Systematic Review of the Global Literature on Uncomplicated Recurrent Urinary Tract Infections in Women: Underscoring Major Heterogeneity.

OBJECTIVE: To examine the global literature database on uncomplicated recurrent urinary tract infections (rUTI), this systematic review assesses the availability of rUTI data based on geographic region and elucidates the current state of research and gaps in knowledge. METHODS: The databases PubMed, Embase, WHO Global Index Medicus, and SciELO were searched for keywords related to rUTI between 2000 and 2023. Three independent reviewers screened studies restricted to female participants age ≥18 years with uncomplicated rUTIs. Studies were excluded if they did not provide a definition for rUTI or did not cite or report an estimate for rUTI prevalence. The review was registered in PROSPERO and conformed to PRISMA guidelines. RESULTS: The search yielded 2947 studies of which 124 were ultimately included. Convenience samples were used for 91% of studies and sample sizes were 30% n <50, 29% n = 50-99, 22% n = 100-199, 36% n ≥200. Most studies were conducted in Europe (41%) or North America (39%), were prospective (52%), at tertiary centers (49%) and included all ages ≥18 (60%). The most common definition for rUTI was 2 UTI/6 m or 3 UTI/1y (62%). Regardless of study location, most studies cited prevalence estimates for rUTI derived from U.S.-based populations. CONCLUSION: This study represents the first formal investigation of the global literature base on uncomplicated rUTI. Studies on rUTIs are globally of small scale and definitions used for rUTI are heterogeneous. More studies are needed to ascertain the true prevalence of rUTI outside of North America and Europe.

Bladder-resident bacteria associated with increased risk of recurrence after electrofulguration in women with antibiotic-recalcitrant urinary tract infection.

Background: Antibiotic-recalcitrant recurrent urinary tract infection (rUTI) is has become increasingly observed in postmenopausal women. Therefore, when standard antibiotic therapies have failed, some elect electrofulguration (EF) of areas of chronic cystitis when detected on office cystoscopy. EF is thought to remove tissue-resident bacteria that have been previously detected in the bladder walls of postmenopausal women with rUTI. We hypothesized that increased bladder bacterial burden may be associated with incomplete rUTI resolution following EF. Methods: Following IRB approval, bladder biopsies were obtained from 34 consenting menopausal women electing EF for the advanced management of rUTI. 16S rRNA FISH was performed using both universal and Escherichia probes and tissue-resident bacterial load was quantified. Time to UTI relapse after EF was recorded during a six-month follow-up period and the association of bladder bacterial burden and clinical covariates with UTI relapse was assessed. Results: We observed bladder-resident Escherichia in 52% of all participants and in 92% of participants with recent E. coli UTI. Time-to-relapse analysis revealed that women with high bladder bacterial burden as detected by the universal probe had a significantly ( p =0.035) higher risk of UTI within six months of EF (HR=3.15, 95% CI: 1.09-9.11). Interestingly, bladder-resident Escherichia was not significantly associated ( p =0.26) with a higher risk of UTI relapse (HR= 2.14, 95% CI: 0.58-7.90). Conclusions: We observed that total bladder bacterial burden was associated with a 3.1x increased risk of rUTI relapse within six months. Continued analysis of the relationship between bladder bacterial burden and rUTI outcomes may provide insight into the management of these challenging patients.

Identifying Patient and Surgical Criteria for Same-Day Discharge After Robotic-Assisted Sacrocolpopexy.

Introduction: To review the postrobotic-assisted sacrocolpopexy (RASC) course of women admitted for 23 hours post-RASC and identify events requiring intensive medical care or potentially leading to deleterious outcome or urgent readmission if that patient had same-day discharge (SDD) instead of observed overnight. Methods: Patients undergoing RASC from January to December 2020 at one institution were identified and relevant data were obtained via retrospective chart review. Patient exclusions: RASC start time after 12:00 PM, concurrent posterior colporrhaphy, rectopexy, or hysterectomy, or conversion to open. Results: Sixty-nine patients (median age 71 years old) met study criteria with majority American Society of Anesthesiologists class 2 (n = 46, 67%) or 3 (n = 22, 32%). Patient characteristics included prior abdominal surgeries (n = 58, 84%), prior hysterectomy/prolapse repair (n = 25, 37%), known allergy to pain medication (n = 25, 36%), and administration of a postoperative antiemetic (n = 37, 54%) or intra-/postoperative keterolac (n = 36, 52%). Median surgery length was 269 minutes. Postoperative events that may have resulted in urgent readmissions if they had SDD were observed in 6% of patients. In the 1st week post-RASC, there were no readmissions. Conclusions: In this limited quality assurance study, patients undergoing RASC experienced no major complications requiring intensive care. Postoperative events were almost entirely nausea and pain, with no readmissions within the 1st week.

