Fertility Knowledge and Educational Experiences of Graduating Medical Students: A Multi-Institution Survey

Objective: Our goal was to assess the fertility knowledge and educational experiences of graduating U.S. medical students to evaluate areas of improvement for future educational interventions. Design: Web-based cross-sectional survey. Subjects: Medical students graduating in 2023 from the University of Miami Miller School of Medicine (SOM), New York University (NYU) Grossman SOM, Wayne State University SOM, Perelman SOM at the University of Pennsylvania, and Mayo Clinic Alix SOM. Main Outcome Measures: Fertility-related knowledge and educational experiences of U.S. medical students in their final year of school. Results: In total, 117 students (14.4%) completed the survey. The average knowledge score was 78%. Twenty-three (22%) overestimated the age of most precipitous fertility decline, and 50 (52%) overestimated the chance of getting pregnant for a 40-year-old person with ovaries. One-third of students (30, 32%) incorrectly believe that physicians have equivalent infertility rates to the general population. Students were less cognizant of male fertility issues, incorrectly believing there was no negative impact on male fertility by age (43, 42%) among other factors. Seventy-five (81%) reported less than 5 hours of fertility-related education in medical school. Only one-third (32%) were satisfied or very satisfied with the fertility education they received. In an open-response question, students expressed interest in additional education on transgender and cancer patient care, fertility preservation, assisted reproductive technologies, and reproductive life planning in medicine. Conclusions: There is a need and an opportunity for medical education programs to enhance fertility education. Giving students and trainees the knowledge required to make informed decisions for their family-building purposes and improving their ability to counsel patients adequately should be a goal of future educational endeavors. The data collected in this study will serve as a guide for the development of fertility-related learning modules for medical students and trainees.

Out-of-State Students at State Medical Schools and Increasing Medical Education Debt

PURPOSE

Medical school tuition has increased at alarming rates ahead of inflation over the past 20 years. The authors investigated whether state-funded medical schools have had an increased number of out-of-state matriculants, which may create a diaspora of displaced in-state medical students matriculating to out-of-state programs and incurring substantial debt.

METHOD

Publicly available data from the Association of American Medical Colleges (AAMC) were accessed from 2004 through 2019 for applicants and matriculants at U.S. state-funded schools. Schools listed as public that reported tuition charges in the AAMC Tuition and Student Fees reports were included in this study. The numbers and trends of medical school applications and trends in tuition costs and average indebtedness were summarized for in-state and out-of-state matriculants. Values were analyzed by group as median and interquartile range (IQR). Group differences were assessed via t tests. P values less than .05 were considered statistically significant.

RESULTS

From 2004 through 2019, the annual number of out-of-state matriculants in state-funded schools increased 7% (16%-23% [7,195-11,144]). Among 74 schools with data in 2004, the median percentage of out-of-state applications increased from 60% (IQR, 31%-74%) to 80% (IQR, 57%-85%; P < .001), and the median percentage of out-of-state matriculants increased from 13% (IQR, 5%-23%) to 17% (IQR, 11%-33%; P < .001). In 2004, the mean (standard error) debt upon completion of medical school (inflation adjusted to 2018 dollars) was $144,100 ($10,950); by 2016, the mean debt had increased to $251,600 ($32,040), a 75% increase over 12 years.

CONCLUSIONS

Since 2004, substantial increases have occurred in out-of-state matriculants at state-funded medical schools. This may displace residents from attending their in-state schools, causing them to attend out-of-state or private medical schools, where tuition is typically much higher.

