The changing profile of patients who used emergency department services in the United States: 1996 to 2005.

STUDY OBJECTIVE: Because of the vital role of emergency departments (EDs) in the US health care system, it is important to monitor the changes in the patient mix over time to identify existing problems and ways to improve the system. The current study aimed to identify raw and population-adjusted time trends for demographic characteristics, socioeconomic characteristics, access to care, utilization of care, and general health of ED users and heavy ED users. METHODS: Ten years' worth of nationally representative data was derived from the Medical Expenditure Panel Survey, 1996 to 2005. Raw time trends of various patient characteristics for ED users, nonusers, and heavy users were estimated to demonstrate changes in ED patient mix. Population-attributable fraction was used to generate population-adjusted trends that elucidate the net changes in subpopulations' propensities to ED use in relation to those of the general population. RESULTS: Between 1996 and 2005, the total number of noninstitutionalized individuals who used ED services increased from 34.2 to 40.8 million. That is, the proportion of ED users in the US population increased from 12.7% to 13.8%. Increasing proportions of elderly and those who perceived themselves to be in poor or fair physical health among ED users, particularly heavy users, were found in both raw and population-adjusted trends. Several subpopulations demonstrated increasing levels of ED use after population adjustment: blacks, patients within 100% to 199% of the federal poverty line, patients with only Medicare, patients with greater than or equal to 2 types of insurance, and patients with at least 1 inpatient stay. Decreasing population-adjusted trends were found in the proportions of female patients, Hispanics, patients at greater than or equal to 200% of the federal poverty line, the uninsured, and patients with only private insurance, respectively. CONCLUSION: EDs play a larger role in the management of geriatric patients over time. The increasing burden of the aging population in the EDs poses challenges in the training of future emergency physicians, care for older patients, public health insurance, and health care system reform.

Effects of pegylated interferon alfa-2b on the pharmacokinetic and pharmacodynamic properties of methadone: a prospective, nonrandomized, crossover study in patients coinfected with hepatitis C and HIV receiving methadone maintenance treatment.

BACKGROUND: Hepatitis C virus (HCV) infection is common among methadone-maintained HIV-positive individuals. Pegylated interferon (pegIFN) used in combination with ribavirin is conventional treatment for HCV. However, pegIFN has been associated with adverse effects (AEs) that may simulate opioid withdrawal and be confused with insufficient methadone dosage. OBJECTIVE: The aim of this study was to determine, using methadone pharmacokinetic properties, whether methadone dosage adjustments are needed on initiation of treatment with pegIFN alfa-2b for HCV in methadone-maintained HIV-positive patients. METHODS: This prospective, nonrandomized, crossover study was conducted at the Albert Einstein College of Medicine and Montefiore Medical Center (Bronx, New York). Patients who were aged > or =18 years, coinfected with chronic HCV and HIV, and had been receiving methadone maintenance treatment (dosage, 40-200 mg/d PO) for at least 8 weeks prior to enrollment were eligible. We determined mean methadone C(max), T(max), Cn,in, AUC, and oral clearance (CL/F) values over a 24-hour period before (baseline) and after the administration of pegIFN alfa-2b 1.5 microg/kg SC (2 doses given 1 week apart). To determine differences in opiate withdrawal symptoms, one of the primary investigators administered the Subjective Opiate Withdrawal Scale (SOWS) and Objective Opiate Withdrawal Scale (OOWS) at baseline and 7, 14, and 21 days after the administration of the first dose. Study participants underwent weekly clinical evaluation for signs and symptoms of methadone withdrawal and for AEs of pegIFN. RESULTS: Nine patients were included in the study (7 men, 2 women; 7 Hispanic, 2 black; mean [SD] age, 41 [8.3] years; mean [SD] weight, 75.0 [12.3] kg). We did not observe any significant changes from baseline in mean C(max), T(max), C(min), AUC, and CL/F values despite 80% power to detect a 30% change in either direction. Changes from baseline in SOWS and OOWS scores were not statistically significant. The only AEs reported were mild and consistent with those expected after pegIFN alfa-2b administration, such as inflammation at the injection site and mild, brief, flu-like symptoms. CONCLUSION: Based on the results of this small, prospective, nonrandomized study, pegIFN alfa-2b did not appear to precipitate opioid withdrawal in this sample of methadone-maintained persons with HIV and chronic HCV coinfection; methadone dosage adjustments were unlikely to be needed.

The Infectious Disease Manpower Crisis: Finding the Cure.

The challenges of infectious diseases, including new pathogens, dangerous outbreaks, antibiotic-resistant bacteria, and the perils of international travel have never been more publically appreciated. These challenges require a well-trained workforce of infectious disease specialists. Just when the need appears to be greatest, however, the interest in infectious diseases among today's young physicians is at its lowest point.

The Family Medicine Accelerated Track at Texas Tech University Health Sciences Center.

Meeting Texas' future health care needs will be challenging, including the goal for a physician workforce more balanced toward primary care. To help expand the primary care physician workforce, Texas Tech University Health Sciences Center (TTUHSC) School of Medicine developed the Family Medicine Accelerated Track (FMAT), a three-year curriculum that culminates in the MD degree and links medical students to family medicine residency programs at TTUHSC campuses in Lubbock, Amarillo, or the Permian Basin (Odessa and Midland). Twenty current family medicine residents are graduates of the FMAT program, and 30 medical students are enrolled in the program, which is charting a path for curricular innovation in medical education that will be increasingly competency-based.