Cranberry Supplement, D-Mannose, and Other OTC Modalities for Prevention of Recurrent UTI in Women Post-Electrofulguration.

Purpose: To assess patient reliance on various over-the-counter (OTC) modalities used for prevention of recurrent urinary tract infection (RUTI) after electrofulguration (EF). Patients and Methods: Following IRB approval, qualifying women were offered a short survey over the phone by a medical researcher to collect information about their use of various OTC modalities for prophylaxis of RUTI. Data was compared between two cohorts, ≥70 years old and <70 years old, using chi-squared and Student's t-tests. Results: From a database of 324 patients, 163 accepted the interview. 17% (28/163) reported current use of cranberry supplements, 10% (16/163) D-mannose supplements, and 42% (69/163) another non-prescription modality for RUTI prophylaxis. The non-geriatric (<70 years old) cohort spent, on average, $80 less annually on cranberry/D-mannose supplements (P=0.043) than the geriatric cohort and were more likely to use non-prescription modalities for the prevention of UTI (52% vs 30%; P=0.0061). Individuals using D-mannose were also much more likely to purchase their product online compared to those using cranberry supplements (85% vs 56%). Across all modalities, the perceived benefit difference in reducing UTI/year ranged from a median of 0 for Pyridium® (phenazopyridine hydrochloride) to four for probiotics, with D-mannose and cranberry at two/year, and those increasing daily fluid consumption at 2.5 fewer UTI/year. Conclusion: Continued use of non-prescription modalities for RUTI prophylaxis were common among women with an EF history, but varied based on age groups. Across both age cohorts, annual expenditure and perceived benefit also varied among different OTC prophylactic modalities. Awareness of type and method of OTC modality implementation by patients with RUTI is essential to aligning use with current field recommendations.

Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes.

BACKGROUND: Inadequate functional health literacy is common, but its impact on patients with chronic diseases is not well described. OBJECTIVE: To examine among patients with hypertension or diabetes the relationship between their functional health literacy level and their knowledge of their chronic disease and treatment. METHODS: We conducted a cross-sectional survey of patients with hypertension and diabetes presenting to the general medicine clinics at 2 urban public hospitals. Literacy was measured by the Test of Functional Health Literacy in Adults. Knowledge of their illness was assessed in patients with diabetes or hypertension using 21 hypertension and 10 diabetes questions based on key elements in educational materials used in our clinics. RESULTS: A total of 402 patients with hypertension and 114 patients with diabetes were enrolled. Mean (+/- SD) knowledge scores for patients with hypertension with inadequate (n = 189), marginal (n = 49), or adequate (n = 155) literacy were 13.2 +/- 3.1, 15.3 +/- 2.2, and 16.5 +/- 2.3, respectively (range, 4-20; P < .001). A total of 92% of patients with hypertension and adequate literacy levels knew that a blood pressure reading of 160/100 mm Hg was high compared with 55% of those in the lowest reading level (P < .001). Mean (+/- SD) knowledge scores for patients with diabetes with inadequate (n = 50), marginal (n = 13), or adequate (n = 51) literacy were 5.8 +/- 2.1, 6.8 +/- 1.9, and 8.1 +/- 1.6, respectively (range, 1-10; P < .001). A total of 94% of patients with diabetes and adequate functional health literacy knew the symptoms of hypoglycemia compared with 50% of those with inadequate literacy (P < .001). CONCLUSIONS: Inadequate functional health literacy poses a major barrier to educating patients with chronic diseases, and current efforts to overcome this appear unsuccessful.

Molecular cloning and characterisation of GPR74 a novel G-protein coupled receptor closest related to the Y-receptor family.

