Type 2 diabetes mellitus is a metabolic disease of carbohydrate metabolism. However, it should also be considered a vascular disease because diabetic patients have a strong predilection for atherosclerosis. With the increasing prevalence and earlier age at onset of diabetes, the projected effect of diabetes on cardiovascular health and resource utilization is sobering. The mechanisms of the high rate of atherosclerosis are multifactorial and give clinicians and researchers insights into potential preventive therapies. Effective pharmacologic and lifestyle interventions are available for primary and secondary prevention of cardiovascular complications. However, data show that these interventions continue to be underutilized. Treatment of patients with type 2 diabetes and coronary artery disease is similar to that of patients with coronary artery disease alone. However, patients with diabetes benefit more from treatments that reduce coronary artery disease risk.

The optimal strategy to prevent recurrent presumed paradoxical emboli in patients with patent foramen ovale is unknown.

Immune reactions to small molecular compounds, such as drugs, can cause a variety of diseases involving the skin, liver, kidney, and lungs. In many drug hypersensitivity reactions, drug-specific CD4+ and CD8+ T cells recognize drugs through their alphabeta T-cell receptors in an MHC-dependent way. Drugs stimulate T cells if they act as haptens and bind covalently to peptides or if they have structural features that allow them to interact with certain T-cell receptors directly. Immunohistochemical and functional studies of drug-reactive T cells in patients with distinct forms of exanthema reveal that distinct T-cell functions lead to different clinical phenotypes. In maculopapular exanthema, perforin-positive and granzyme B-positive CD4+ T cells kill activated keratinocytes, while a large number of cytotoxic CD8+ T cells in the epidermis is associated with formation of vesicles and bullae. Drug-specific T cells also orchestrate inflammatory skin reactions through the release of various cytokines (for example, interleukin-5, interferon) and chemokines (such as interleukin-8). Activation of T cells with a particular function seems to lead to a specific clinical picture (for example, bullous or pustular exanthema). Taken together, these data allow delayed hypersensitivity reactions (type IV) to be further subclassified into T-cell reactions, which through the release of certain cytokines and chemokines preferentially activate and recruit monocytes (type IVa), eosinophils (type IVb), or neutrophils (type IVd). Moreover, cytotoxic functions by either CD4+ or CD8+ T cells (type IVc) seem to participate in all type IV reactions.

Statins reduce cardiovascular events to a greater extent than can be explained by their effect on lipids. Several studies have attempted to elucidate mechanisms by which statins reduce cardiovascular risk.

National surveys indicate a need for additional training in geriatrics during internal medicine residencies. This paper describes 1) "best practices" for integrating geriatrics education into internal medicine residency programs, 2) barriers to implementation of these practices, and 3) possible ways to improve geriatrics training for internal medicine residents. These best practices were determined by a systematic review of the literature and through interviews with leaders of 26 residency and geriatrics programs concerned with geriatrics training for residents. The most successful programs have clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, in the hospital or in ambulatory practice), patient care across sites or transitions of care, and interdisciplinary teamwork. Barriers include attitudes, few faculty, need for relationships with nontraditional training sites, and lack of funding. Local solutions include engaging the internal medicine program director to accomplish a mutual goal--for example, by creating a model geriatrics training experience in which residents demonstrate their skill in a new Accreditation Council of Graduate Medical Education competency (such as systems-based practice). National solutions include reaching consensus on the competencies in geriatrics that should be achieved by board-eligible internists. This may mean increasing the number of questions that test geriatrics competency in the certifying and in-training examinations, increasing numbers of faculty members able to teach and model geriatric care, developing "effective medical resident teaching" courses for nonphysician faculty, and lobbying for improved systems of care.

To ensure its growth and prosperity, general internal medicine will need to embrace care of the elderly, research on aging, and geriatrics education as components of its core mission. Experts agree that general internal medicine fellows could benefit from increased opportunities in research on aging and geriatrics education; however, important barriers will hamper efforts to integrate geriatrics training into general internal medicine fellowship programs. This article reviews the barriers to integration and proposes solutions for overcoming those barriers. As a result of interviews and meetings with a broad representation of general internists, geriatricians, funding agencies, and policymakers, we propose 2 interventions: 1) the development of institutional program grants to foster collaboration between general internal medicine and geriatrics faculty in the training of general internal medicine fellows and 2) the creation of a 3-year fellowship program combining general internal medicine and geriatrics. This article discusses the importance of evaluating these and other programs intended to increase the geriatrics experience of general internal medicine fellows, and it describes the potential implications of these changes for a broad array of stakeholder institutions.

The need for adequate geriatrics training for the physician workforce has been recognized for decades. However, there are not enough academic geriatricians to provide for the educational needs of trainees, and this situation is not expected to change in the future. General internists are often responsible for teaching medical students and internal medicine residents to care for elderly patients in inpatient and ambulatory settings. These academic general internists could play a pivotal role in providing geriatrics instruction. To characterize what is being done to develop geriatrics-oriented general internal medicine faculty, we identified current practices, "best practices," goals and targets, and barriers to achieving those goals and targets. We reviewed the literature on faculty-development programs for general internal medicine faculty, and we held focus groups and structured interviews with general internal medicine unit chiefs and directors of Geriatric Centers of Excellence at 46 medical schools throughout the United States. We found a need for programs to develop geriatrics-oriented academic general internists. Although general internal medicine faculties seem receptive to further geriatrics training, important obstacles exist. These include inadequate time and resources as well as motivational and attitudinal challenges. We discuss potential solutions for overcoming these barriers and the implications of these solutions for stakeholders.

