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Evidence-based medicine (EBM) has emerged has a critical clinical competency in the 21st century. Medical schools usually introduce students to critical appraisal in the preclinical years, but there have been few evaluated interventions in teaching EBM in the clinical years. We describe a strategy to encourage students to practice EBM during a required ambulatory medicine clerkship. During this clerkship, our students are required to submit an EBM report, which is prompted by an individual case, and structured with a 5-step approach. One small-group session is devoted to modeling this approach with a case of chest pain. Using a checklist to grade 216 consecutive EBM reports, we found that students were quite successful with the exercise, achieving on average 89.6% of possible checklist points. Students who followed the structure of the exercise closely were more likely to extend their discussions beyond that required and to suggest potential further areas of investigation or design. [ABSTRACT FROM AUTHOR]

Healthcare organizations offer numerous clinical and academic leadership pathways for physicians, among which the position of program director (PD) is considered to be a prominent educational leadership role. As PDs are instrumental in the recruitment and training of the next generations of physicians, PD gender distribution can affect the present and future of a medical specialty. This study offers a dialectical perspective in understanding how international PDs negotiate gendered understanding of their work/role by using the framework of Relational Dialectics Theory 2.0. Thirty-three interviews of PDs from Qatar, Singapore, and the United Arab Emirates were conducted and, using contrapuntal analysis, the competing discourses of meanings of gender in the PD work/role were examined. Competing discourses where structural, cultural, and professional meanings of gender were interrogated revealed inherent multiple meanings of how gender is understood in PD work/roles. In making sense of these meanings of gender, PDs express dilemmas of traditional gender binaries of masculine/feminine work/role meanings to explain the term in different ways in their everyday organizational and cultural struggles. The findings have implications for PD recruitment and retention in teaching hospitals.

Phenomenon: Program director ( PD)-resident relationships are important in shaping resident experiences and educational outcomes. Yet, there is limited literature on the development or meaning of these relationships, particularly from the PD perspective. Through qualitative interviews, we explore how PDs navigate their role to develop and maintain relationships with their trainees, and elucidate how these relationships impact the PDs personally and professionally., Approach: Qualitative study using individual semi-structured interviews of former and current PDs (n = 33) from multiple specialties and hospitals in accredited residency programs in Qatar, Singapore, and the United Arab Emirates. We used attachment theory and narrative analysis to investigate how PDs perceive and describe relationship building with their residents amidst tensions of familiarizing themselves with their new role., Findings: PD-resident relationships are complex and multidimensional, shifting over time, changing patterns and evolving to respond to different contexts. PDs initially negotiate their own roles, while navigating their relationships with residents and other stakeholders to create their professional identities. PDs develop professional alliances, defining for the resident the profession and its expectations. As residents negotiate the various challenges of their training, the role of the PD emerges into one of providing emotional support and advocacy. The support and attachment are often enduring and extend beyond the period of residency training., Insights: Our study examines the experiences of program directors as they negotiate complex educator-learner relationships. The PDs described roles that extended beyond their job description. Although all interviewees reported that the PD position was challenging, they focused on the rewarding aspects of the job and how their relationships helped sustain them through the difficulties. Through their reflections, the PDs described the personal satisfaction and benefits of their interactions with the residents, and how the engagement contributed to personal and professional success.

Background: Depressive symptoms and burnout are common among medical students. However, few studies have investigated their trajectory over the course of medical school., Objective: Evaluate year-by-year changes in depressive and burnout symptoms over the course of medical school training., Design: Prospective study., Participants: Medical students who matriculated at a private medical school in Maryland from 2010 to 2016 (n=758)., Main Measures: Clinically significant depressive symptoms were defined as a score of ≥10 on the 9-item Patient Health Questionnaire (PHQ-9), and burnout was measured using the Maslach Burnout Inventory (MBI). High emotional exhaustion, high depersonalization, and low personal accomplishment were defined as scores of ≥ 27, ≥10, and ≤33 on the respective MBI subscales., Key Results: At matriculation, the prevalences of significant depressive symptoms, high emotional exhaustion, high depersonalization, and low personal accomplishment were 4.3%, 9.4%, 8.6%, and 37.7%, respectively. After adjustment for age, sex, race/ethnicity, marital status, and cohort, compared with year 1, the odds of significant depressive symptoms was significantly higher at the beginning of the 2nd, 3rd, and 4th years of study (ORs=2.63, 2.85, and 3.77, respectively; all ps<0.001). Compared with the 1st year, the odds of high emotional exhaustion also increased during the 2nd, 3rd, and 4th years of study, (ORs=3.46, 4.79, 8.20, respectively; all ps<0.001), as did the odds of high depersonalization (ORs=3.55, 6.14, 12.53, respectively; all ps<0.001). The odds of low personal accomplishment did not significantly differ across years of study., Conclusions: The results of this study suggest that symptoms of depression and burnout may increase during medical school. Because of the high prevalence of depressive symptoms and burnout in medical students, interventions earlier in the medical career pathway that aim to prevent, detect, and treat these symptoms may be of benefit to the physician community., (© 2021. Society of General Internal Medicine.)

Problem: Some focus on recognizing excellence in clinical teaching has been lost with the increasing emphasis placed on clinical efficiency and value. Clinical teaching awards and academies of educators aim to address this problem. In 2015, medical student leaders at the Johns Hopkins University School of Medicine created the Distinguished Teaching Society (DTS), a student-driven program to recognize the best clinical educators., Approach: Medical students designed a comprehensive scoring rubric focusing on 3 domains: feedback and evaluation, role model behavior, and teaching process. A student committee solicits student nominations providing narratives endorsing faculty or house staff for potential inclusion in the DTS. Using the rubric, student judges score each deidentified narrative nomination, as well as an application from finalists and comments about finalists submitted by the student body. Inductees are recognized at an annual ceremony., Outcomes: From academic years 2015-2016 to 2018-2019, students nominated 254 unique candidates, and 82 nominees (32%) were inducted into the DTS. The majority of inductees were faculty and male. In 2017-2018 and 2018-2019, nearly half of inductees were female, and less than 10% of inductees self-reported as underrepresented in medicine and/or LGBTQ+. The Department of Internal Medicine had the greatest departmental representation. There were no statistically significant differences in the proportional representation within the nomination and inductee cohorts by gender, rank, and department. Several process changes were made in response to student feedback and to increase nominee and inductee diversity., Next Steps: Next steps include adding a diversity and inclusion chair to the student committee and collecting survey data on student and DTS inductee opinions on how to improve learner-teacher engagement and the clinical learning environment. Future activities may include educational workshops, panel discussions, mentorship programs, and networking events. Other medical schools may find value in considering similar structures., (Copyright © 2020 by the Association of American Medical Colleges.)