A novel gene product, GPR74, with homology to the seven transmembrane-domain receptor superfamily, has been cloned. GPR74 has been identified from the expressed sequence tags (EST) database. Subsequent PCR amplification of that sequence and screening of a human heart cDNA library led to the isolation of a 1.7-kb cDNA clone encoding a protein of 408 amino acids. GPR74 shows highest amino acid identity (33%) to the human neuropeptide Y-receptor subtype Y2. The human and mouse genes for GPR74 have been isolated and their exon-intron structures determined. In both species the gene consists of four exons spanning around 20 kb with the exon-intron borders being 100% conserved. Northern analysis of various human tissues reveals highest levels of mRNA expression in brain and heart. In situ hybridisation analysis of rat brain tissue confirms this result and identifies the hippocampus and amygdala nuclei as the brain areas with particular high expression of GPR74 mRNA. Fluorescence in situ hybridisation, PCR analysis on a radiation hybrid panel and interspecific mouse backcross mapping have localised the genes to human chromosome 4q21 and mouse chromosome 5. Expression of the human GPR74 cDNA as a GFP-fusion protein in various cell lines reveals the inability of the recombinant receptor protein to reach the cell surface. This is consistent with the lack of NPY specific binding in these cells and suggests that unknown factors are required for a full functional receptor complex.

Reading skills and family planning knowledge and practices in a low-income managed-care population.

OBJECTIVE: To examine the relationship between reading ability and family planning knowledge and practices among Medicaid managed care enrollees. METHODS: A total of 406 women age 19-45 years enrolled in TennCare and members of Prudential HealthCare Community Plan in Memphis, Tennessee were interviewed to determine their methods of contraception, desire for additional information about contraceptives, and knowledge about the time in menstrual cycle they are at highest risk for pregnancy. Patient reading ability was assessed by an abbreviated version of the Test of Functional Health Literacy of Adults. The independent associations between reading ability, desire for additional contraceptive information, and knowledge about the highest risk time for pregnancy were assessed with logistic regression. RESULTS: Almost 10% of the respondents had low reading skills. Women who had used an intrauterine device, douching, rhythm, or levonorgestrel implants as methods of birth control had higher rates of low reading skills than women who used other methods of birth control. Compared with women with good reading skills, women with low reading skills were 2.2 times (95% confidence interval [CI] 1.1, 4.4) more likely to want to know more about birth control methods and 4.4 times (95% CI 2.2, 9.0) more likely to have incorrect knowledge about when they were most likely to get pregnant. These relationships were significant even after controlling for age, race, and marital status. CONCLUSION: Health providers and organizations that serve historically underserved populations must understand that some individuals have a low level of reading ability that limits family planning education.

Literacy and contraception: exploring the link.

OBJECTIVE: To describe what is known about the relation of literacy skills to contraceptive use and to suggest directions for future research. An overview of what is known about the literacy skills of Americans and the prevalence of inadequate functional health literacy is presented. Information about reading requirements for various methods of contraception and advice from health educators on dealing with low-literate populations are described. DATA SOURCES: MEDLINE, PsychInfo, and ERIC searches for the last 20 years were completed using the terms literacy, literacy and health, family planning, health status, educational status, risk factors, contraception, and pregnancy. METHODS OF STUDY SELECTION: The primary literature searches identified 125 articles. After reviewing abstracts for these articles, we excluded 79, because they contained no specific mention of literacy or educational status relating to contraception. TABULATION INTEGRATION, AND RESULTS: We were unable to identify and study specifically devoted to the relation between functional literacy and actual use of contraceptives. Forty-six with relevant background or related information were identified: literacy and health (19), adult literacy (nine), literacy and contraception (11), and literacy and family planning (seven). Over one-third of English-speaking and 62% of Spanish-speaking patients had inadequate or marginal functional health literacy in a study conducted at two urban public hospitals. Studies by health educators have demonstrated that information for many types of contraceptives is frequently above the patient's reading level. Available epidemiologic information on the relation between educational status and unplanned pregnancy is also presented. CONCLUSIONS: Although no study has specifically addressed how functional health literacy affects contraceptive use, it is reasonable to hypothesize that functional health literacy influences contraceptive knowledge, attitudes, and behaviors. Future research should focus on the relation between functional health literacy and actual use of various contraceptives.

Comparison of Y-receptor subtype expression in the rat hippocampus.

