Table of Contents

Abatacept is the first drug to use inhibition of activation of T cells as a therapeutic pathway. In this 1-year, randomized, placebo-controlled trial involving 116 centers and 652 patients with rheumatoid arthritis, abatacept reduced disease activity in patients who had active disease despite taking methotrexate. The drug is effective, but defining its true role will require longer trials in different patient populations.

In this study of 488 841 military recruits, significantly more women than men had autoimmune disorders. Compared with asthmatic women, nonasthmatic women had a significantly higher prevalence of all autoimmune disorders except for the antiphospholipid syndrome. Type 1 diabetes mellitus, vasculitis, and rheumatoid arthritis were less prevalent in men with asthma than in those without. Asthma status may affect the prevalence of major autoimmune disorders. Preexisting asthma seems to protect against the development of autoimmune disorders to varying degrees in men and women.

Because blood flow in the coronary arteries takes place largely during diastole, an increase in risk for coronary artery disease with excessive lowering of diastolic blood pressure is plausible, although unproven. In this secondary analysis of data from a large randomized trial of 2 antihypertensive drugs in patients with coronary artery disease, the risk for the primary outcome, all-cause death, and myocardial infarction increased with low diastolic blood pressure. This relationship did not occur for stroke.

The authors measured the effect of hospital or patient characteristics on the quality of care in 69 820 patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. They found too little use of systemic corticosteroid and antibiotic therapy, too much use of unnecessary and potentially harmful treatments, and considerable variation in practice across hospitals.

The Association of Program Directors in Internal Medicine (APDIM) Council has developed a strategy for redesigning residency training. The redesign process will require substantial changes to the educational environment, oversight, curriculum, faculty reward system, and funding of graduate medical education in internal medicine. The APDIM proposes immediate, short-term, and long-term solutions.

Pooled results from 19 trials with 33 826 asthmatic participants found that long-acting β-agonists increased exacerbations requiring hospitalization and life-threatening exacerbations compared with placebo. Hospitalizations were statistically significantly increased with salmeterol and formoterol and in children and adults. The risk for asthma-related deaths was increased, with a pooled risk difference of 0.07% (95% CI, 0.01% to 0.1%).

Interventional cardiologists have stopped using bare metal stents for percutaneous angioplasty in favor of drug-eluting stents. The authors argue that the evidence about the long-term incremental risks, benefits, and costs is not adequate to conclude that drug-eluting stents are superior to bare metal stents.

The American College of Physicians supports the need for reform throughout the continuum of training in internal medicine. Today's internists must have the necessary knowledge, skills, and attitudes to meet the challenges of an expanding body of medical knowledge and a rapidly evolving system of health care delivery. This paper synthesizes 2 American College of Physicians position papers on redesign of training.

On the basis of the trial by Kremer and colleagues in this issue, along with other trials, the U.S. Food and Drug Administration (FDA) recently approved abatacept for active rheumatoid arthritis. The author discusses the Kremer study and argues that the study questions answered in the “registration” trials necessary to gain FDA approval are mostly irrelevant for daily clinical practice.

The report by Salpeter and colleagues in this issue is a new entrant in the debate about long-acting β-agonists and asthma. The investigators found that use of long-acting β-agonists was associated with increased asthma exacerbations, increased asthma-related deaths, and increased hospitalizations compared with placebo. Does this settle the controversy once and for all?

This issue features 2 position papers on reforming internal medicine residency education. Although the proposed reforms are visionary, far-reaching, and appealing, they lack a road map and the necessary endorsements, as well as a strategy for uniting internal medicine around a future course for the discipline. The leaders of internal medicine must make a sustained, determined effort to overcome the barriers to implementing these recommendations.