A Scoping Review of Published Intimate Partner Violence Curricula for Medical Trainees

Intimate partner violence (IPV) affects many, and health care has the potential to provide a safe space for individuals experiencing IPV. However, physicians cite lack of time and education as barriers. The aim of this study is to complete a review of published IPV curricula in medical school, residency training, and postresidency training. We performed a scoping review to provide a quantitative assessment and summary review of existing IPV curricula. In May 2020, a librarian conducted a search of Ovid MEDLINE, Ovid EMBASE, and Scopus. We evaluated each article for the following curriculum content and structure items: (1) year introduced; (2) delivery method; (3) curriculum type; (4) curriculum content; (5) curriculum effectiveness; and (6) implementation barriers. Fifty-six articles met criteria, most were for medical school learners (n = 32, 57.1%) and short-term (lasting less than one academic year) (n = 41, 73.2%). For residency, IPV curricula were most frequently taught in family medicine, internal medicine, and emergency medicine. Formal lecture and use of standardized patients were the most popular delivery methods. Most curricula taught risk factors for and identification of individuals who have experienced IPV. The most cited implementation barrier was limited time in standard medical education, followed by inability to measure the effectiveness of the curriculum. There was great variation in the methods of assessing effectiveness of IPV curricula. Published IPV curricula are varied, without consistent validated tools for assessing efficacy. Future initiatives to establish a standard of competency for medical students regarding IPV, including a standard curriculum, may better ensure that physicians are capable of identifying and caring for individuals who have experienced IPV.

Parental leave policy information during residency interviews

BACKGROUND

During interviews, medical students may feel uncomfortable asking questions that might be important to them, such as parental leave. Parental leave policies may be difficult for applicants to access without asking the program director or other interviewers. The goal of this study is to evaluate whether parental leave information is presented to prospective residents and whether medical students want this information.

METHODS

Fifty-two program directors (PD's) at 3 sites of a single institution received a survey in 2019 to identify whether parental leave information is presented at residency interviews. Medical students received a separate survey in 2020 to identify their preferences. Fisher exact tests, Pearson χ² tests and Cochran-Armitage tests were used where appropriate to assess for differences in responses.

RESULTS

Of the 52 PD's, 27 responded (52%) and 19 (70%) indicated that information on parental leave was not provided to candidates. The most common reason cited was the belief that the information was not relevant (n = 7; 37%). Of the 373 medical students, 179 responded (48%). Most respondents (92%) wanted parental leave information formally presented, and many anticipated they would feel extremely or somewhat uncomfortable (68%) asking about parental leave. The majority (61%) felt that these policies would impact ranking of programs "somewhat" or "very much."

CONCLUSIONS

Parental leave policies may not be readily available to interviewees despite strong interest and their impact on ranking of programs by prospective residents.

Surgical Menopause and Estrogen Therapy Modulate the Gut Microbiota, Obesity Markers, and Spatial Memory in Rats

Menopause in human females and subsequent ovarian hormone deficiency, particularly concerning 17β-estradiol (E2), increase the risk for metabolic dysfunctions associated with obesity, diabetes type 2, cardiovascular diseases, and dementia. Several studies indicate that these disorders are also strongly associated with compositional changes in the intestinal microbiota; however, how E2 deficiency and hormone therapy affect the gut microbial community is not well understood. Using a rat model, we aimed to evaluate how ovariectomy (OVX) and subsequent E2 administration drive changes in metabolic health and the gut microbial community, as well as potential associations with learning and memory. Findings indicated that OVX-induced ovarian hormone deficiency and E2 treatment had significant impacts on several health-affecting parameters, including (a) the abundance of some intestinal bacterial taxa (e.g., Bifidobacteriaceae and Porphyromonadaceae), (b) the abundance of microbial short-chain fatty acids (SCFAs) (e.g., isobutyrate), (c) weight/BMI, and (d) high-demand spatial working memory following surgical menopause. Furthermore, exploratory correlations among intestinal bacteria abundance, cognition, and BMI underscored the putative influence of surgical menopause and E2 administration on gut-brain interactions. Collectively, this study showed that surgical menopause is associated with physiological and behavioral changes, and that E2-linked compositional changes in the intestinal microbiota might contribute to some of its related negative health consequences. Overall, this study provides novel insights into interactions among endocrine and gastrointestinal systems in the post-menopausal life stage that collectively alter the risk for the development and progression of cardiovascular, metabolic, and dementia-related diseases.

