Christine Kilgore

WASHINGTON — The attention and funding given to electronic health records under the Recovery Act means that “it's time for pediatricians to get involved,” said Janet Marchibroda, former chief executive officer of the eHealth Initiative.

Wider adoption of health IT “is definitely going to happen now—we're there,” Ms. Marchibroda told attendees at the annual meeting of the American Academy of Pediatrics.

Outside of the meeting halls, however, there was skepticism that enough pediatricians would be candidates for the financial incentives provided through the Recovery Act to make a significant difference.

In an interview, Dr. Joseph H. Schneider, chairperson of the AAP's Council on Clinical Information Technology (COCIT), said that requirements that practices demonstrate specific case mix thresholds in order to qualify for Medicaid EHR incentives mean that “for many pediatricians, this offer of money is really a hollow promise.”

The Recovery Act—formally known as the American Recovery and Reinvestment Act of 2009—set aside almost $45 billion of stimulus money to encourage the adoption of electronic health records through Medicare and Medicaid incentives that will be offered to providers who purchase a certified EHR system and make “meaningful use” of the technology, Ms. Marchibroda explained at the meeting.

Another $564 million will support statewide “Health Information Exchange (HIE) Cooperative Agreements” that will “help build HIE capacity,” she said, and $643 million will support approximately 70 health IT “regional extension centers” that will help health care providers select and implement E technology. States and nonprofit organizations applied for grants for these programs this fall; both efforts should be underway this month, she said.

“A lot will be happening in your communities,” said Ms. Marchibroda, now chief health care officer at IBM. “It's time to start a conversation with all the organizations with which you interact [from hospital systems to health plans and labs].”

Opportunities to purchase EHRs with Medicaid incentive money will come later, however—and only for those non–hospital-based pediatricians who have at least a 30% Medicaid patient volume or those who practice predominantly in federally qualified health centers or rural health clinics and have at least 30% of the patient volume attributable to “needy” patients.

Pediatricians with a 20% Medicaid volume will be eligible to receive two-thirds of the incentives, but even this lower threshold will exclude many pediatricians, said Dr. Schneider, who practices pediatrics in Dallas.

This means that pediatricians with at least 30% Medicaid volume could receive up to $63,750 over a 5-year period under the Recovery Act, he said. And those with at least 20% Medicaid volume could receive up to $42,500 over a 5-year period.

For those who do qualify, Ms. Marchibroda explained after the meeting, Medicaid will pay up to 85% of the costs related to EHR adoption and operations.

Another problem for pediatricians, Dr. Schneider said, lies with the “meaningful use” requirements. Such requirements will be defined nationally for incentives provided through the Medicare program, but for Medicaid-provided incentives, states have the ability under the Recovery Act to define their own meaningful use standards.

At least some states have been discussing the possibility of developing common definitions, and some have been waiting to see the draft Medicare regulations defining meaningful use that were expected from the Centers for Medicare and Medicaid Services last month. (A final rule will be issued in spring 2010.)

By tying funds to Medicaid, “Congress has left us with a tough ball to untangle,” he said. (Some types of measures of meaningful use, like the provision of personal health record information to patients and the ability to exchange information with other providers, are common to pediatric and adult care, but other measures—like quality measures—can be quite different, Dr. Schneider said.)

EHR vendors have catered more to the larger market of adult patient populations in designing their systems thus far, and “if states end up with varying meaningful use definitions and definitions that are significantly different from Medicare's, then the EHR vendors will probably ignore pediatric needs [even more],” Dr. Schneider said.

At various points in time, the AAP has urged Congress to include the Children's Health Insurance Program in the EHR incentive process, to repeal the ability of state Medicaid programs to modify the definition of meaningful use from a national standard, and to lower the threshold for Medicaid as far as possible in order to provide incentive payments to as many Medicaid providers as possible.