Background: Residency program directors (PDs) need to navigate diverse roles and responsibilities as clinical teachers, administrators, and drivers of educational improvement. Little is known about the experience of PDs leading transformation of international residency programs., Objective: We explored the lived experiences of international residency PDs and developed an understanding of how PDs manage educational program transformation., Methods: Using a phenomenological approach, semi-structured interviews were conducted with current and former PDs involved in the transformation to competency-based medical education in the first international settings to be accredited by the Accreditation Council for Graduate Medical Education-International (ACGME-I). Thirty-three interviews with PDs from Qatar, Singapore, and the United Arab Emirates were conducted from September 2018 to July 2019, audio-recorded, and transcribed. Data were independently coded by 2 researchers. A thematic analysis was conducted and patterns that reflected coping and managing educational reform were identified., Results: PDs described distinctive patterns of navigating the educational transformation. Five themes emerged: PDs (1) embraced continuous learning and self-development; (2) managed change in the context of their local settings; (3) anticipated problems and built support networks to effectively problem-solve; (4) maintained relationships with stakeholders for meaningful and constructive interactions; and (5) focused on intrinsic qualities that helped them navigate challenges., Conclusions: International PDs were presented with significant challenges in implementing educational transformation but coped successfully through distinctive patterns and methods., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background: This is the first randomized controlled trial evaluating the impact of note template design on note quality using a simulated patient encounter and a validated assessment tool., Objective: To compare note quality between two different templates using a novel randomized clinical simulation process., Design: A randomized non-blinded controlled trial of a standard note template versus redesigned template., Participants: PGY 1-3 IM residents., Interventions: Residents documented the simulated patient encounter using one of two templates. The standard template was modeled after the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment, and deemphasized less useful elements., Main Measures: Note length; time to note completion; note template evaluation by resident authors; note evaluation by faculty reviewers., Key Results: 36 residents participated, 19 randomized to standard template, 17 to new. New template generated shorter notes (103 vs 285 lines, p < 0.001) that took the same time to complete (19.8 vs 21.6 min, p = 0.654). Using a 5-point Likert scale, residents considered new notes to have increased visual appeal (4 vs 3, p = 0.05) and less redundancy and clutter (4 vs 3, p = 0.006). Overall template satisfaction was not statistically different. Faculty reviewers rated the standard note more up-to-date (4.3 vs 2.7, p = 0.001), accurate (3.9 vs 2.6, p = 0.003), and useful (4 vs 2.8, p = 0.002), but less organized (3.3 vs 4.5, p < 0.001). Total quality was not statistically different., Conclusions: Residents rated the new note template more visually appealing, shorter, and less cluttered. Faculty reviewers rated both note types equivalent in the overall quality but rated new notes inferior in terms of accuracy and usefulness though better organized. This study demonstrates a novel method of a simulated clinical encounter to evaluate note templates before the introduction into practice., Trial Registration: ClinicalTrials.gov ID: NCT04333238.

Background: Program directors (PDs) are integral to the education of the next generation of physicians. Yet, administrative burdens, substantial patient care responsibilities, and lack of protected time for teaching may contribute to work-life imbalance and physician burnout, leading to high rates of attrition. Data on international residency program leadership turnover are lacking., Objective: This study aimed to quantify PD turnover in Accreditation Council for Graduate Medical Education-International (ACGME-I) accredited programs in Singapore, United Arab Emirates (UAE), and Qatar, and to compare to US PD attrition rates., Methods: Data on PD turnover in international programs was extracted from the ACGME-I Accreditation Data System for academic years 2010-2011 through 2018-2019 for Singapore and 2013-2014 through 2018-2019 for UAE and Qatar. Rates of PD turnover were calculated by country and by ACGME-I medical-, surgical-, and hospital-based specialty groupings and compared using χ 2 test. Annual US PD turnover data was extracted from the ACGME's Data Resource Book., Results: Seventy programs met inclusion criteria. International PD attrition was high, with 56 programs (80%) changing PDs since program inception, and 16 programs (29%) having 2 or more PD turnovers. There was no significant difference between PD turnover rates in hospital (83%), medical (79%), or surgical (78%) specialties. International PD attrition rates varied from 7% to 20% annually and were comparable to PD turnover in US programs (range 12%-15%)., Conclusions: High PD turnover rates in newly accredited international residency programs were noted, although annual attrition rates were comparable to US residency programs., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background: Gender inequities are documented in academic medicine. Within General Internal Medicine (GIM), there are fewer female division directors and first and last authors on publications. With gender parity in US medical school graduates and with Academic Hospital (AH) medicine being a relatively newer discipline, one might postulate that AH would have less gender inequity., Design: A national survey of AH programs was developed via literature review and expert recommendations. Domains included program and faculty information. Gender of the leader was determined via website or telephone call., Participants: Leaders of AH programs associated with the American Association of Medical Colleges (AAMC). Programs without a primary teaching hospital or hospitalist program and those not staffed by university-affiliated physicians were excluded., Main Measures: Description and characteristics of leaders and programs including a multivariable analysis of gender of hospitalist leaders and the portion of female faculty., Key Results: 59% response rate (80 of 135); there were no differences between responders/non-responders in NIH funding (p = 0.12), type of institution (p = 0.09), geographic region (p = 0.15), or year established (p = 0.86). Reported number of female and male faculty were approximately equal. 80% of hospitalist leaders were male; 37% of male hospitalist leaders were professors, no female leaders were professors. In univariate and multivariate analysis only the number of hospitals staffed was a significant predictor of having a female hospitalist leader. There were no significant predictors of having fewer female faculty., Conclusion: This study demonstrated gender inequality in academic hospital medicine regarding leadership and rank. Though there was equal gender distribution of faculty, among leaders most were men and all "full professors" were men. As diversity benefits the tripartite mission research on methods, initiatives and programs that achieve gender equity in leadership are needed.

Gender inequity in academic medicine remains an important issue worldwide. While institutional programs and policies can help promote equity in recruitment, retention, scholarship, promotion, and leadership, they often do not address the physical and social isolation that many women in international academic medicine face. Creating networking opportunities through building women's groups can provide a personal and professional support structure that decreases isolation and promotes the advancement of women. Based on a multidisciplinary literature review on change processes, group formation, and women's empowerment, as well as lessons learned from personal experience, we offer 12 tips to successfully create, maintain, and support physician women's groups, employing Kotter's change-management framework. We believe that these groups can provide a structured platform for networking opportunities to advance women physicians in academic medicine worldwide.

Objective: Surgeons worldwide face unique time and practice pressures differentiating them from other types of physicians, specifically as clinician educators (CEs). The purpose of this study is to identify and describe academic surgical clinician educators (SCEs) in international graduate medical education systems, characterize their perceptions of roles, preparedness, and factors affecting job satisfaction and retention, as compared to nonsurgical international CEs., Design, Setting, and Participants: A cross-sectional survey of CEs was conducted June 2013-June 2014 at academic medical centers in Singapore, Qatar, and the United Arab Emirates that adopted competency-based graduate medical education and received accreditation by the Accreditation Council for Graduate Medical Education-International., Results: Two hundred seventy-six (76.3%) of 359 eligible physicians responded; 64 (23.2%) were SCEs. SCEs were predominantly male (80%), less than 50 years of age (83%), with 64% having been in their current position less than 5 years. Overall, SCEs were significantly less confident, as compared to nonsurgical CEs, in aspects of educational programs, including curriculum development, assessment, and mentorship. SCEs spent significantly more time engaged in patient care activities, as compared to nonsurgeon colleagues. There were no significant differences between SCEs and nonsurgical CEs in terms of work-life balance and satisfaction with responsibilities, position, or potential promotion, with most SCEs intending to stay in academic medicine., Conclusions: Academic SCEs working in the international programs reported overall job satisfaction with a desire to remain in academic medicine. However, SCEs have several faculty development needs. International surgical training programs can develop and expand offerings in teaching and education to improve skills and maintain SCE satisfaction and retention, necessary to successfully train the next generation of surgeons., (Copyright © 2018. Published by Elsevier Inc.)