The mRNA expression patterns for the Y1, Y2, Y4 and Y5 receptor subtypes have been compared at a cellular level within consecutive coronal sections of rat hippocampus, using a uniform method of in situ hybridisation. All four receptor subtypes show different levels and patterns of expression. The Y5 receptor mRNA is most abundant and most widely distributed (CA3 > DG approximately = CA2 approximately = CA1). Numerous Y5 mRNA-expressing neurons are also observed in the dentate gyrus polymorphic layer, while several positively-labelled neurons are detected in the molecular layer and in the stratum oriens. The Y2 receptor displays lower hybridisation signal relative to the Y5, although the expression pattern is similar. Moderate levels of Y1 mRNA expression are detected in the pyramidal cell layer of CA3-CA1 fields. However, only 20% of dentate gyrus granule neurons express Y1 receptor mRNA. In contrast, Y4 receptor mRNA is much less abundant, only small subpopulations of Y4 receptor expressing neurons are detected within the dentate gyrus and the CA3 to CA1 fields. This differential Y-receptor subtype expression pattern indicates specific and separate roles for these receptors in hippocampus processing, which may prove important in dysfunctional states, such as epilepsy and Alzheimer's disease.

Lack of effects of nose-only inhalation exposure on testicular toxicity in male rats.

Reductions in testicular mass, sperm motility, and mating frequency have been attributed to the stresses caused by confinement of Sprague-Dawley male rats in nose-only inhalation exposure tubes. Testicular changes, including an increase in testicular atrophy, have been detected at an increased incidence in male rats used in inhalation studies as compared with rats of the same age and strain used in oral toxicity studies. This study was designed to determine whether nose-only exposure of male rats caused testicular toxicity under conditions of cooling of the exposure room and appropriate acclimation to the exposure tubes. In order to acclimate the rats to the nose-only inhalation exposure apparatus, all male rats were placed in the exposure tubes for at least four successively increasing time intervals (15, 30, 45, and 60 min) on 4 separate days, with a rest period of approximately 48 h between the first and second acclimation. Twenty male rats were exposed nose-only to filtered air for approximately 2 h per day for 28 days before cohabitation and continuing throughout a 14-day cohabitation period. To reduce thermal stress, the exposure room temperature was maintained at 64 to 70 degrees F. Twenty control rats were housed in the same room as the exposed rats but were not placed in exposure tubes. End points monitored were body weight, testicular weight, sperm count, sperm motility, and histopathology of the testes, epididymides, prostate, and seminal vesicles. The control rats gained weight more rapidly than the exposed rats. All the rats in both groups mated successfully, and testicular weights, normalized to body weight, were similar for both groups. More importantly, there were no microscopic changes that could be considered an adverse effect on the reproductive tissues in the male rats placed in exposure tubes. Thus, nose-only exposure for up to 2 h per day for a total of 42 days did not cause adverse effects on the reproductive organs, fertility, or reproductive performance of male rats under the conditions of this study.

The effects of neurokinin receptor antagonists on mustard oil-evoked activation of rat dorsal horn neurons.

Previous evidence indicated that brief nociceptive responses of neurons in laminae IV/V of both rat and cat dorsal horn are more readily inhibited by antagonists at NK2 rather than at NK1 neurokinin receptors. Further support for a role of spinal NK2 receptors in nociception has been provided from experiments assessing modulation of the nociceptive flexor reflex by tachykinins and activation of dorsal horn neurons by brief application of capsaicin to afferents. The present experiments were designed to compare the contribution of NK1 and NK2 receptors in dorsal horn to the sustained neuronal activity induced by peripheral application of the chemical algogen mustard oil (reported to be a selective activator of C afferents). In nearly all of the multireceptive laminae IV/V neurons tested, a selective NK2 receptor antagonist L 659,874 inhibited previously established mustard oil-induced activity. In contrast, two selective NK1 receptor antagonists L 668,169 and GR 82334 were only rarely effective. These results further underline the apparent importance of NK2 receptors in spinal nociceptive processing. NK1 receptors do not appear to play a major role in the present experimental protocol, but they may of course do so under different circumstances.

Inhibition by NK2 but not NK1 antagonists of carrageenan-induced preprodynorphin mRNA expression in rat dorsal horn lamina I neurons.