Current Parental Leave Policies for Medical Students at U.S. Medical Schools: A Comparative Study

PURPOSE

Parental leave for new parents is essential as they adjust to the physical and psychological changes that accompany childbirth and caring for a newborn. This study sought to determine the current state of parental leave policies for medical students at medical schools in the United States.

METHOD

From November to December 2019, 2 researchers independently reviewed the websites of 199 U.S. MD-granting and DO-granting medical schools (including in U.S. territories). Online student handbooks and school webpages were searched for the following keywords: "pregnant" OR "pregnancy" OR "maternity" OR "parent" OR "family" OR "child" OR "birth." Data were analyzed using descriptive statistics. Fisher's exact tests evaluated differences in proportion by group.

RESULTS

Of 199 schools, 65 (32.66%) had parental leave policies available online or in the handbook: 39 of 155 (25.16%) MD-granting and 26 of 44 (59.09%) DO-granting schools. Of those policies, 59 (90.77%) were included in the student handbook. Most policies (28, 43.08%) were included as an option within the school's general leave of absence policy. Both parents were included in 38 (58.46%) policies; 23 (35.38%) policies mentioned only mothers; and 4 (6.15%) were unknown. An option to maintain original graduation date was offered in 21 (32.1%) schools' policies. Three schools (4.62%) included adoption as qualifying for parental leave. When comparing MD and DO programs, DO programs were statistically more likely to have a parental leave policy: 39 (25.16%) vs 26 (59.09%); P < .001.

CONCLUSIONS

Balancing medical school with pregnancy and childbirth necessitates administrative support to address the inherent scheduling challenges. Currently, many schools lack parental leave policies for medical students that are easily accessible, are separate from formal leaves of absence, allow for at least 12 weeks, and are tailored to the student academic year to ensure on-time completion of medical education.

Screening Women at High Risk for Cervical Cancer: Special Groups of Women Who Require More Frequent Screening

The updated cervical cancer screening guidelines recommend that women at average risk who have negative screening results undergo cervical cytological testing every 3 to 5 years. These recommendations do not pertain to women at high risk for cervical cancer. This article reviews recommendations for cervical cancer screening in women at high risk.

Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Gender Bias

BACKGROUND

Gender bias has been identified as one of the drivers of gender disparity in academic medicine. Bias may be reinforced by gender subordinating language or differential use of formality in forms of address. Professional titles may influence the perceived expertise and authority of the referenced individual. The objective of this study is to examine how professional titles were used in the same and mixed-gender speaker introductions at Internal Medicine Grand Rounds (IMGR).

METHODS

A retrospective observational study of video-archived speaker introductions at consecutive IMGR was conducted at two different locations (Arizona, Minnesota) of an academic medical center. Introducers and speakers at IMGR were physician and scientist peers holding MD, PhD, or MD/PhD degrees. The primary outcome was whether or not a speaker's professional title was used during the first form of address during speaker introductions at IMGR. As secondary outcomes, we evaluated whether or not the speakers professional title was used in any form of address during the introduction.

RESULTS

Three hundred twenty-one forms of address were analyzed. Female introducers were more likely to use professional titles when introducing any speaker during the first form of address compared with male introducers (96.2% [102/106] vs. 65.6% [141/215]; p < 0.001). Female dyads utilized formal titles during the first form of address 97.8% (45/46) compared with male dyads who utilized a formal title 72.4% (110/152) of the time (p = 0.007). In mixed-gender dyads, where the introducer was female and speaker male, formal titles were used 95.0% (57/60) of the time. Male introducers of female speakers utilized professional titles 49.2% (31/63) of the time (p < 0.001).

CONCLUSION

In this study, women introduced by men at IMGR were less likely to be addressed by professional title than were men introduced by men. Differential formality in speaker introductions may amplify isolation, marginalization, and professional discomfiture expressed by women faculty in academic medicine.