Gender inequity in academic medicine remains an important issue worldwide, with more female faculty entering academic medicine internationally. Some academic institutions have initiated programs and created policies to promote gender equity, but disparities remain in faculty numbers, promotions rates, research productivity and access to funding and resources. We offer 12 tips for best practices in the broad domains of faculty recruitment, retention and scholarship, promotion and leadership that institutions and individual faculty can adopt to promote gender equity. While the 12 tips form a comprehensive approach, each tip can be implemented individually depending on institutional needs and culture. Each tip includes practical advice for implementation supported by a successful example from the literature.

Introduction: Burnout and depression are well-described in medical students and physicians and can lead to adverse personal and patient outcomes; however, their time course and risk factors remain understudied. Here, we measured multiple domains of mental and physical health and wellness and assessed gender differences among incoming physician trainees beginning residency at an academic medical center., Methods: Using a cross-sectional study design, all incoming trainees (i.e. housestaff) at Johns Hopkins Hospital received a questionnaire assessing depression, burnout, sleep, exercise, and alcohol consumption, among other domains. Standardized instruments were utilized for questionnaire development. Tests of significance were two-tailed., Results: 196 of 229 incoming housestaff (86%) completed the survey, and 49% were female. A history of depression was reported in 8%, and 5.4% met criteria for at least moderate depression by Patient Health Questionnaire (PHQ-9). Females were more likely to report a history of depression than males (13% vs. 3%, p=0.02) but had similar PHQ-9 scores. Four percent of participants reported feeling they were in the wrong profession. Goal and mean sleep were 7 and 6.7 hours/night, respectively. Forty-seven percent reported exercising once/week or not at all. While mean reported weekly alcohol consumption was three drinks, participants reported consuming ≥5 drinks in one sitting on average 1.6 times in the prior 6 months, and 4% used alcohol to sleep., Conclusions: Incoming housestaff reported generally favorable mental and physical health at the beginning of residency training. However, exercise rates were low, and ill-suited alcohol consumption was noted, though infrequent. The few areas of possible improvement were largely similar between males and females. Wellness interventions might capitalize on the relatively high morale and health at the completion of medical school by helping to promote healthy habits, including regular exercise and avoidance of excess alcohol consumption, throughout future training and practice.

Problem: Creating and supporting opportunities for innovation that showcase and reward creativity in medical and biomedical education is critically important for academic institutions, learners, and faculty., Approach: In 2014, the Institute for Excellence in Education at Johns Hopkins University School of Medicine created a small grant program called Education Shark Tank, in which two to five finalist teams present their proposals on innovative initiatives to improve education to four or five senior educator "sharks" at an educational conference, with an audience. The sharks then "grill" the presenters, considering which if any to fund, focusing on the rationale, feasibility, appropriateness of the outcome measures, evaluation and assessment plan, and proposed method of dissemination. They also make suggestions that challenge the presenters to assess and improve their designs., Outcomes: In the program's first year (2014), funds were divided equally between two projects, both of which were successfully completed and one of which led to a journal publication; this led to increased funding for the program in 2015. Participants have called Education Shark Tank a "challenging and rewarding experience.", Next Steps: Education Shark Tank can facilitate educational innovation and scholarship via engaging and challenging interactions between grant applicants and reviewers in a public venue. The authors plan to conduct a five-year survey (after 2018) of all Education Shark Tank finalists to determine the success and challenges the funded projects have had, what scholarly dissemination has occurred, whether nonfunded projects were able to move forward, and the value of the feedback and mentoring received.

Background: Facial lipoatrophy is common in people on antiretroviral (ARV) regimens for HIV/AIDS and can impair health-related quality of life., Objectives: We developed the Facial Appearance Inventory (FAI) to measure the impact of ARV-associated facial lipoatrophy., Methods: Qualitative methods were used to identify key concerns of people with facial lipoatrophy. The major concerns were used to identify 24 items for the FAI. The FAI was administered to a cross-sectional sample of 96 people with HIV and facial lipoatrophy and compared to the established Assessment of Body Change Distress (ABCD) and MOS-HIV questionnaires., Results: Mean age was 48.8 years, 87.5% were men, 69.8% were Caucasian, and 60% had some college education. Mean CD4 count was 435 cells/mm(3). There were few missing data, and the summary score showed no floor or ceiling effects, with a mean (SD) of 25.6 (17.9). Cronbach's alpha for the scale was 0.98. FAI items satisfied criteria for convergent and discriminant construct validity. FAI items were more strongly correlated with mental health domains (R = 0.33) than with physical health domains (R = 0.26) on the MOS-HIV. Patients with greater severity of lipoatrophy had significantly worse scores than those with less severity (James 3-4, vs. James 0-2). There were no significant differences for FAI scores by age group, income group, CD4 cell count, or HIV viral load group. Those with less education and those with darker skin types reported less impairment (P < .05)., Conclusions: The 24-item FAI shows evidence for reliability, validity, and usefulness as a measure of the impact of facial lipoatrophy., (© 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Objectives: To describe clinician-educators (CEs) in new graduate medical education (GME) systems and characterize perception of preparedness, roles and rewards, and factors affecting job satisfaction and retention., Methods: A cross-sectional survey of all CEs of institutions using competency-based GME and accredited by the Accreditation Council for Graduate Medical Education-International (ACGME-I)., Results: 274 of 359 eligible participants (76.3%) responded, representing 47 residency programs across 17 specialties. CEs were predominantly married men aged in their 40s, employed at their current institution 9.3 years (±6.4 years). CEs judged themselves competent or expert in teaching skills (91.5%), trainee assessment (82%) and mentoring (75%); less so in curriculum development (44%) and educational research skills (32%). Clinical productivity was perceived by the majority (62%) as the item most valued by their institutions, with little or no perceived value for teaching or educational efforts. Overall, 58.3% were satisfied or very satisfied with their roles, and 77% expected to remain in academic medicine for 5 years. A strong negative correlation was found between being a program or associate program director and likelihood of staying in academic medicine (aOR 0.42; 0.22 to 0.80)., Conclusions: In the GME systems studied, CEs, regardless of country or programme, report working in environments that value clinical productivity over educational efforts. CEs feel competent and prepared for many aspects of their roles, have positive attitudes towards teaching, and report overall job satisfaction, with most likely to remain in academic medicine. As medical training advances internationally, the impact on and by CEs requires ongoing attention., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Graduate medical education (GME) is responding to calls for reform by adopting competency-based frameworks and, in some countries, by rapidly implementing external accreditation systems. The Accreditation Council for Graduate Medical Education International (ACGME-I) began accrediting institutions in 2009. This study aimed to describe ACGME-I-accredited institutions and explore perceptions of their leaders and clinician educators (CEs) regarding preparedness, challenges, and initial impact of accreditation., Method: Cross-sectional surveys of all ACGME-I-accredited institutions' leaders and CEs were conducted from June 2013 to June 2014. Eligible participants were identified through institution Web sites and GME offices. Combinations of Web- and paper-based surveys were employed., Results: Completed surveys were received from 24 (70.6%) of 34 institutional leaders and 274 (76.3%) of 359 CEs, representing 3 countries, 8 academic medical centers, 2 affiliated teaching hospitals, and 47 residency programs. Leaders and CEs felt prepared in the domains of knowledge and implementation of the competencies. Top challenges were excessive "demands on faculty time" and "bureaucratic procedures." The majority of both groups perceived a positive impact of accreditation on all learner, faculty, institution, and patient outcomes; most perceived no impact on patient satisfaction. Overall, 79.2% of leaders and 75.8% of CEs agreed or strongly agreed that seeking ACGME-I accreditation was worthwhile., Conclusions: This study indicates that despite the challenges identified, initial perceptions of the impact of ACGME-I accreditation are positive. Findings from this study may be useful to institutions and countries considering similar GME reform, though long-term outcome data are needed.

