Caring for vulnerable populations: curricula in U.S. internal medicine residencies.

The Accreditation Council for Graduate Medical Education (ACGME) encourages internal medicine training programs to include specific curricula devoted to health care issues of vulnerable populations. Our aim was to determine the prevalence of curricula involving selected vulnerable populations among U.S. Internal Medicine residencies. We conducted a survey of Program Directors of all US Internal Medicine Residencies assessing whether the program had a curriculum for six vulnerable populations (racial and ethnic minorities, non-English speaking patients, lesbians, gay men, victims of domestic violence and patients with substance abuse problems). Most residencies address substance abuse and victims of domestic violence, while there remains a lack of dedicated teaching on other vulnerable populations, including lesbians, gay men, racial and ethnic minorities and non-English speaking patients.

Venous thrombosis and conjugated equine estrogen in women without a uterus.

BACKGROUND: Postmenopausal hormone therapy has been associated with a 2- to 3-fold increased risk of venous thromboembolism (VT) (including deep vein thrombosis and pulmonary embolism) in observational studies and secondary prevention clinical trials. Clinical trial data on the effects of estrogen alone on VT are limited. METHODS: The Women's Health Initiative estrogen trial enrolled 10 739 women aged 50 to 79 years without a uterus. Participants were randomly assigned to receive conjugated equine estrogen (0.625 mg/d) or placebo. RESULTS: During a mean of 7.1 years, VT occurred in 111 women randomly assigned to receive estrogen (3.0 per 1000 person-years) and 86 randomly assigned to receive placebo (2.2 per 1000 person-years; hazard ratio, 1.32; 95% confidence interval, 0.99-1.75). Deep venous thrombosis was reported in 85 women randomly assigned to receive estrogen (2.3 per 1000 person-years) and 59 randomly assigned to receive placebo (1.5 per 1000 person-years; hazard ratio, 1.47; 95% confidence interval, 1.06-2.06). The VT risk was highest in the first 2 years. There were no significant interactions between estrogen use and age, body mass index, or most other VT risk factors. Comparison of Women's Health Initiative VT findings for estrogen and previous Women's Health Initiative findings for estrogen plus progestin showed that the hazard ratios for estrogen plus progestin were significantly higher than those for estrogen alone (P = .03), even after adjusting for VT risk factors. CONCLUSION: An early increased VT risk is associated with use of estrogen, especially within the first 2 years, but this risk increase is less than that for estrogen plus progestin.

Women and alcohol.

Primary care providers are uniquely positioned to educate women about alcohol use and misuse. Early identification and intervention can significantly limit the adverse consequences of alcohol abuse. Physicians must recognize the risk factors, presentation, and treatment issues relevant to women.

Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women's Health Initiative Randomized Trial.

CONTEXT: The Women's Health Initiative trial of combined estrogen plus progestin was stopped early when overall health risks, including invasive breast cancer, exceeded benefits. Outstanding issues not previously addressed include characteristics of breast cancers observed among women using hormones and whether diagnosis may be influenced by hormone effects on mammography. OBJECTIVE: To determine the relationship among estrogen plus progestin use, breast cancer characteristics, and mammography recommendations. DESIGN, SETTING, AND PARTICIPANTS: Following a comprehensive breast cancer risk assessment, 16 608 postmenopausal women aged 50 to 79 years with an intact uterus were randomly assigned to receive combined conjugated equine estrogens (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) or placebo from 1993 to 1998 at 40 clinical centers. Screening mammography and clinical breast examinations were performed at baseline and yearly thereafter. MAIN OUTCOME MEASURES: Breast cancer number and characteristics, and frequency of abnormal mammograms by estrogen plus progestin exposure. RESULTS: In intent-to-treat analyses, estrogen plus progestin increased total (245 vs 185 cases; hazard ratio [HR], 1.24; weighted P<.001) and invasive (199 vs 150 cases; HR, 1.24; weighted P =.003) breast cancers compared with placebo. The invasive breast cancers diagnosed in the estrogen plus progestin group were similar in histology and grade but were larger (mean [SD], 1.7 cm [1.1] vs 1.5 cm [0.9], respectively; P =.04) and were at more advanced stage (regional/metastatic 25.4% vs 16.0%, respectively; P =.04) compared with those diagnosed in the placebo group. After 1 year, the percentage of women with abnormal mammograms was substantially greater in the estrogen plus progestin group (716 [9.4%] of 7656) compared with placebo group (398 [5.4%] of 7310; P<.001), a pattern which continued for the study duration. CONCLUSIONS: Relatively short-term combined estrogen plus progestin use increases incident breast cancers, which are diagnosed at a more advanced stage compared with placebo use, and also substantially increases the percentage of women with abnormal mammograms. These results suggest estrogen plus progestin may stimulate breast cancer growth and hinder breast cancer diagnosis.

