change, Dr. Henderson said. “People are promoted from the first year to the second year to the third year based on how much time they've spent in the program,” he said.

“The problem is that in that 1 year, two residents may have a very different actual clinical experience. One resident may see twice as many patients as another resident,” he noted. “So the question becomes, why do you promote people within the 3 years simply based on the amount of time they've spent? Wouldn't it be better to promote them based on the acquisition of certain required skills or competencies?” But such an approach would require more intense supervision of each resident.

Residency reform is needed to address the dearth of IM residents, Dr. Henderson added. “Fewer students are choosing internal medicine as a career—and this has implications not only for the quality of individuals who go into internal medicine but also for the workforce.” Given the aging U.S. population, this shortage could lead to a national crisis in primary care. The coming paucity of internists will most acutely affect geriatrics, an area of increasing need, he noted.

Recruitment to internal medicine, particularly general internal medicine, may be stymied by value differences between two generations—physicians in current practice and those now going into residency.

Today's residents “have seen their parents grow up being workaholics, but they want a balance in their lives,” Dr. Keenan said. “Internal medicine demands a lot of hours, after-hours phone calls, and weekend call, yet you don't get reimbursed very well for these activities.” This contrasts with the pager-free shift work of emergency physicians, he said. Yet heavy patient loads make hospitals loath to reduce the 80-hour weeks that IM residents must endure.

The changes discussed by the task force are similar to those recommended by the American College of Physicians in a position paper published in the June 2006 issue of the Annals of Internal Medicine (2006;144:927–32).

The next AAIM meeting will be in 2008 and is open to all practicing internists, as well as academic staff in departments of internal medicine. For more information, visit www.im.org

One option is to have residents spend 3 months in ambulatory care and then rotate back to the hospital. DR. SCHUSTER

Leaders of academic internal medicine are developing plans to reform residency training so residents can spend more time in ambulatory settings and so programs can promote residents on the basis of their mastery of certain skills.

The recently convened Education Redesign Task Force of the Alliance for Academic Internal Medicine (AAIM) is expected to issue its final report during the first 6 months of 2007.

The task force recommendations are likely to guide those of the Residency Review Committee for Internal Medicine of the Accreditation Council for Graduate Medical Education, which updates its requirements every 3 years, according to Dr. Barbara Schuster, president of the Association of Professors of Medicine, one of the component organizations of the AAIM. (The other four AAIM organizations are the Association of Program Directors in Internal Medicine, the Association of Specialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine.)

The task force, which met in October in New Orleans during an AAIM meeting that was closed to the press, focused its efforts on defining the core curriculum of internal medicine residency, identifying resources needed in residency programs, and assessing ways to evaluate residents, Dr. Schuster said in an interview.

The committee also discussed basing training and progress within residency on demonstration of the specific ACGME competencies, rather than gauging progress according to time spent in residency, she said. Those competencies are patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.

Giving residents more training in ambulatory care was of great interest, Dr. Schuster said.

One option discussed by the task force, she said, was having residents spend 3 months in ambulatory care and then rotate back to the hospital, instead of spending a half-day in ambulatory care every week. Educators are concerned that having residents spend a half-day each week is not effective, and that residents sometimes can't come into the ambulatory clinic “because they've been on call the night before or because they're worried about their patient in the ICU.”

That sentiment was shared by two internists from the University of California-Davis Medical Center in Sacramento who attended the meeting.

“One criticism is that we have residents spend way too much time in the hospital,” said Dr. Craig R. Keenan, director of the primary care residency program in the internal medicine department. But a change would require reforms in funding of residency programs, he said, given that teaching hospitals and university medical schools are funded in large part based on the number of patients who receive treatment from residents in the hospital.

Another potential obstacle is the integral role that teaching hospitals—and by extension, their residents—play in caring for uninsured and underinsured patients, said Dr. Mark C. Henderson, who is vice chair for education in the internal medicine department.