Background: It is not known whether medical students support the Affordable Care Act (ACA) or possess the knowledge or will to engage in its implementation as part of their professional obligations., Objective: To characterize medical students' views and knowledge of the ACA and to assess correlates of these views., Design: Cross-sectional email survey., Participants: All 5,340 medical students enrolled at eight geographically diverse U.S. medical schools (overall response rate 52% [2,761/5,340])., Main Measures: Level of agreement with four questions regarding views of the ACA and responses to nine knowledge-based questions., Key Results: The majority of respondents indicated an understanding of (75.3%) and support for (62.8%) the ACA and a professional obligation to assist with its implementation (56.1%). The mean knowledge score from nine knowledge-based questions was 6.9 ± 1.3. Students anticipating a surgical specialty or procedural specialty compared to those anticipating a medical specialty were less likely to support the legislation (OR = 0.6 [0.4-0.7], OR = 0.4 [0.3-0.6], respectively), less likely to indicate a professional obligation to implement the ACA (OR = 0.7 [0.6-0.9], OR = 0.7 [0.5-0.96], respectively), and more likely to have negative expectations (OR = 1.9 [1.5-2.6], OR = 2.3 [1.6-3.5], respectively). Moderates, liberals, and those with an above-average knowledge score were more likely to indicate support for the ACA (OR = 5.7 [4.1-7.9], OR = 35.1 [25.4-48.5], OR = 1.7 [1.4-2.1], respectively) and a professional obligation toward its implementation (OR = 1.9 [1.4-2.5], OR = 4.7 [3.6-6.0], OR = 1.2 [1.02-1.5], respectively)., Conclusions: The majority of students in our sample support the ACA. Support was highest among students who anticipate a medical specialty, self-identify as political moderates or liberals, and have an above-average knowledge score. Support of the ACA by future physicians suggests that they are willing to engage with health care reform measures that increase access to care.

Background: Audience response systems (ARSs) are electronic devices that allow educators to pose questions during lectures and receive immediate feedback on student knowledge. The current literature on the effectiveness of ARSs is contradictory, and their impact on student learning remains unclear., Objectives: This randomised controlled trial was designed to isolate the impact of ARSs on student learning and students' perception of ARSs during a lecture., Methods: First-year medical student volunteers at Johns Hopkins were randomly assigned to either (i) watch a recorded lecture on an unfamiliar topic in which three ARS questions were embedded or (ii) watch the same lecture without the ARS questions. Immediately after the lecture on 5 June 2012, and again 2 weeks later, both groups were asked to complete a questionnaire to assess their knowledge of the lecture content and satisfaction with the learning experience., Results: 92 students participated. The mean (95% CI) initial knowledge assessment score was 7.63 (7.17 to 8.09) for the ARS group (N=45) and 6.39 (5.81 to 6.97) for the control group (N=47), p=0.001. Similarly, the second knowledge assessment mean score was 6.95 (6.38 to 7.52) for the ARS group and 5.88 (5.29 to 6.47) for the control group, p=0.001. The ARS group also reported higher levels of engagement and enjoyment., Conclusions: Embedding three ARS questions within a 30 min lecture increased students' knowledge immediately after the lecture and 2 weeks later. We hypothesise that this increase was due to forced information retrieval by students during the learning process, a form of the testing effect., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: To determine perceptions of general internal medicine (GIM) division directors of the importance of and support for clinician-educators' (CEs') scholarship., Method: In 2010, the authors identified 127 accredited U.S. MD-granting medical schools with a GIM division, identified 144 GIM directors, and were able to survey 129 of them. Directors were asked to rate the importance of specific CE scholarly accomplishments for promotion from assistant to associate professor, to describe current research support for CEs, and to state how they would support the scholarly work of CEs if they had funding., Results: Fifty-five directors (42.6%) from 52 institutions responded; there were no significant differences between responding and nonresponding schools. Curriculum development, presentations at national meetings and other institutions, review articles, and book chapters were rated as "most/very important" or "important/somewhat important" by over 90%. Approximately half rated published original peer-reviewed articles as "most/very important"; slightly less than half rated these "not important," a difference associated with having a specific CE track. If $100,000 per year were available to enhance the scholarly productivity of CEs, directors suggested spending it on faculty development, project coordination, protected time for CEs, and methodological and statistical support., Conclusions: This nationwide survey of GIM division directors confirms that academic CEs in GIM are judged on a wide variety of scholarly activities, many of which are consistent across institutions. However, academic GIM CEs need to understand their institutions' specific criteria, especially regarding the value placed on original, peer-reviewed publications.

Clinician Educators' (CEs) focus on patient care and teaching, yet many academic institutions require dissemination of scholarly work for advancement. This can be difficult for CEs. Our division developed the Clinician-Educator Mentoring and Scholarship Program (CEMSP) in an effort to assist CEs with scholarship, national reputation, recognition, promotion and job satisfaction. The key components are salary-supported director and co-director who coordinate the program and serve as overall mentors and link CEs and senior faculty, and a full-time Senior Research Coordinator to assist with all aspects of scholarship, a close relationship with the General Internal Medicine (GIM) Methods Core provides advanced statistical support. Funding for the program comes from GIM divisional resources. Perceived value was evaluated by assessing the number of manuscripts published, survey of faculty regarding usage and opinion of CEMSP, and a review of faculty promotions. Although impossible to attribute the contributions of an individual component, a program specifically aimed at helping GIM CE faculty publish scholarly projects, increase participation in national organizations and focus on career progression can have a positive impact.

