Shobita Rajagopalan

Tuberculosis and Aging: A Global Health Problem

Despite the World Health Organizations declaration that the spread of tuberculosis is a global emergency and despite the implementation of strong tuberculosis-control initiatives, this highly infectious disease continues to affect all vulnerable populations, including the elderly population (age > or =65 years). Tuberculosis in aging adults remains a clinical and epidemiological challenge. Atypical clinical manifestations of tuberculosis in older persons can result in delay in diagnosis and initiation of treatment; thus, unfortunately, higher rates of morbidity and mortality from this treatable infection can occur. Underlying illnesses, age-related diminution in immune function, the increased frequency of adverse drug reactions, and institutionalization can complicate the overall clinical approach to tuberculosis in elderly patients; maintenance of a high index of suspicion for tuberculosis in this vulnerable population is, thus, undoubtedly justifiable.

Serious infections in elderly patients with diabetes mellitus.

The elevated serum glucose levels associated with diabetes mellitus (DM) alter host immune responses, resulting in a well-documented increase in the predisposition to infectious processes. Furthermore, the cumulative effect of age-related immune senescence, superimposed on this enhanced risk of infections, can lead to serious and life-threatening infections in elderly patients with DM. Because infection associated with aging can frequently present in a subtle and atypical manner, prompt recognition of infection and treatment with appropriate empirical broad-spectrum antimicrobial agents, in conjunction with surgical intervention, is often necessary to eradicate such infections. Common sites of serious infection associated with DM include the head and neck, biliary tract, and urinary tract, as well as the skin, soft tissue, and bony structures of the feet in particular.

Impact of the University of California, Los Angeles/Charles R. Drew University Medical Education Program on medical students' intentions to practice in underserved areas.

Purpose To estimate the impact of a U.S. inner-city medical education program on medical school graduates’ intentions to practice in underserved communities. Method The authors conducted an analysis of secondary data on 1,088 medical students who graduated from either the joint University of California, Los Angeles/Charles R. Drew University Medical Education Program (UCLA/Drew) or the UCLA School of Medicine between 1996 and 2002. Intention to practice in underserved communities was measured using students’ responses to questionnaires administered at matriculation and graduation for program improvement by the Association of American Medical Colleges. Multivariate logistic regression analysis was used to compare the odds of intending to practice in underserved communities among UCLA/Drew students with those of their counterparts in the UCLA School of Medicine. Results Compared with students in the UCLA School of Medicine, UCLA/Drew students had greater adjusted odds of reporting intention to work in underserved communities at graduation, greater odds of maintaining or increasing such intentions between matriculation and graduation, and lower odds of decreased intention to work in underserved communities between matriculation and graduation. Conclusions Training in the UCLA/Drew program was independently associated with intention to practice medicine in underserved communities, suggesting that a medical education program can have a positive effect on students’ goals to practice in underserved areas.

Antimicrobial therapy in the elderly.

This article focuses on the special characteristics of infection in the elderly and provides an update of the principles of antibiotic selection, use of specific antibiotics, and empiric use of antimicrobials in the treatment of infectious diseases in this particularly vulnerable group. Antituberculous, antifungal, and antiviral agents are mentioned briefly; detailed information regarding these classes of agents in reference to aging can be found in standard reviews of antimicrobial therapy in the elderly.

Tuberculosis in long-term-care facilities

The geriatric population represents the largest reservoir of Mycobacterium tuberculosis infection in developed nations, including the United States. Tuberculosis (TB) case rates in the United States are highest for this age group compared with other age categories. The subtle clinical manifestations of TB in the elderly often can pose potential diagnostic dilemmas and therapeutic challenges, resulting in increased morbidity and mortality in this age group; this treatable infection unfortunately often is detected only at autopsy. Compared with their community-dwelling counterparts, the institutionalized elderly are at a greater risk both for reactivation of latent TB and for the acquisition of new TB infection. Prevention and control of TB in facilities providing long-term care to the elderly thus cannot be overemphasized.

Using Virtual Patients to Improve Cardiac Examination Competency in Medical Students

Cardiac examination (CE) skills are in decline. Most prior studies employed audio recordings, evaluating only one aspect of CE (i.e., auscultation) that precluded correlation with visible observations. To address these deficiencies, we developed a curriculum using virtual patient examinations (VPEs); bedside recordings of patients with visible and audible cardiovascular findings presented as interactive multimedia.

A framework for developing, implementing, and evaluating a cancer survivorship curriculum for medical students.

ABSTRACTBACKGROUNDCancer survivorship care is not adequately addressed in current medical school curricula.OBJECTIVESTo develop, implement, and evaluate a modular cancer survivorship curriculum that is portable to other educational settings and is designed to provide medical students with a foundation of knowledge, attitudes, and skills related to care for cancer survivors.PROGRAM DESCRIPTIONAn expert consensus panel developed a set of learning objectives related to cancer survivorship to guide the development of educational modules, such as computer-based self-instructional modules, problem-based learning cases, videos, and clinical exercises. Course and clerkship chairs were directly involved in the development and implementation of the modules.EVALUATIONA cohort study with a historical control group demonstrated that fourth-year medical students increased their knowledge in survivorship issues and their self-reported level of comfort in care activities compared to similar students who did not receive the survivorship curriculum.CONCLUSIONSOur framework resulted in a cancer survivorship curriculum that was implemented in a modular manner across the medical curriculum that improved learning and that is potentially portable to other educational settings.

Preparedness for caring of cancer survivors: A multi-institutional study of medical students and oncology fellows

Background. Despite recent advances in cancer survivorship knowledge and care, most medical schools lack a comprehensive survivorship curriculum, potentially leaving students ill-prepared for caring of survivors. Methods. A total of 211 students and 22 oncology fellows in 3 institutions completed a questionnaire assessing knowledge and experience in survivorship care. Results. Medical students and oncology fellows lack knowledge in key survivorship issues. Students were exposed to cancer survivors frequently in medical school but only half received instruction or practiced critical components of survivorship care. Conclusions. Improvement of both undergraduate and postgraduate training in survivorship care is urgently warranted.

Norovirus Infections in Long-Term Care Facilities.

Noroviruses have emerged as one of the leading causes of viral gastroenteritis worldwide, affecting community‐dwelling and institutionalized older adults. Recent global epidemics present a growing challenge to the healthcare system and to long‐term care facilities. Noroviruses spread readily and rapidly through multiple routes (e.g., person‐to‐person contact, contact with contaminated surfaces, airborne dissemination of vomitus) and thus are able to sustain an epidemic efficiently and successfully. Although norovirus gastroenteritis is a short self‐limited illness in healthy immunocompetent individuals, it can result in significant morbidity and mortality in vulnerable compromised persons such as frail elderly persons and older residents of nursing homes. Diagnosis is made by clinical assessment and confirmed primarily by stool evaluation using polymerase chain reaction. Treatment is confined to supportive measures. Public health prevention and control strategies provide guidance regarding surveillance and the necessary steps to curb the clinical effect and spread of norovirus infections in various settings, including long‐term care.

Tuberculosis in Older Adults

Tuberculosis (TB) remains one of the worlds most lethal infectious diseases. Preventive and control strategies among other high-risk groups, such as the elderly population, continues to be a challenge. Clinical features of TB in older adults may be atypical and confused with age-related diseases. Diagnosis and management of TB in the elderly person can be difficult; treatment can be associated with adverse drug reactions. This article reviews the current global epidemiology, pathogenesis, clinical characteristics, diagnosis, management, and prevention of Mycobacterium tuberculosis infection in community-dwelling and institutionalized aging adults.