The evaluation of acute knee pain often includes radiography of the knee.

Magnetic resonance cholangiopancreatography (MRCP) is one of many newer noninvasive tests that can image the biliary tree.

Abdominal aortic aneurysms (AAAs) occur in 1 of 20 older men, remain asymptomatic for many years, and, if left untreated, cause death from rupture in about one third of patients. Ultrasonography is a suitable screening test for AAA, and elective repair can prevent rupture. Although these features suggest a promising target for a screening program, evidence of benefit from AAA screening has only recently become available. Four randomized trials of ultrasonographic screening involving more than 125 000 men have been reported, and each trial observed a reduction in AAA-related mortality (which was statistically significant in 2 trials), ranging from 21% to 68%. One trial in women found no benefit. Other studies indicate that screening can begin in men older than 65 years of age and does not need to be repeated if results are negative. An AAA larger than 5.5 cm in diameter should be considered for elective open or endovascular repair. Most aneurysms detected at screening are smaller and should be kept under surveillance with periodic imaging measurement. Widespread elective repair of small AAAs could reduce the benefits and increase the costs of screening. No medical treatments have been proven to reduce the enlargement rate. If elective repair is reserved for larger AAAs, one-time ultrasonographic screening for AAA can be recommended for men 65 to 79 years of age who have ever smoked [correction].

Giant-cell arteritis is an immune-mediated disease characterized by granulomatous infiltrates in the wall of medium-size and large arteries. The immunopathology consists of 2 components. Excessive cytokine production (for example, of interleukin-1 and interleukin-6) induces systemic inflammation with an exuberant acute-phase response. In parallel, interferon-gamma, which is released by T cells captured in the arterial wall, activates tissue-injurious macrophages. In response to the immune injury, the artery generates hyperplasia of the intima that leads to luminal occlusion and subsequent tissue ischemia. Despite the systemic character of the disease, distinct vascular territories are preferentially affected. On the basis of the predominant involvement, clinical subtypes can be distinguished: cranial giant-cell arteritis with ischemic complications in the eye, the face, and the central nervous system; large-vessel giant-cell arteritis with occlusions in the subclavian or axillary vessels; aortic giant-cell arteritis; giant-cell arteritis presenting as an intense systemic inflammatory syndrome with nonstenosing vasculitis; and "isolated" polymyalgia rheumatica with myalgias, systemic inflammation, and subclinical vasculitis. Temporal artery biopsy remains the diagnostic procedure of choice to detect arteritis in cranial vessels. In other vascular territories, giant-cell arteritis is most commonly diagnosed by vascular imaging. Laboratory studies characteristically document the marked elevations of nonspecific acute-phase reactants, such as C-reactive protein and erythrocyte sedimentation rate. Cytokines, such as interleukin-6, that induce the acute-phase reaction are currently being explored as more sensitive biological markers of disease activity. Corticosteroids are highly effective in suppressing systemic inflammation, but they do not eliminate the immune responses in the vessel wall. In general, the clinical outcome of giant-cell arteritis is excellent, and efforts must now concentrate on tailoring therapies to the needs of the individual patient.

Because approximately 1 in 10 women with a breast lump or abnormal mammography result will have breast cancer, a series of decisions must be taken by a primary care practitioner to exclude or establish a diagnosis of breast cancer among these women.

Angiotensin-converting enzyme (ACE) inhibitors reduce blood pressure and urine protein excretion and slow the progression of chronic kidney disease.

Successful aging seems to refer to a broad set of circumstances that include but transcend healthy aging. The contribution of medical care to successful aging may lie in better management of chronic diseases. Health services research can contribute to successful aging by informing the delivery of medical care in this area. It can provide useful insights into what kinds of new approaches have proven successful and how to implement and sustain these changes. However, many of these lessons from health services research have been ignored in practice to date.

The Compression of Morbidity paradigm, introduced in 1980, maintains that if the average age at first infirmity, disability, or other morbidity is postponed and if this postponement is greater than increases in life expectancy, then cumulative lifetime morbidity will decrease-compressed between a later onset and the time of death. The National Long-Term Care Survey, the National Health Interview Survey, and other data now document declining disability trends beginning in 1982 and accelerating more recently. The decline is about 2% per year, contrasted with a decline in mortality rates of about 1% per year, thereby documenting compression of morbidity in the United States at the population level. Longitudinal studies now link good health risk status with long-term reductions in cumulative lifetime disability; persons with few behavioral health risks have only one-fourth the disability of those who have more risk factors, and the onset of disability is postponed from 7 to 12 years, far more than any increases in longevity in the groups. Randomized, controlled trials of health enhancement programs in elderly populations show reduction in health risks, improved health status, and decreased medical care utilization. Health policy initiatives now being undertaken have promise of increasing and consolidating health gains for the elderly.