Importance: On July 1, 2011, the Accreditation Council for Graduate Medical Education implemented further restrictions of its 2003 regulations on duty hours and supervision. It remains unclear if the 2003 regulations improved trainee well-being or patient safety., Objective: To determine the effects of the 2011 Accreditation Council for Graduate Medical Education duty hour regulations compared with the 2003 regulations concerning sleep duration, trainee education, continuity of patient care, and perceived quality of care among internal medicine trainees., Design and Setting: Crossover study design in an academic research setting., Participants: Medical house staff., Intervention: General medical teams were randomly assigned using a sealed-envelope draw to an experimental model or a control model., Main Outcome Measures: We randomly assigned 4 medical house staff teams (43 interns) using a 3-month crossover design to a 2003-compliant model of every fourth night overnight call (control) with 30-hour duty limits or to one of two 2011-compliant models of every fifth night overnight call (Q5) or a night float schedule (NF), both with 16-hour duty limits. We measured sleep duration using actigraphy and used admission volumes, educational opportunities, the number of handoffs, and satisfaction surveys to assess trainee education, continuity of patient care, and perceived quality of care. RESULTS The study included 560 control, 420 Q5, and 140 NF days that interns worked and 834 hospital admissions. Compared with controls, interns on NF slept longer during the on call period (mean, 5.1 vs 8.3 hours; P = .003), and interns on Q5 slept longer during the postcall period (mean, 7.5 vs 10.2 hours; P = .05). However, both the Q5 and NF models increased handoffs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with NF that it was terminated early., Conclusions and Relevance: Compared with a 2003-compliant model, two 2011 duty hour regulation-compliant models were associated with increased sleep duration during the on-call period and with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.

Background: Low testosterone (T) has been associated with insulin resistance and diabetes mellitus (DM) among men in population-based studies. These studies included racially diverse men, but did not target for inclusion individuals with opiate use, Hepatitis C Virus (HCV) infection, or Human Immunodeficiency Virus (HIV) infection, which disproportionately affect inner-city populations and may alter the relationship between T and DM., Methods: We studied the association between free T (FT) and abnormal glucose metabolism among male participants in t he Study of HIV, Injection Drug Use, Nutrition, and Endocrinology (SHINE). We used logistic regression to examine the relationship between log FT and both insulin resistance and prediabetes/DM., Results: Of 175 men, 43 (24.6%) had low FT (FT < 52 pg/mL). There were more men in the low FT group on methadone maintenance (39.5% v. 15.2%, p=.001), but there was no difference in FT by HIV or HCV status. Overall, 23 men (13.1%) had prediabetes/DM, which was unrelated to FT (OR of prediabetes/DM for each log increase in FT = 0.56, 95% CI 0.13-2.41). FT was also not related to insulin resistance., Conclusions: The prevalence of hypogonadism was high in this inner-city cohort and was associated with methadone use. However, low FT was not related to insulin resistance or prediabetes/DM. Continued work to identify diabetes risk factors among inner-city populations will help determine targets for intervention to reduce diabetes incidence. Treatment trials of testosterone to reduce diabetes among hypogonadal men may be of particular relevance to opiate users, many of whom are hypogonadal.

Background: Adoption of CDC recommendations for routine, voluntary HIV screening of all Americans age 13–64 years has been slow. One method to increase adherence to clinical practice guidelines is through medical school and residency training., Objective: To explore the attitudes, barriers, and behaviors of clinician educators (CEs) regarding advocating routine HIV testing to their trainees., Design/participants: We analyzed CE responses to a 2009 survey of Society of General Internal Medicine members from community, VA, and university-affiliated clinics regarding HIV testing practices., Main Measures: Clinician educators were asked about their outpatient practices, knowledge and attitudes regarding the revised CDC recommendations and whether they encouraged trainees to perform routine HIV testing. Associations between HIV testing knowledge and attitudes and encouraging trainees to perform routine HIV testing were estimated using bivariate and multivariable logistic regression., Results: Of 515 respondents, 367 (71.3%) indicated they supervised trainees in an outpatient general internal medicine clinic. These CEs demonstrated suboptimal knowledge of CDC guidelines and over a third reported continued risk-based testing. Among CEs, 196 (53.4%) reported that they encourage trainees to perform routine HIV testing. Higher knowledge scores (aOR 5.10 (2.16, 12.0)) and more positive attitudes toward testing (aOR 8.83 (4.21, 18.5)) were independently associated with encouraging trainees to screen for HIV. Reasons for not encouraging trainees to screen included perceived low local prevalence (37.2%), competing teaching priorities (34.6%), and a busy clinic environment (34.0%)., Conclusions: Clinician educators have a special role in the dissemination of the CDC recommendations as they impact the knowledge and attitudes of newly practicing physicians. Despite awareness of CDC recommendations, many CEs do not recommend universal HIV testing to trainees. Interventions that improve faculty knowledge of HIV testing recommendations and address barriers in resident clinics may enhance adoption of routine HIV testing.

Background: Premature coronary artery disease (CAD) is a major concern in human immunodeficiency virus (HIV)-infected African Americans. The objectives of the study were to estimate the incidence of subclinical CAD, defined by the presence of coronary plaque and/or calcification on cardiac computed tomography (CT), and to identify the associated risk factors in this vulnerable population., Subjects and Methods: Between August 2003 and September 2010, 188 HIV-infected African Americans without known, or symptoms of, CAD underwent cardiac CT. The subset without demonstrable disease underwent a second cardiac CT approximately 2 years later. The incidence of disease over that period and the effects of antiretroviral treatment and other known and hypothesized risk factors were investigated., Results: Sixty-nine of these 188 African Americans had evidence of subclinical disease on the initial cardiac CT, confirming prior high prevalence reports. A second cardiac CT was performed on 119 African Americans without disease approximately 2 years later. The total person-years of follow-up was 284.4. Subclinical CAD was detected in 14 of these, yielding an overall incidence of 4.92/100 person-years (95% confidence interval, 2.69-8.26). Among the factors investigated, only male sex and vitamin D deficiency were independently associated with the development of subclinical CAD. The study did not find significant associations between CD4 count, HIV viral load, antiretroviral treatment use, or cocaine use and the incidence of subclinical CAD., Conclusions: The incidence of subclinical CAD in African Americans with HIV infection is provocatively high. Larger studies are warranted to confirm the role of vitamin D deficiency in the development of CAD in HIV-infected African Americans.

Purpose: To determine whether medical students and faculty perceive differences in the effectiveness of interactions with real patients versus simulated patients (SPs) in communication skills training., Method: In 2008, the authors recruited volunteer outpatients (VOs) from the Johns Hopkins University School of Medicine internal medicine practice to participate in communication skills training for all first-year medical students. VOs and SPs were assigned to clinic rooms in the simulation center. Each group of five students and its preceptor rotated through randomly assigned rooms on two of four session days; on both days, each student interviewed one patient for 15 minutes, focusing on past medical and family history or social history. Patients used their own histories, not scripts; students were not blinded to patient type. Students and faculty then rated aspects of the interview experience. Generalized linear latent and mixed-models analysis was used to compare ratings of communication skills training with VOs versus SPs., Results: All 121 first-year students participated in 242 interviews, resulting in 237 usable questionnaires (98%). They rated their experiences with VOs significantly higher than those with SPs on comfort, friendliness, amount of learning, opportunity to build relationships, and overall meeting of communication skills training needs. The 24 faculty preceptors' ratings of the 242 interactions did not differ significantly between VOs and SPs., Conclusions: Use of VOs was well received by students and faculty for teaching communication skills. Expanding and further studying VOs' participation will allow greater understanding of their potential role in communication skills training of preclinical medical students.