“Teaching hospitals bear the largest share of uncompensated care,” he said. “So most of the underinsured are taken care of by residents in the large urban centers. To take residents away to offices, where they can get better training, could worsen the crisis of care for the uninsured and underinsured.”

Thus “the stewards of the teaching programs … have to advocate to disentangle our residents from the financial and service needs of their teaching hospitals,” he said. “We have to somehow protect their education and design their education based on what they need to learn, rather than how many patients the hospital has and the fact that they're overwhelmed and need bodies to provide that service.”

Promotion within residency is an area that many IM educators consider to be in need of change, Dr. Henderson said. “People are promoted from the first year to the second year to the third year based on how much time they've spent in the program,” he said.

“The problem is that in that 1 year, two residents may have a very different actual clinical experience. One resident may see twice as many patients as another resident,” he noted. “So the question becomes, why do you promote people within the 3 years simply based on the amount of time they've spent? Wouldn't it be better to promote them based on the acquisition of certain required skills or competencies?” But such an approach would require more intense supervision of each resident.

Residency reform is needed to address the dearth of IM residents, Dr. Henderson added. “Fewer students are choosing internal medicine as a career—and this has implications not only for the quality of individuals who go into internal medicine but also for the workforce.” Given the aging U.S. population, this shortage could lead to a national crisis in primary care. The coming paucity of internists will most acutely affect geriatrics, an area of increasing need, he noted.

Recruitment to internal medicine, particularly general internal medicine, may be stymied by value differences between two generations—physicians in current practice and those now going into residency.

Today's residents “have seen their parents grow up being workaholics, but they want a balance in their lives,” Dr. Keenan said. “Internal medicine demands a lot of hours, after-hours phone calls, and weekend call, yet you don't get reimbursed very well for these activities.” This contrasts with the pager-free shift work of emergency physicians, he said. Yet heavy patient loads make hospitals loath to reduce the 80-hour weeks that IM residents must endure.

The changes discussed by the task force are similar to those recommended by the American College of Physicians in a position paper published in the June 2006 issue of the Annals of Internal Medicine (2006;144:927–32).

The next AAIM meeting will be in 2008 and is open to all practicing internists, as well as academic staff in departments of internal medicine. For more information, visit www.im.org

One option is to have residents spend 3 months in ambulatory care and then rotate back to the hospital. DR. SCHUSTER

Leaders of academic internal medicine are developing plans to reform residency training so residents can spend more time in ambulatory settings and so programs can promote residents on the basis of their mastery of certain skills.

The recently convened Education Redesign Task Force of the Alliance for Academic Internal Medicine (AAIM) is expected to issue its final report during the first 6 months of 2007.

The task force recommendations are likely to guide those of the Residency Review Committee for Internal Medicine of the Accreditation Council for Graduate Medical Education, which updates its requirements every 3 years, according to Dr. Barbara Schuster, president of the Association of Professors of Medicine, one of the component organizations of the AAIM. (The other four AAIM organizations are the Association of Program Directors in Internal Medicine, the Association of Specialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine.)

The task force, which met in October in New Orleans during an AAIM meeting that was closed to the press, focused its efforts on defining the core curriculum of internal medicine residency, identifying resources needed in residency programs, and assessing ways to evaluate residents, Dr. Schuster said in an interview.

The committee also discussed basing training and progress within residency on demonstration of the specific ACGME competencies, rather than gauging progress according to time spent in residency, she said. Those competencies are patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.

Giving residents more training in ambulatory care was of great interest, Dr. Schuster said.

One option discussed by the task force, she said, was having residents spend 3 months in ambulatory care and then rotate back to the hospital, instead of spending a half-day in ambulatory care every week. Educators are concerned that having residents spend a half-day each week is not effective, and that residents sometimes can't come into the ambulatory clinic “because they've been on call the night before or because they're worried about their patient in the ICU.”

That sentiment was shared by two internists from the University of California-Davis Medical Center in Sacramento who attended the meeting.

“One criticism is that we have residents spend way too much time in the hospital,” said Dr. Craig R. Keenan, director of the primary care residency program in the internal medicine department. But a change would require reforms in funding of residency programs, he said, given that teaching hospitals and university medical schools are funded in large part based on the number of patients who receive treatment from residents in the hospital.