Care of Women During Menopause

We would like to introduce a new section in the Journal of Women's Health, the Clinical Update. Important studies are continually published in both this Journal and other medical publications. However, it is difficult for busy providers to stay current with the changing literature. The Clinical Update is designed to serve as a review of recently published, high-impact, and potentially practice-changing journal articles, digested for our readers. The Clinical Update will be published on a quarterly basis. Each edition of the update will focus on a specific women's health topic, with planned topics to include menopause, sexual dysfunction, breast health, contraception, osteoporosis, and cardiovascular disease.

Women's health 2015: an update for the internist

The field of women's health is varied and dynamic. Major studies in 2014 and the first half of 2015 suggest that selective serotonin reuptake inhibitors are not strongly associated with congenital heart defects, that paroxetine 7.5 mg is effective for treating menopausal symptoms, and that women with heart failure may benefit more from cardiac resynchronization therapy than men.

Effects of different hormone therapies on breast pain in recently postmenopausal women: findings from the Mayo Clinic KEEPS breast pain ancillary study

Abstract Background: It is estimated that 70% of women in Western societies experience breast pain at least once during their lifetime. In the Women's Health Initiative (WHI), women treated with oral conjugated equine estrogen (0.625 mg) with or without continuous oral medroxyprogesterone acetate (2.5 mg) had a higher incidence of breast pain than those who received placebo. The effect of other hormone therapy regimens on breast pain is unknown. We compared breast pain among healthy, recently menopausal women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS) at Mayo Clinic.

METHODS

Women were randomized to: 0.45 mg/day oral conjugated equine estrogen (o-CEE) plus 200 mg/day micronized progesterone (m-P) for the first 12 days of the month, 50 μg/day transdermal 17β estradiol (t-E2) plus m-P for 12 days, or placebo pills and patch. Participants completed the Mayo Clinic breast pain questionnaire at baseline and yearly for the duration of the study.

RESULTS

Participants (116) averaged 53.0 years of age and 1.6 years past their last menses at baseline. At baseline, 12 women (10%) reported breast pain with an average worst pain score [from 0 (no pain) to 10 (worst pain)] of 0.39±1.28. With treatment, the number of women reporting pain did not increase, and with either intention-to-treat or per-protocol analyses, breast pain scores did not differ significantly (p=0.39) among groups: t-E2 (0.53±1.21), o-CEE (0.32±0.78), placebo (0.23±0.87).

CONCLUSION

Four years of treatment with o-CEE at a lower dose than that studied in the WHI with cyclic m-P or transdermal E2 with cyclic m-P did not increase breast pain in healthy, recently menopausal women.

Imploding and exploding migraine headaches: comparison of methods to diagnose pain directionality

BACKGROUND

The study aims to compare methods of determining headache directionality (imploding, exploding, and/or ocular headaches) in women with migraine, investigate the concordance between physician assignment and patient self-assignment of pain directionality, and evaluate whether patients assigned their headaches to the same direction when queried using different methods. Directionality of migraine headache pain (imploding, exploding, or ocular) may reflect differences in the underlying pathogenesis of individual migraine attacks among and within individuals. Emerging evidence suggests that directionality of pain in migraine sufferers may predict response to onabotulinumtoxin A. The best method of determining headache directionality in migraine sufferers has not been systematically explored.

METHODS

We conducted a prospective cross-sectional survey study of 198 female patients with migraine presenting to a Women's Health Clinic. Patients determined the directionality (imploding, exploding, and/or ocular) of their own migraine pain by choosing among 3 pictures graphically representing directionality and also by responding to a written question regarding directionality. Clinicians then classified directionality of migraine pain using structured interviews. Concordance between clinician assignment of directionality and patient self-assignment was determined with Kappa coefficients.