Background: Rapid HIV testing could increase routine HIV testing. Most previous studies of rapid testing were conducted in acute care settings, and few described the primary care providers' perspective., Objective: To identify characteristics of general internal medicine physicians with access to rapid HIV testing, and to determine whether such access is associated with differences in HIV-testing practices or perceived HIV-testing barriers., Design: Web-based cross-sectional survey conducted in 2009., Participants: A total of 406 physician members of the Society of General Internal Medicine who supervise residents or provide care in outpatient settings., Main Measures: Surveys assessed provider and practice characteristics, HIV-testing types, HIV-testing behavior, and potential barriers to HIV testing., Results: Among respondents, 15% had access to rapid HIV testing. In multivariable analysis, physicians were more likely to report access to rapid testing if they were non-white (OR 0.45, 95% CI 0.22, 0.91), had more years since completing training (OR 1.06, 95% CI 1.02, 1.10), practiced in the northeastern US (OR 2.35; 95% CI 1.28, 4.32), or their practice included a higher percentage of uninsured patients (OR 1.03; 95% CI 1.01, 1.04). Internists with access to rapid testing reported fewer barriers to HIV testing. More respondents with rapid than standard testing reported at least 25% of their patients received HIV testing (51% versus 35%, p = 0.02). However, access to rapid HIV testing was not significantly associated with the estimated proportion of patients receiving HIV testing within the previous 30 days (7.24% vs. 4.58%, p = 0.06)., Conclusion: Relatively few internists have access to rapid HIV testing in outpatient settings, with greater availability of rapid testing in community-based clinics and in the northeastern US. Future research may determine whether access to rapid testing in primary care settings will impact routinizing HIV testing.

The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in primary care but little is known about general internists' views of this practice. We conducted a national, cross-sectional, Internet-based survey of 446 general internists in 2009 regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient internal medicine practices. Internists' awareness of revised CDC guidelines was high (88%), but only 52% had increased HIV testing, 61% offered HIV screening regardless of risk, and a median 2% (range 0-67%) of their patients were tested in the past month. Internists practicing in perceived higher risk communities reported greater HIV screening. Consent requirements were a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. Interventions that promote HIV screening regardless of risk and streamlined consent requirements will likely increase adoption of routine HIV screening in general medicine practices.

Bone mineral density (BMD) is an important factor linked to bone health. Little is known of the prevalence of low BMD and its associated risk factors in an urban underserved population. Between 2001 and 2004, we recruited 338 subjects who completed drug use and medical history questionnaires, underwent hormonal measurements, and underwent whole-body dual-energy X-ray absorptiometry (DXA) for evaluation of BMD and body composition. Of these, 132 subjects had site-specific DXA (lumbar spine and hip) performed. Osteoporosis was defined as a T-score of -2.5 or less for men 50 years of age and older and postmenopausal women and a Z-score of -2.0 or less in men younger than 50 years of age and premenopausal women at either the lumbar spine, total hip, or femoral neck, according to National Osteoporosis Foundation (NOF) guidelines. The cohort consisted of mostly African-American, middle-aged people with a high prevalence of illicit drug use, 50% HIV(+), and 39% hepatitis C(+). Osteoporosis was identified in 22% of subjects (24 men, 5 women), with the majority of cases (90%) attributable to osteoporosis at the lumbar spine. Osteoporosis was more common in men than in women. Lower whole-body BMD among women was associated with multiple risk factors, but only with lower lean mass among men. Osteoporosis was highly prevalent in men, mainly at the spine. The risk factors for bone loss in this population need to be further clarified. Screening men for osteoporosis starting at age 50 might be warranted in this population given the multiple risk factors and the unexpectedly high prevalence of low BMD., (Copyright © 2011 American Society for Bone and Mineral Research.)

Objective: Peripheral fat loss and visceral fat gain have been reported in HIV infection. There are limited data on long-term change in adipose tissue in HIV-infected patients vs. controls. Therefore, we determined change in regional adipose tissue from baseline examination to 5 years later among participants in the study of Fat Redistribution and Metabolic Change in HIV Infection., Methods: Regional adipose tissue volume was measured using MRI at both examinations in 477 HIV-infected and 214 control men and women. Lipoatrophy was defined as leg subcutaneous adipose tissue (SAT) below the cutoff point marking the lowest decile (10%) of controls at each examination., Results: HIV-infected and control participants showed similar adipose tissue gains. In men, all SAT depots and visceral adipose tissue started lower and remained lower on average in HIV-infected vs. controls. In women, leg and arm SAT also started lower and remained lower in HIV-infected vs. controls. Mean leg SAT of HIV-infected men was 67% of control men at baseline and 65% at follow-up; for women 83% and 77%. At baseline, 48% of HIV-infected participants had lipoatrophy; on average those with baseline lipoatrophy gained 0.96L of leg SAT compared with 1.23L gain for controls in the lowest decile (P = 0.16). At follow-up, 53% of HIV-infected participants had lipoatrophy. In multivariable models, discontinuation of stavudine appeared to produce little gain in leg SAT ( approximately 1.1%/year)., Conclusion: HIV-infected participants did not substantially recover SAT compared with controls, although both showed average gains. HIV-associated lipoatrophy persisted after 5 years of follow-up.

Routine HIV screening is recommended by the Centers for Disease Control and Prevention (CDC), but it is unknown how well internal medicine residents are trained in HIV risk assessment, testing, counseling, and initial management of HIV patients. We sought to determine internal medicine residents' attitudes about HIV training and the factors that influence their HIV care performance utilizing a cross-sectional survey of 321 second- and third-year internal medicine residents from four programs in Baltimore, Boston, Detroit, and New York City between March and June 2006. Measurements included HIV care experience; attitudes, competency, and adequacy of HIV training; and basic HIV care performance and factors impacting performance. Two hundred twenty-three residents (69%) completed the survey. While 50% of residents reported over 30 HIV inpatient encounters in the past year, the majority of residents had limited outpatient exposure providing care for only 1-5 HIV outpatients. Managing HIV patients was rated an excellent educational opportunity by 89% of residents and 77% planned to care for HIV patients in the future. However, 39% stated that they did not feel competent to provide HIV outpatient care. Higher rates of residents reported deficiency in outpatient HIV training compared to outpatient non-HIV training (p < 0.05) or inpatient HIV training (p < 0.05). Residents reported substandard HIV risk assessment, testing, counseling, and initial management performance. Self-reported proficiency correlated with the number of HIV outpatients cared for and perceived training adequacy. Current residency training in HIV care remains largely inpatient-based and residents frequently rate HIV outpatient training as inadequate.