Previous evidence indicated that NK2 rather than NK1 receptors play a central role in mediating the electrophysiological responses of dorsal horn neurons to brief cutaneous stimuli such as noxious heat (but not noxious pinch) and moderately sustained stimuli such as mustard oil, topically applied over 10-20 min. The present experiments were designed to investigate, by in situ hybridisation histochemistry, a delayed genomic response in dorsal horn neurons (the expression of preprodynorphin mRNA induced by intraplantar carrageenan injection) and explore the role of NK1 and NK2 receptors in mediating this response. In anaesthetised rats with bilateral intraplantar injections of carrageenan, neurokinin receptor antagonists were administered unilaterally by prolonged ionophoresis into the superficial dorsal horn. The marked increase in preprodynorphin mRNA expression elicited by carrageenan was inhibited (both in terms of number of expressing cells and their level of expression) by NK2 but not NK1 antagonists.

Diuretic renography in evaluating dilated upper urinary tract in children.

The diuretic renogram provides a previously unavailable noninvasive method for assessing and following urinary tract dilation of diverse cause, and defining true obstruction in children. Technetium-99m-DTPA (diethylenetriaminepentaacetic acid) is injected intravenously and a posteriorly placed gamma scintillation camera used to image the kidneys, ureters, and bladder. Furosemide is subsequently injected to stimulate a diuresis, and the washout pattern of isotope is monitored (time-activity histogram). Nonobstructive, obstructive, and poor renal function patterns were seen. Forty patients with varying degrees of hydroureteronephrosis were evaluated. Tracings were performed serially and compared with the clinical course in time, as well as with pressure flow studies and operative findings. All patients with a nonobstructed diuretic renogram did well, except for 1 boy in whom ureteropelvic obstruction developed later. Difficulty in evaluating the obstructive renogram pattern occurred only in some children with severe (grade V) hydronephrosis. Further standardization of the diuretic renogram with regard to time of diuretic injection, state of patient hydration, and regions of imaging may improve diagnostic accuracy.

Breast and cervical cancer screening in an inner-city medical walk-in clinic: taking advantage of an often missed opportunity.

BACKGROUND: Despite established evidence that screening for breast and cervical cancer reduces mortality in women, screening is underutilized, especially in poor, minority women. We hypothesized that a high percentage of women presenting for care to an inner-city medical walk-in clinic would report inadequate screening for breast and cervical cancer by current standards, accept same-day screening, and comply with recommended follow-up. METHODS: To determine how many women presenting to our medical Walk-In Clinic were inadequately screened for breast and cervical cancer and how many were willing to undergo same-day screening, we surveyed all women at this site over a three month period. We then implemented a one-year, same-day screening program and contacted patients with abnormal screening results by letter or phone to encourage follow up. We tracked patients to assess compliance with follow-up. RESULTS: Of the 2,363 women in the initial survey, 1,230 (52%) reported inadequate screening, of whom 55% reported interest in same-day screening. Over the one year screening period, we screened 403 women for breast and/or cervical cancer. Of the 48 women with abnormal Pap tests, compliance with initial Gynecology Clinic follow-up was 56%. Compliance was 49% with mammography appointments, and 77% for follow-up to Breast Clinic for clinical and/or mammographic abnormalities. These compliance rates compare favorably to those for screening performed in more traditional settings. CONCLUSION: Our results support the establishment of cancer screening programs in nontraditional settings such as walk-in clinics and emergency departments to target patients who are at high risk for remaining unscreened.

Evidence for a role of tachykinin NK2 receptors in mediating brief nociceptive inputs to rat dorsal horn (laminae III-V) neurons.

Since the NK2 receptor-selective tachykinin, neurokinin A is present in fine primary afferent neurons in addition to the NK1 receptor-selective tachykinin, substance P, we have addressed the relative role of NK1 and NK2 receptors in somatosensory processing in spinal dorsal horn. Recording extracellularly from rat laminae III-V neurons whilst ionophoresing drugs nearby, the selective NK1 receptor antagonists L 688,169, GR 82334 and [D-Pro4,D-Trp7,910Phe11]substance P-(4-11) failed to influence neuronal responses to cutaneous pinch or noxious heat but often enhanced responses to innocuous brush. In contrast, the highly selective NK2 receptor antagonist L 659,874 profoundly inhibited responses to noxious heat but not pinch or brush. Highly selective synthetic agonists for both NK1 and NK2 receptors ([N-acetyl-Arg6,Sar9,Met(O2)11]substance P-(6-11) and GR 64349, respectively) and also NKA showed the inverse effects on sensory responses to those brought about by their antagonists. At higher ionophoretic currents, both NK1 and NK2 receptor agonists increased spontaneous activity. This increased basal firing induced by GR 64349 and neurokinin A (but not that due to [N-acetyl-Arg6,Sar9,Met(O2)11]substance P-(6-11) appeared to partially pre-empt further excitatory responses to noxious heat. It is concluded that although both NK1 and NK2 receptors can clearly mediate excitation of dorsal horn neurons, it is not NK1, but rather NK2 receptors that are important as the physiological transducer of brief thermal nociceptive inputs in this model.