Another potential obstacle is the integral role that teaching hospitals—and by extension, their residents—play in caring for uninsured and underinsured patients, said Dr. Mark C. Henderson, who is vice chair for education in the internal medicine department.

“Teaching hospitals bear the largest share of uncompensated care,” he said. “So most of the underinsured are taken care of by residents in the large urban centers. To take residents away to offices, where they can get better training, could worsen the crisis of care for the uninsured and underinsured.”

Thus “the stewards of the teaching programs … have to advocate to disentangle our residents from the financial and service needs of their teaching hospitals,” he said. “We have to somehow protect their education and design their education based on what they need to learn, rather than how many patients the hospital has and the fact that they're overwhelmed and need bodies to provide that service.”

Promotion within residency is an area that many IM educators consider to be in need of change, Dr. Henderson said. “People are promoted from the first year to the second year to the third year based on how much time they've spent in the program,” he said.

“The problem is that in that 1 year, two residents may have a very different actual clinical experience. One resident may see twice as many patients as another resident,” he noted. “So the question becomes, why do you promote people within the 3 years simply based on the amount of time they've spent? Wouldn't it be better to promote them based on the acquisition of certain required skills or competencies?” But such an approach would require more intense supervision of each resident.

Residency reform is needed to address the dearth of IM residents, Dr. Henderson added. “Fewer students are choosing internal medicine as a career—and this has implications not only for the quality of individuals who go into internal medicine but also for the workforce.” Given the aging U.S. population, this shortage could lead to a national crisis in primary care. The coming paucity of internists will most acutely affect geriatrics, an area of increasing need, he noted.

Recruitment to internal medicine, particularly general internal medicine, may be stymied by value differences between two generations—physicians in current practice and those now going into residency.

Today's residents “have seen their parents grow up being workaholics, but they want a balance in their lives,” Dr. Keenan said. “Internal medicine demands a lot of hours, after-hours phone calls, and weekend call, yet you don't get reimbursed very well for these activities.” This contrasts with the pager-free shift work of emergency physicians, he said. Yet heavy patient loads make hospitals loath to reduce the 80-hour weeks that IM residents must endure.

The changes discussed by the task force are similar to those recommended by the American College of Physicians in a position paper published in the June 2006 issue of the Annals of Internal Medicine (2006;144:927–32).

The next AAIM meeting will be in 2008 and is open to all practicing internists, as well as academic staff in departments of internal medicine. For more information, visit www.im.org

One option is to have residents spend 3 months in ambulatory care and then rotate back to the hospital. DR. SCHUSTER

Children whose mothers consumed the highest levels of vitamin E during pregnancy had less asthma and wheezing than did their peers whose mothers consumed less vitamin E while pregnant, according to findings from a cohort study.

Dr. Graham Devereux and colleagues from the University of Aberdeen (Scotland) found that 5-year-old children of women with the highest intake of vitamin E during pregnancy had the lowest incidence of wheezing, physician visits because of wheezing, and both suspected and physician-diagnosed asthma (Am. J. Respir. Crit. Care Med. 2006;174:499–507).

A group of 2,000 expectant mothers was initially recruited in 1997 and 1999 from prenatal clinics, at a median of 12 weeks' gestation. A total of 1,856 women completed a questionnaire, underwent a skin-prick test to assess atopic status, and provided a blood sample. At 32 weeks' gestation, 1,704 women answered a food-frequency questionnaire (FFQ) to assess dietary intake during the preceding 3 months. Upon delivery, maternal and infant (cord blood) plasma was sampled in 1,134 mothers and 877 infants and analyzed for antioxidant content via liquid chromatography.

Six weeks after their singleton children turned 5 years old, a questionnaire was mailed to each child's family to assess history of wheezing and asthma; 1,253 were completed and received. A total of 1,120 parents who responded to this questionnaire filled out an additional FFQ based on the child's diet, and parents of 797 children accepted an invitation to take the child to the hospital for spirometry, skin-prick testing, and fraction of exhaled nitric oxide measurement.