RESULTS

Subjects were females between the ages of 18 and 77 years (mean 48 years). According to patient selection of representative pictures, 62 (31.6%) had imploding headaches with or without ocular pain, 36 (18.4%) had exploding headaches with or without ocular pain, 78 (39.8%) had ocular pain only, and 20 (10.2%) had imploding and exploding headaches with or without ocular pain. Two subjects did not respond. According to patient responses to a written question, 80 (41.0%) had imploding headaches with or without ocular pain, 53 (27.2%) had exploding headaches with or without ocular pain, 46 (23.6%) had ocular pain only, and 16 (8.2%) had imploding and exploding headaches with or without ocular pain. Three subjects did not respond. For physician assignment, 69 (34.9%) subjects had imploding headaches with or without ocular pain, 89 (45%) had exploding headaches with or without ocular pain, 14 (7.1%) had ocular pain only, and 26 (13.1%) had imploding and exploding headaches with or without ocular pain. The concordance (Kappa coefficient) between physician assignment of headache directionality with patient response to the written question was 0.33 (weak agreement), between physician assignment and patient assignment via selection of representative pictures was 0.35 (weak agreement), and between patient assignment via written question and via selection of representative pictures was 0.35 (weak agreement).

CONCLUSIONS

The assignment of headache directionality varied substantially depending upon the method of determination. The concordance between clinician assignment, patient-self assignment via answering a written question, and patient self-assignment via choosing a representative picture was weak. Improved methods of determining pain directionality are needed.

Long-term follow-up of a facilitated peer mentoring program

BACKGROUND

Mentoring plays an important role in career success of academic medical faculty. New mentoring models such as peer mentoring have emerged.

AIM

To evaluate the long-term impact of a facilitated peer mentoring program on academic achievements.

METHOD

Women faculty at the instructor or assistant professor rank were recruited to voluntarily participate in a facilitated peer mentoring program. Recruitment occurred over 3.8 years between 2005 and 2009. A 26-item questionnaire to assess academic skill, career satisfaction, and self-efficacy was administered before program participation and again with seven additional questions in 2011. Curriculum vitae were reviewed retrospectively to tally peer-reviewed publications, other academic activities, and promotions.

RESULTS

Participants had long-term improvement in their perceived mastery of academic skills. Peer-reviewed publications, book chapters, abstracts, posters, and other academic activities increased when activities before the program were compared to those in the five years after program enrollment. At follow-up, participants reported positive perceptions of the program and 44% continued to work with their original peer mentor groups.

CONCLUSIONS

Involvement in the facilitated peer mentoring program was associated with increased skills and academic activities for most participants. Future studies are needed to assess its applicability and success among various demographic groups in academic medicine.

Gender distribution of U.S. medical school faculty by academic track type

PURPOSE

Over the past 30 years, the number and type of academic faculty tracks have increased, and researchers have found differences in promotion rates between track types. The authors studied the gender distribution of medical school faculty on the traditional tenure track (TTT) and clinician-educator track (CET) types.

METHOD

The authors analyzed gender and academic track type distribution data from the March 31, 2011, snapshot of the Association of American Medical Colleges' Faculty Roster. Their final analysis included data from the 123 medical schools offering the TTT type and the 106 offering the CET type, which excluded any schools with 10 or fewer faculty on each track type.

RESULTS

The original dataset included 134 medical schools representing 138,508 full-time faculty members, 50,376 (36%) of whom were women. Of the 134 medical schools, 128 reported at least one of four track types: TTT, CET, research track, and other. Of the 83 medical schools offering the CET type, 64 (77%) had a higher proportion of female than male faculty on that track type. Of the 102 medical schools offering the TTT type, only 20 (20%) had a higher proportion of female than male faculty on that track type.

CONCLUSIONS

Medical schools offering the CET type reported higher proportions of female faculty on that track type. Given that faculty on the CET type lag behind their TTT colleagues in academic promotion, these findings may contribute to continued challenges in gaining academic and leadership parity for women in academic medicine.