Autoradiographic distribution of [3H]-(S)-zacopride-labelled 5-HT3 receptors in human brain.

Autoradiographic binding studies using the 5-HT3 (5-hydroxytryptamine3) receptor radioligand, [3H]-(S)-zacopride (0.5 nM), identified a heterogeneous distribution of specific binding sites (defined by granisetron, 1 microM) throughout the human brain. Highest radiolabelled 5-HT3 receptor densities were detected in discrete nuclei within the brainstem (nucleus tractus solitarius, area postrema, spinal trigeminal nerve nucleus; 50-200 fmol/mg tissue equivalent) with more modest levels of expression in the forebrain (e.g. hippocampus, nucleus accumbens, putamen, caudate; 4-17 fmol/mg tissue equivalent). Within the hippocampal formation, radiolabelled 5-HT3 receptors were differentially distributed with highest levels in the granule cell layer of the dentate gyrus. Saturation studies with [3H]-(S)-zacopride (0.05-16 nM; non-specific binding defined by granisetron, 10 microM) binding to homogenates of human putamen indicated that [3H]-(S)-zacopride (0.05-16 nM; non-specific binding defined by granisetron, 10 microM) binding to homogenates of human putamen indicated that [3H]-(S)-zacopride labelled an apparently homogenous population of binding sites (Bmax = 72 + 7 fmol mg-1 protein, pKd = 8.69 +/- 0.09, Hill coefficient = 0.99 +/- 0.06, mean +/- SEM, n = 4). The pharmacological profile of [3H]-(S)-zacopride binding to homogenates of putamen indicated the selective labelling of the human variant of the 5-HT3 receptor. The marked differences, however, in the pharmacology (e.g. low affinity for D-tubocurarine) and relative distribution (e.g. presence of 5-HT3 receptors in the human extrapyramidal system) of 5-HT3 receptors in the human forebrain when compared with other species further necessitates caution in predicting clinical responses based on data generated in animal models of disease.

Variation in lengths of training among residents enrolled in pediatrics and internal medicine training programs.

Data were gathered in 1987 from 180 pediatrics and 302 internal medicine residency training programs about (1) the length of vacation provided their residents, (2) time allowed them for absence from work for reasons other than vacation, (3) how many of them during the previous three years had been required to extend their training to make up absences from work, and (4) whether a system was in place to cover their unexpected absences from work. All these variables affect the duration--but not necessarily the quality--of training that residents actually experience. The data show that these variables demonstrated wide ranges that depended on the postgraduate year of training, the discipline, the program size, and the program type (university, university-affiliated, freestanding, or military). The Accreditation Council for Graduate Medical Education, training program directors, and the American Board of Pediatrics and the American Board of Internal Medicine each need to consider these variables in making their respective decisions about accrediting training programs, verifying the clinical competence of trainees, and certifying program graduates.

Surveying graduates of combined internal medicine-pediatrics residency programs.

Graduates of all U.S. combined internal medicine-pediatrics residency programs were surveyed in 1987 regarding a variety of demographic information about their residencies and current practices, the residency curricula they had followed for both specialties, and recommendations for modifications in training. The 71 responding graduates (from a total of 112) reported patient care as their major involvement (mean of 42.9 hours per week), with a majority (83%) seeing patients in both pediatric and adult age groups. Most were involved in primary care only (64%). The graduates reported that during both pediatrics and internal medicine training, they had had too many inpatient and intensive care rotations and too few elective and ambulatory rotations. The most important subspecialty rotations in internal medicine were considered to be cardiology, dermatology, and pulmonary medicine; and in pediatrics, infectious disease, cardiology, and adolescent medicine. The graduates recommended more outpatient subspecialty rotations, ambulatory rotations in medicine and pediatrics, and a combined medicine-pediatrics continuity clinic.