Ultimately, “children born to mothers with the lowest quintile of vitamin E intake [were] 3.47 times more likely to be of the persistent wheezing phenotype than [were] children born to mothers with the highest quintile of vitamin E intake,” the investigators wrote.

They had reported an association between maternal vitamin E intake during pregnancy and asthma at age 2 years in the same cohort.

Children whose mothers consumed the highest levels of vitamin E during pregnancy had less asthma and wheezing than did their peers whose mothers consumed less vitamin E while pregnant, according to findings from a cohort study.

Dr. Graham Devereux and colleagues from the University of Aberdeen (Scotland) found that 5-year-old children of women with the highest intake of vitamin E during pregnancy had the lowest incidence of wheezing, physician visits because of wheezing, and both suspected and physician-diagnosed asthma (Am. J. Respir. Crit. Care Med. 2006;174:499–507).

A group of 2,000 expectant mothers was initially recruited in 1997 and 1999 from prenatal clinics, at a median of 12 weeks' gestation. A total of 1,856 women completed a questionnaire, underwent a skin-prick test to assess atopic status, and provided a blood sample. At 32 weeks' gestation, 1,704 women answered a food-frequency questionnaire (FFQ) to assess dietary intake during the preceding 3 months. Upon delivery, maternal and infant (cord blood) plasma was sampled in 1,134 mothers and 877 infants and analyzed for antioxidant content via liquid chromatography.

Six weeks after their singleton children turned 5 years old, a questionnaire was mailed to each child's family to assess history of wheezing and asthma; 1,253 were completed and received. A total of 1,120 parents who responded to this questionnaire filled out an additional FFQ based on the child's diet, and parents of 797 children accepted an invitation to take the child to the hospital for spirometry, skin-prick testing, and fraction of exhaled nitric oxide measurement.

Ultimately, “children born to mothers with the lowest quintile of vitamin E intake [were] 3.47 times more likely to be of the persistent wheezing phenotype than [were] children born to mothers with the highest quintile of vitamin E intake,” the investigators wrote.

They had reported an association between maternal vitamin E intake during pregnancy and asthma at age 2 years in the same cohort.

Children whose mothers consumed the highest levels of vitamin E during pregnancy had less asthma and wheezing than did their peers whose mothers consumed less vitamin E while pregnant, according to findings from a cohort study.

Dr. Graham Devereux and colleagues from the University of Aberdeen (Scotland) found that 5-year-old children of women with the highest intake of vitamin E during pregnancy had the lowest incidence of wheezing, physician visits because of wheezing, and both suspected and physician-diagnosed asthma (Am. J. Respir. Crit. Care Med. 2006;174:499–507).

A group of 2,000 expectant mothers was initially recruited in 1997 and 1999 from prenatal clinics, at a median of 12 weeks' gestation. A total of 1,856 women completed a questionnaire, underwent a skin-prick test to assess atopic status, and provided a blood sample. At 32 weeks' gestation, 1,704 women answered a food-frequency questionnaire (FFQ) to assess dietary intake during the preceding 3 months. Upon delivery, maternal and infant (cord blood) plasma was sampled in 1,134 mothers and 877 infants and analyzed for antioxidant content via liquid chromatography.

Six weeks after their singleton children turned 5 years old, a questionnaire was mailed to each child's family to assess history of wheezing and asthma; 1,253 were completed and received. A total of 1,120 parents who responded to this questionnaire filled out an additional FFQ based on the child's diet, and parents of 797 children accepted an invitation to take the child to the hospital for spirometry, skin-prick testing, and fraction of exhaled nitric oxide measurement.

Ultimately, “children born to mothers with the lowest quintile of vitamin E intake [were] 3.47 times more likely to be of the persistent wheezing phenotype than [were] children born to mothers with the highest quintile of vitamin E intake,” the investigators wrote.