Chemoprevention of breast cancer

The development of pharmacologic agents for the prevention of breast cancer is a significant milestone in medical and laboratory research. Despite these advances, the endorsement of preventive options has become challenging and complex, as physicians are expected to counsel and tailor their recommendations using a personalized approach taking into account medical comorbidities, degree of risk and patient preferences. This article provides a comprehensive overview of the major breast cancer prevention trials, review of the pharmacologic options available for breast cancer prevention, and strategies for integrating chemoprevention of breast cancer in high-risk women into clinical practice.

Patient understanding of the revised USPSTF screening mammogram guidelines: need for development of patient decision aids

BACKGROUND

The purpose of the study was to examine patients' understanding of the revised screening mammogram guidelines released by the United States Preventive Services Task Force (USPSTF) in 2009 addressing age at initiation and frequency of screening mammography.

METHODS

Patients from the Departments of Family Medicine, Internal Medicine, and Obstetrics and Gynecology (n = 150) at a tertiary care medical center in the United States completed a survey regarding their understanding of the revised USPSTF guidelines following their release, within four to six months of their scheduled mammogram (March 2010 to May 2010).

RESULTS

Of the patients surveyed, 97/147 (67%) indicated increased confusion regarding the age and frequency of screening mammography, 61/148 (41%) reported increased anxiety about mammograms, and 58/146 (40%) reported anxiety about their own health status following the release of the revised screening guidelines. Most of the patients surveyed, 111/148 (75%), did not expect to change their timing or frequency of screening mammograms in the future.

CONCLUSION

Results from this survey suggested increased confusion and possibly an increase in patients' anxiety related to screening mammography and their own health status following the release of the revised USPSTF screening mammogram guidelines to the public and subsequent media portrayal of the revised guidelines. Although the study did not specifically address causality for these findings, the results highlight the need for improvements in the communication of guidelines to patients and the public. Development of shared decision-making tools and outcomes should be considered to address the communication challenge.

Hormone therapy for management of menopausal symptoms: understanding [corrected] breast cancer risk

Since the publication of the Women's Health Initiative, women seeking relief from menopausal symptoms often express concerns about the risk of hormone therapy (HT). In women at increased risk for breast cancer or with a personal history of breast cancer, the decision to use HT for the treatment of menopausal symptoms must be carefully considered in the context of the most recent literature. It is well established that HT is the most effective treatment for climacteric symptoms and sexual dysfunction. The evidence to date on the use of HT in women with a history of breast cancer is complicated by the fact that the majority of breast cancers are estrogen responsive and the concern about risk of recurrence. Over the past decade, survival after breast cancer treatment has continued to improve resulting in millions of survivors worldwide. As a result of breast cancer therapies, the prevalence of menopausal symptoms is increasing in survivors, and both clinicians and patients are seeking safe and effective therapies for symptom management. This article will review the role of HT in the treatment of menopausal symptoms in women without breast cancer and those with a personal history of breast cancer or those who are at increased risk of breast cancer. Management of menopause-related symptoms will be reviewed with a focus on strategies to improve quality of life.

Developing a reproductive life plan

The purpose of this article is 2-fold: to emphasize the importance of a reproductive life plan and to define its key elements. We review the 2006 recommendations from the Centers for Disease Control and Prevention (CDC) regarding ways to improve the delivery of preconception health care to women in the United States, with particular focus on encouraging individual reproductive responsibility throughout the life span and on encouraging every woman to develop a reproductive life plan. We propose recommendations for the content of a reproductive life plan and explore ways to incorporate the guidelines from the CDC into clinical practice. By encouraging women to consider their plans for childbearing before they become pregnant, clinicians have the opportunity to influence behavior before pregnancy, which may decrease the incidence of unintended pregnancies and adverse pregnancy outcomes.