The aim of the study was to assess whether long-term antiretroviral therapy (ART) is associated with the risk of coronary plaques in HIV-infected cardiovascularly asymptomatic African Americans. Between August 2003 and December 2007, 176 HIV-infected cardiovascularly asymptomatic African Americans were consecutively enrolled in an observational study investigating the effects of ART on subclinical atherosclerosis in Baltimore, Maryland. Computed tomography coronary angiography was performed to detect coronary plaques. The overall prevalence rate of coronary plaques was 30%. After adjusting for gender, total cholesterol, and cocaine use, logistic regression analysis revealed that exposure to ART for more than 18 months (adjusted odds ratio [OR]: 2.20, 95% confidence interval [CI]: 1.01, 4.79) was independently associated with the presence of coronary plaques. A higher HIV viral load was univariately associated with the presence of noncalcified plaques. Use of ART (>18 months) was independently associated with the presence of noncalcified plaques (adjusted OR: 7.61, 95% CI: 1.67, 34.7), whereas cocaine use (>15 years) was independently associated with the presence of calcified plaques (adjusted OR: 2.51, 95% CI: 1.11, 5.67). This study suggests that long-term exposure to ART may be associated with coronary plaques. Because long-term use of ART and HIV replication may be associated with the presence of noncalcified plaques, some of which may be more vulnerable to rupture, an intensive lifestyle intervention to reduce traditional risk factors for coronary artery disease (CAD) is ultimately vital to those who are on ART. This study also suggests that cocaine cessation is the single most effective strategy to prevent CAD in HIV-infected cocaine users.

Central fat accumulation is increasingly recognized as a problem for patients with HIV infection. The term "lipodystrophy" has been used to describe collectively a constellation of body habitus changes and metabolic abnormalities commonly observed in HIV-infected patients, particularly since the advent of highly active antiretroviral therapy. Visceral fat accumulation can place patients at increased risk of coronary artery disease.Furthermore, body shape changes are a source of distress to patients that may compromise treatment adherence.Reduction of abdominal obesity can therefore be considered part of therapy in HIV-positive patients with visceral adipose tissue (VAT) accumulation. Currently, there are no drugs approved by the Food and Drug Administration for the treatment of HIV-associated central fat accumulation. Lifestyle modifications such as diet and exercise and switching antiretroviral therapies appear to be of limited value in reducing VAT. Metformin has shown some benefit in reducing VAT but at the expense of accelerating peripheral fat loss, and the thiazolidinediones have no effect on VAT. Similarly, testosterone does not appear to reduce VAT in these patients,and there are no data on anabolic steroids. Two large, randomized controlled trials have demonstrated the efficacy of recombinant human growth hormone (rhGH) in reducing visceral adipose tissue. There are also promising data regarding treatment with growth hormone releasing hormone (GHRH).

Background: Teaching faculty have valuable perspectives on the impact of residency duty hour regulations on medical students., Objective: The objective of this study was to elicit faculty views on the impact of residency duty hour regulations on medical students' educational experience on inpatient medicine rotations., Design and Participants: We conducted a National Survey of Key Clinical Faculty (KCF) at 40 internal medicine residency programs affiliated with U.S. medical schools using a random sample stratified by National Institutes of Health funding and program size., Measurements: This study measures KCF opinions on the effect of duty hour regulations on students' education., Results: Of 154 KCF targeted, 111 responded (72%). Fifty-two percent of KCF reported worsening in the overall quality of students' education compared to just 2.7% reporting improvement (p < 0.001). In multivariate analysis adjusted for gender, academic rank, specialty, and years of teaching experience, faculty who spent >/=15 hours per week teaching were more likely to report worsening in medical students' level of responsibility on inpatient teams [odds ratio (OR) 3.1; 95% confidence interval (CI) 1.3-7.6], ability to follow patients throughout hospitalization (OR 3.2; 95% CI 1.3-7.9), ability to develop working relationships with residents (OR 2.3; 95% CI 1.0-5.2), and the overall quality of students' education (OR 3.3; 95% CI 1.4-8.1) compared to faculty who spent less time teaching., Conclusion: Key clincal faculty report concerns about the impact of duty hour regulations on aspects of medical students' education in internal medicine. Medical schools and residency programs should identify ways to ensure optimal educational experiences for students within duty hour requirements.

Approximately 1.3 million people in the United States and an estimated 33.2 million worldwide are infected with HIV. In the past, HIV/AIDS was considered to be uniformly fatal. With the introduction of highly active antiretroviral therapy (HAART), HIV has become a chronic, manageable disease in countries that are able to provide this therapy. The preservation of lives has not been without complications. In these patients, metabolic and stereotypical body disfiguring fat changes have emerged and have been lumped under the term lipodystrophy. Lipoatrophy and fat accumulation are generally thought to be separate yet overlapping phenomena. The prevalence rates for lipoatrophy may be as high as 25% to 38%; estimates for fat accumulation vary widely (from 14%-63%). Far from being "purely cosmetic," these fat changes can have a profoundly negative social and psychological impact, causing patients to feel disfigured, isolated, and stigmatized. Further, lipodystrophy may also negatively impact compliance with HAART. While there is evidence that the use of new HIV medications can prevent the development of these fat changes, many patients already manifest fat abnormalities; switching HAART, especially after lipodystrophy has progressed, offers only limited benefit. In addition, many resource-poor nations continue to rely on older HAART out of necessity. Because of this, methods are needed to address disfiguring body shape changes. The authors review the prevalence of lipoatrophy and lipohypertrophy, focusing on the impact on patients as well as reviewing available treatment options.

Background: Long-term use of cocaine (⩾15 years) and antiretroviral therapy (ART) have been implicated in cardiovascular complications. Nevertheless, the individual and combined effects of ART and cocaine use on silent coronary artery disease have not been fully investigated.Methods: Computed tomography coronary angiography was performed for 165 human immunodeficiency virus (HIV)– infected African American study participants aged 25–54 years in Baltimore, Maryland, with contrast-enhanced 64-slice multidetector computed tomography imaging.Result: Significant (⩾50%) coronary stenosis was detected in 24 (15%) of 165 participants. The prevalence of significant stenosis among those who had used cocaine for ⩾15 years and had received ART for ⩾6 months was 42%. Exact logistic regression analysis revealed that long-term cocaine use(adjusted odds ratio, 7.75; 95% confidence interval, 2.26–31.2) and exposure to ART for ⩾6 months(adjusted odds ratio, 4.35; 95% confidence interval, 1.30–16.4) were independently associated with the presence of significant coronary stenosis. In addition, after controlling for confounding factors,both stavudine use for ⩾6 months or combivir use for ⩾6 months were independently associated with the presence of significant coronary stenosis.Conclusions: Long-term exposure to ART may be associated with silent coronary artery disease;however, the magnitude of increased risk associated with ART was much lower than the risk associated with cocaine use or traditional risk factors. Cardiovascular monitoring and aggressive modification of cardiovascular risk factors are essential for reducing the risk of coronary artery disease in HIV-infected individuals. Extensive efforts should also be made to develop effective cocaine use cessation programs for HIV-infected cocaine users.