They had reported an association between maternal vitamin E intake during pregnancy and asthma at age 2 years in the same cohort.

Sudden cardiac death in many cases announces its onset with telltale symptoms long before it strikes, according to findings from a prospective study in Germany.

Dirk Müller, Ph.D., and colleagues at Charité Medical University of Berlin, analyzed event and symptom data from 323 patients struck by presumed cardiac arrest over the course of 1 year who were treated by a Berlin helicopter ICU and for whom a resuscitation attempt was made and pre-event symptoms were available. Symptom data were collected on the scene by emergency physicians (Circulation. 2006;114[11]:1146–50).

Only 25% of patients had no symptoms before the onset of sudden cardiac death (SCD), and of the remaining 75%, symptoms lasted a median of 50 minutes. Angina pectoris preceded SCD in 22% of patients at a median duration of 120 minutes.

Dyspnea was evident in 15% and lasted a median of 30 minutes. Smaller percentages experienced nausea or vomiting (7%) or dizziness or syncope (5%). For 90% of patients, symptoms lasted more than 5 minutes, and for 64%, symptoms lasted more than an hour.

Sudden cardiac death in many cases announces its onset with telltale symptoms long before it strikes, according to findings from a prospective study in Germany.

Dirk Müller, Ph.D., and colleagues at Charité Medical University of Berlin, analyzed event and symptom data from 323 patients struck by presumed cardiac arrest over the course of 1 year who were treated by a Berlin helicopter ICU and for whom a resuscitation attempt was made and pre-event symptoms were available. Symptom data were collected on the scene by emergency physicians (Circulation. 2006;114[11]:1146–50).

Only 25% of patients had no symptoms before the onset of sudden cardiac death (SCD), and of the remaining 75%, symptoms lasted a median of 50 minutes. Angina pectoris preceded SCD in 22% of patients at a median duration of 120 minutes.

Dyspnea was evident in 15% and lasted a median of 30 minutes. Smaller percentages experienced nausea or vomiting (7%) or dizziness or syncope (5%). For 90% of patients, symptoms lasted more than 5 minutes, and for 64%, symptoms lasted more than an hour.

Sudden cardiac death in many cases announces its onset with telltale symptoms long before it strikes, according to findings from a prospective study in Germany.

Dirk Müller, Ph.D., and colleagues at Charité Medical University of Berlin, analyzed event and symptom data from 323 patients struck by presumed cardiac arrest over the course of 1 year who were treated by a Berlin helicopter ICU and for whom a resuscitation attempt was made and pre-event symptoms were available. Symptom data were collected on the scene by emergency physicians (Circulation. 2006;114[11]:1146–50).

Only 25% of patients had no symptoms before the onset of sudden cardiac death (SCD), and of the remaining 75%, symptoms lasted a median of 50 minutes. Angina pectoris preceded SCD in 22% of patients at a median duration of 120 minutes.

Dyspnea was evident in 15% and lasted a median of 30 minutes. Smaller percentages experienced nausea or vomiting (7%) or dizziness or syncope (5%). For 90% of patients, symptoms lasted more than 5 minutes, and for 64%, symptoms lasted more than an hour.

Waiting up to 2 minutes after delivery to cut the umbilical cord led to increased iron status at 6 months, with no adverse associations for mothers or infants, and could be valuable in preventing developmental delays associated with iron deficiencies, according to findings from a large randomized controlled trial.

Dr. Camila M. Chaparro of the University of California, Davis, and colleagues reported results from 358 mother-and-singleton infant pairs delivered at a large obstetric hospital in Mexico City. The primary outcomes were infant blood and iron status at age 6 months—the longest follow-up to date in any trial of delayed cord clamping (Lancet 2006;367:1997–2004).

The investigators randomized mothers to one of two groups: In one group, the umbilical cord was clamped after 10 seconds. In the other group, it was clamped after 2 minutes—coinciding roughly with the usual cessation of cord pulsations—unless the physician determined earlier cord removal was necessary. Ultimately, the mean clamping time for the early-clamping group was roughly 17 seconds, compared with about 94 seconds for the delayed-clamping group—a difference of just over 1 minute.