Bioidentical hormone therapy

The change in hormonal milieu associated with perimenopause and menopause can lead to a variety of symptoms that can affect a woman's quality of life. Postmenopausal hormone therapy (HT) is an effective, well-tolerated treatment for these symptoms. However, combined HT consisting of conjugated equine estrogen and medroxyprogesterone acetate has been associated with an increased number of health risks when compared with conjugated equine estrogen alone or placebo. As a result, some women are turning to alternative hormonal formulations known as compounded bioidentical HT because they perceive them to be a safer alternative. This article defines compounded bioidentical HT and explores the similarities and differences between it and US Food and Drug Administration-approved HT. We will examine the major claims made by proponents of compounded bioidentical HT and recommend strategies for management of patients who request bioidentical HT from physicians.

Female Genital Mutilation: Cultural Awareness and Clinical Considerations

Clinicians in the United States are increasingly encountering girls and women who have undergone female genital mutilation. To foster a more trusting relationship with such patients, health care providers must have an accurate understanding of the cultural background surrounding this practice, a working knowledge of the different types of female genital mutilation procedures that may be encountered, and an awareness of both the acute and long-term complications. Some of these complications are potentially fatal, and the correct clinical diagnosis can be lifesaving.

Managing aromatase inhibitors in breast cancer survivors: not just for oncologists

The role of the general internist in the care of breast cancer survivors is increasing as the number of women living with breast cancer continues to rise. Most breast cancers occurring in women older than 50 years are estrogen receptor- and/or progesterone receptor-positive, and adjuvant endocrine therapy plays an important role in the treatment plan. Aromatase inhibitors are becoming the preferred endocrine therapy, and general internists caring for breast cancer survivors need to be familiar with their use and adverse effect profile. This article reviews the use of aromatase inhibitors, the frequency of common adverse effects, and strategies for their management.

Coccidioidomycosis in elderly persons

BACKGROUND

Coccidioidomycosis is a fungal infection acquired via inhalation of airborne fungal arthrospores of Coccidioides species in regions of endemicity in the deserts of the southwestern United States and northern Mexico. In recent years, the incidence of coccidioidomycosis has increased in areas of endemicity, and previous studies have found the highest incidence of coccidioidal infection in Arizona among persons in older age groups.

METHODS

We conducted a retrospective review of data for all patients with coccidioidomycosis who were treated at our institution that compared clinical manifestations of coccidioidomycosis in patients aged >or=60 years with those in patients aged <60 years.

RESULTS

We compared 210 patients aged >or=60 years with 186 patients aged <60 years. No significant differences were observed with regard to manifestations of coccidioidomycosis, even after adjustment for comorbid conditions, excluding immunosuppression. Regardless of age, when coccidioidal illnesses in immunosuppressed patients were compared with those in nonimmunosuppressed patients, immunosuppressed patients were significantly more likely to have extrapulmonary dissemination of infection, to require hospitalization, and to have progressive infection or to die of coccidioidomycosis. Univariate logistic regression identified immunosuppression as the only marker that increased risk of extrapulmonary dissemination of infection (odds ratio, 2.13;P=.05), hospitalization (odds ratio, 2.68; P<.001), and death (odds ratio, 8.39; P<.001). Multivariate analysis revealed that neither age nor an interaction of age and immunosuppression had a significant impact on coccidioidal manifestations.

CONCLUSIONS

Coccidioidomycosis is a serious illness in all patients, but its different manifestations in older-aged persons, compared with those in younger-aged persons, may be related to immunosuppression rather than age alone.

The patient-centered medical home and preconception care: an opportunity for internists

The patient-centered medical home is defined by the American College of Physicians as a comprehensive approach for delivering medical care to patients. Internists have the role of caring for patients from adolescence through adulthood and have the opportunity to deliver preconception care. Preconception care is the promotion of the health and well-being of a woman and her partner before pregnancy. The goal is to improve pregnancy-related outcomes through interventions that occur before conception and before the patient would ordinarily seek prenatal care. Using the model of the patient-centered medical home, internists can provide comprehensive preconception care to improve the health of women before pregnancy and thus to decrease the risk of adverse pregnancy outcomes.