Postmenopausal hormone therapy in the aftermath of the WHI. What patients need to know.

HT is now relegated primarily to the treatment of menopausal symptoms. It should be used for this indication at the lowest effective dose and for the shortest duration possible. Consideration should be given to other strategies to control symptoms when patients are willing to try less effective but potentially safer alternatives to HT. There is little support for the HT to prevent chronic conditions. The risks of combined HT appear to outweigh the benefits. However, the jury is still out regarding the use of estrogen alone. Ongoing research is likely to provide more informaton about the effects of HT on quality of life, cognition, and prevention of Alzheimer's disease. These potential benefits could tip the balance in favour or HT use for some patients. Any decision about starting or stopping HT requires a comprehensive discussion between the physician and the patient regarding benefits, risks, and uncertainties. The WHI results underscore the importance fo well-designed randomized controlled trials to inform our treatment discussions. Even the best observational studies have the portential to mislead us.

Alcohol use disorders in women. Screening methods and approaches to treatment.

Primary care physicians have a unique opportunity to educate women about alcohol use and to identify those with alcohol problems. Early identification and intervention can significantly limit the adverse consequences of alcohol abuse. To identify alcohol abuse and intervene most effectively, physicians need to recognize the differences in risk factors, presentation, and treatment relevant to women.

Principles of diagnosing and managing postmenopausal osteoporosis for the podiatric physician.

Osteoporosis is an asymptomatic disease until a fracture occurs. The prevalence of osteoporosis will rise with the aging of the population. Recent advances have led to more efficacious treatment options. Targeted screening, educating patients about preventive strategies, and providing appropriate treatment for those at high risk will allow physicians to reduce the enormous morbidity and mortality associated with osteoporosis.

Perioperative care of the patient with hip fracture.

Primary care physicians can intervene to reduce perioperative complications due to comorbid medical illness in patients hospitalized with hip fracture. We review the role of the primary care physician in the treatment and prevention of perioperative morbidity and mortality.

Diagnosing and managing post menopausal osteoporosis: opportunities for fracture prevention.

Osteoporosis is an asymptomatic disease until a fracture occurs. Management includes primary prevention, early detection through targeted screening, and implementation of appropriate treatment and monitoring strategies. This article explores these issues in depth.

Evaluating a lesbian and gay health care curriculum.

BACKGROUND: Many physicians are not prepared to deal with the health care concerns of their lesbian and gay patients. PURPOSE: To examine the impact of a seminar on the self-reported level of preparedness and comfort in dealing with lesbian and gay patients among general internal medicine residents. METHODS: General internal medicine residents at Rhode Island Hospital, Brown University participated in the 3-hr seminar. Residents voluntarily filled out preseminar and postseminar surveys measuring their self-reported level of preparedness and comfort in dealing with the health care, psychosocial, and sexual issues of lesbians and gay men. RESULTS: There was improvement in residents' self-reported level of preparation and comfort after the seminar. CONCLUSIONS: The results of the seminar are promising. Future evaluations of educational programs are needed to address whether improvements in preparation and comfort result in lasting changes and whether an educational intervention can improve the patient-physician interaction.