At 6 months of age, the delayed-clamping infants had significantly higher levels than the early-clamping infants in several measures (adjusted for maternal factors): stored iron (58 mg vs. 31 mg), body iron (343 mg vs. 316 mg), mean corpuscular volume (81.0 fL vs. 79.5 fL), and ferritin (50.7 mcg/L vs. 34.4 mcg/L). Moreover, the incidence of iron deficiency (less than 9 mcg/L) in the early-clamping infants was 7%, compared with 1% in the delayed-clamping group, and unadjusted incidence of iron-deficiency anemia was 4% in early-clamping infants vs. 0% in the delayed-clamping group, the investigators noted.

Waiting up to 2 minutes after delivery to cut the umbilical cord led to increased iron status at 6 months, with no adverse associations for mothers or infants, and could be valuable in preventing developmental delays associated with iron deficiencies, according to findings from a large randomized controlled trial.

Dr. Camila M. Chaparro of the University of California, Davis, and colleagues reported results from 358 mother-and-singleton infant pairs delivered at a large obstetric hospital in Mexico City. The primary outcomes were infant blood and iron status at age 6 months—the longest follow-up to date in any trial of delayed cord clamping (Lancet 2006;367:1997–2004).

The investigators randomized mothers to one of two groups: In one group, the umbilical cord was clamped after 10 seconds. In the other group, it was clamped after 2 minutes—coinciding roughly with the usual cessation of cord pulsations—unless the physician determined earlier cord removal was necessary. Ultimately, the mean clamping time for the early-clamping group was roughly 17 seconds, compared with about 94 seconds for the delayed-clamping group—a difference of just over 1 minute.

At 6 months of age, the delayed-clamping infants had significantly higher levels than the early-clamping infants in several measures (adjusted for maternal factors): stored iron (58 mg vs. 31 mg), body iron (343 mg vs. 316 mg), mean corpuscular volume (81.0 fL vs. 79.5 fL), and ferritin (50.7 mcg/L vs. 34.4 mcg/L). Moreover, the incidence of iron deficiency (less than 9 mcg/L) in the early-clamping infants was 7%, compared with 1% in the delayed-clamping group, and unadjusted incidence of iron-deficiency anemia was 4% in early-clamping infants vs. 0% in the delayed-clamping group, the investigators noted.

Waiting up to 2 minutes after delivery to cut the umbilical cord led to increased iron status at 6 months, with no adverse associations for mothers or infants, and could be valuable in preventing developmental delays associated with iron deficiencies, according to findings from a large randomized controlled trial.

Dr. Camila M. Chaparro of the University of California, Davis, and colleagues reported results from 358 mother-and-singleton infant pairs delivered at a large obstetric hospital in Mexico City. The primary outcomes were infant blood and iron status at age 6 months—the longest follow-up to date in any trial of delayed cord clamping (Lancet 2006;367:1997–2004).

The investigators randomized mothers to one of two groups: In one group, the umbilical cord was clamped after 10 seconds. In the other group, it was clamped after 2 minutes—coinciding roughly with the usual cessation of cord pulsations—unless the physician determined earlier cord removal was necessary. Ultimately, the mean clamping time for the early-clamping group was roughly 17 seconds, compared with about 94 seconds for the delayed-clamping group—a difference of just over 1 minute.

At 6 months of age, the delayed-clamping infants had significantly higher levels than the early-clamping infants in several measures (adjusted for maternal factors): stored iron (58 mg vs. 31 mg), body iron (343 mg vs. 316 mg), mean corpuscular volume (81.0 fL vs. 79.5 fL), and ferritin (50.7 mcg/L vs. 34.4 mcg/L). Moreover, the incidence of iron deficiency (less than 9 mcg/L) in the early-clamping infants was 7%, compared with 1% in the delayed-clamping group, and unadjusted incidence of iron-deficiency anemia was 4% in early-clamping infants vs. 0% in the delayed-clamping group, the investigators noted.