The mechanism of CD4(+) T-cell depletion during chronic human immunodeficiency virus type 1 (HIV-1) infection remains unknown. Many studies suggest a significant role for chronic CD4(+) T-cell activation. We assumed that the pathogenic process of excessive CD4(+) T-cell activation would be reflected in the transcriptional profiles of activated CD4(+) T cells. Here we demonstrate that the transcriptional programs of in vivo-activated CD4(+) T cells from untreated HIV-positive (HIV(+)) individuals are clearly different from those of activated CD4(+) T cells from HIV-negative (HIV(-)) individuals. We observed a dramatic up-regulation of cell cycle-associated and interferon-stimulated transcripts in activated CD4(+) T cells of untreated HIV(+) individuals. Furthermore, we find an enrichment of proliferative and type I interferon-responsive transcription factor binding sites in the promoters of genes that are differentially expressed in activated CD4(+) T cells of untreated HIV(+) individuals compared to those of HIV(-) individuals. We confirm these findings by examination of in vivo-activated CD4(+) T cells. Taken together, these results suggest that activated CD4(+) T cells from untreated HIV(+) individuals are in a hyperproliferative state that is modulated by type I interferons. From these results, we propose a new model for CD4(+) T-cell depletion during chronic HIV-1 infection.

Objective: To determine the prevalence of illicit drug use and the impact on HIV treatment., Design: Multivariable regression of cross-sectional data from 1163 HIV-infected and 294 controls from the Study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM)., Methods: An analysis of (1) prevalence of specific illicit drug use (ever, current), (2) being on HAART among those with an indication and (3) current HIV RNA and CD4 cell count among HAART users., Results: Median age was 42 years, approximately 50% were non-Caucasian and 33% were women. Eighty-six percent of HIV-infected and 67% of controls reported ever using illicit drugs (P < 0.0001); 28% of HIV-infected and 16% of controls reported current use (P = 0.0001). In adjusted models, current cocaine use and past heroin use were associated with not currently being on HAART. Among HAART users, those reporting past heroin use were as likely to have an undetectable HIV viral load as those who had never used heroin. Current and past cocaine use and current heroin use was associated with lower odds of undetectable HIV RNA. Past amphetamine use was associated with having an undetectable HIV. Similar results were seen for CD4 lymphocyte counts., Conclusion: Illicit drug use in the US is common, although far fewer report current use than past use. Among HIV-infected patients, understanding of the type of illicit drugs used and whether drug use was in the past or ongoing is important, because of their differential effects on HIV treatment outcomes.

Fat and metabolic abnormalities and their associated factors in HIV-infected patients in Thailand were examined. Body fat and fasting lipids (total cholesterol, TC; triglyceride, TG; and HDL-cholesterol, HDL-c) were evaluated in 247 HIV-infected Thais. Body fat was evaluated by subjects and blinded observers, and measured using dual-energy X-ray absorptiometry. Descriptive statistics and logistic regression were used for analyses. Antiretroviral (ARV)-treated Thais were significantly older, more likely to be male, and had higher education and income compared to untreated subjects. The prevalence of lipoatrophy was 10.3% in ARV-naive patients, 36.7% in patients receiving non-protease inhibitor (PI)-based ARV, and 78.7% in PI-based ARV-treated patients (p < 0.001). Excess abdominal or neck fat was found in 0.8%, 6.7%, and 24.6% of the naive, non-PI-treated, and PI-treated, respectively (p < 0.001). Hypercholesterolemia (TC > or = 240 mg/dl) was found in 4.8%, 26.6%, and 42.6%; hypertriglyceridemia (TG > or = 150 mg/dl) in 8.2%, 48.3%, and 75.4%; and low HDL-c (HDL-c < 40 mg/dl) in 42.9%, 20.0%, and 31.2% of the naive, non-PI treated, and PI-treated, respectively (p < 0.05 for all). Central to peripheral fat ratios were 1.11 +/- 0.03, 1.45 +/- 0.06, and 1.93 +/- 0.08 for the naive, non-PI, and PI-treated, respectively (p < 0.001). Treatment was associated with abnormal fat. The adjusted ORs (95% CI) of lipoatrophy for excess fat were 4.6 (2.0-10.7); 6.3 (0.6-71.1) for ARV-naive vs. non-PI; 5.6 (3.4-9.1); 10.7 (3.4-33.8) for ARV-naive vs. PI, and 5.7 (2.4-13.9); 5.3 (1.2-11.4-13.9) for ARV-naive vs. PI. ARV-associated metabolic abnormalities are common in this non-Western population. Appropriate selection and monitoring of ARV treatment are critical to minimize the risk of long-term complications.

Background: To determine the effect of duty-hour limitations, it is important to consider the views of faculty who have the most contact with residents., Method: We conducted a national survey of key clinical faculty (KCF) at 39 internal medicine residency programs affiliated with US medical schools selected by random sample stratified by federal research funding and program size to elicit their views on the effect of duty-hour limitations on residents' patient care, education, professionalism, and well-being and on faculty workload and satisfaction., Results: Of 154 KCF surveyed, 111 (72%) responded. The KCF reported worsening in residents' continuity of care (87%) and the physician-patient relationship (75%). Faculty believed that residents' education (66%) and professionalism, including accountability to patients (73%) and ability to place patient needs above self-interests (57%), worsened, yet 50% thought residents' well-being improved. The KCF reported spending more time providing inpatient services (47%). Faculty noted decreased satisfaction with teaching (56%), ability to develop relationships with residents (40%), and overall career satisfaction (31%). In multivariate analysis, KCF with 5 years of teaching experience or more were more likely to perceive a negative effect of duty hours on residents' education (odds ratio, 2.84; 95% confidence interval, 1.15-7.00)., Conclusions: Key clinical faculty believe that duty-hour limitations have adversely affected important aspects of residents' patient care, education, and professionalism, as well as faculty workload and satisfaction. Residency programs should continue to look for ways to optimize experiences for residents and faculty within the confines of the duty-hour requirements.

In light of a recent report that short-term treatment with valproic acid (VA) might accelerate the decay of the latent reservoir for HIV-1 in patients receiving combination therapy and allow eventual eradication of the infection, we studied patients with prolonged suppression of viremia who were receiving combination therapy and who had also been receiving chronic VA therapy for neurological or psychiatric conditions. Latently infected cells were readily detected in all patients at levels comparable to those seen in patients receiving combination therapy alone. We conclude that the clinical use of VA has no ancillary effect on the decay of the latent reservoir.

This cross-sectional study of adult (137 male, 128 female), urban, community dwelling users and nonusers of illicit drugs evaluated associations of demographic, medical, and drug factors with body composition. The population was 49% HIV-positive and 94% African-American. In multivariate analysis, there were no body composition differences among males based on drug use. Among females, the highest tertile of drug use had less fat (12.3 vs.19.9 kg, p = .01) and lower body mass index (21.9 vs. 25.1, p = .01) versus less frequent or nonusers. These data suggest a sex difference in body composition associated with drug use.