Now, Dr. Schneider said, the goals of the AAP's COCIT and its new Child Health Informatics Center include working with the states to minimize variation in definitions of meaningful use, and working with the new regional extension centers to “provide a common approach to helping pediatricians” select and implement EHRs that are friendly to their patient populations and their workflow. Surveys done in 2006 showed that one-third of office-based pediatric practices had no plans to implement an EHR system; 70% of these were solo practitioners.

Will the Recovery Act's incentives and technical assistance programs change their minds, or spur on those who are teetering? Ms. Marchibroda said she hopes so, though the goals, she admits, are high. “Congress's intention in the Recovery Act is to grow the numbers to 90% adoption by physicians and 70% by hospitals,” she said. “So we have a long way to go.”

The organization that Ms. Marchibroda led until earlier this year—the eHealth Initiative—is a multidisciplinary nonprofit organization whose members include employers and purchasers, accrediting groups, physician groups, and patient and consumer groups.

WASHINGTON — The attention and funding given to electronic health records under the Recovery Act means that “it's time for pediatricians to get involved,” said Janet Marchibroda, former chief executive officer of the eHealth Initiative.

Wider adoption of health IT “is definitely going to happen now—we're there,” Ms. Marchibroda told attendees at the annual meeting of the American Academy of Pediatrics.

Outside of the meeting halls, however, there was skepticism that enough pediatricians would be candidates for the financial incentives provided through the Recovery Act to make a significant difference.

In an interview, Dr. Joseph H. Schneider, chairperson of the AAP's Council on Clinical Information Technology (COCIT), said that requirements that practices demonstrate specific case mix thresholds in order to qualify for Medicaid EHR incentives mean that “for many pediatricians, this offer of money is really a hollow promise.”

The Recovery Act—formally known as the American Recovery and Reinvestment Act of 2009—set aside almost $45 billion of stimulus money to encourage the adoption of electronic health records through Medicare and Medicaid incentives that will be offered to providers who purchase a certified EHR system and make “meaningful use” of the technology, Ms. Marchibroda explained at the meeting.

Another $564 million will support statewide “Health Information Exchange (HIE) Cooperative Agreements” that will “help build HIE capacity,” she said, and $643 million will support approximately 70 health IT “regional extension centers” that will help health care providers select and implement E technology. States and nonprofit organizations applied for grants for these programs this fall; both efforts should be underway this month, she said.

“A lot will be happening in your communities,” said Ms. Marchibroda, now chief health care officer at IBM. “It's time to start a conversation with all the organizations with which you interact [from hospital systems to health plans and labs].”

Opportunities to purchase EHRs with Medicaid incentive money will come later, however—and only for those non–hospital-based pediatricians who have at least a 30% Medicaid patient volume or those who practice predominantly in federally qualified health centers or rural health clinics and have at least 30% of the patient volume attributable to “needy” patients.

Pediatricians with a 20% Medicaid volume will be eligible to receive two-thirds of the incentives, but even this lower threshold will exclude many pediatricians, said Dr. Schneider, who practices pediatrics in Dallas.

This means that pediatricians with at least 30% Medicaid volume could receive up to $63,750 over a 5-year period under the Recovery Act, he said. And those with at least 20% Medicaid volume could receive up to $42,500 over a 5-year period.

For those who do qualify, Ms. Marchibroda explained after the meeting, Medicaid will pay up to 85% of the costs related to EHR adoption and operations.

Another problem for pediatricians, Dr. Schneider said, lies with the “meaningful use” requirements. Such requirements will be defined nationally for incentives provided through the Medicare program, but for Medicaid-provided incentives, states have the ability under the Recovery Act to define their own meaningful use standards.

At least some states have been discussing the possibility of developing common definitions, and some have been waiting to see the draft Medicare regulations defining meaningful use that were expected from the Centers for Medicare and Medicaid Services last month. (A final rule will be issued in spring 2010.)

By tying funds to Medicaid, “Congress has left us with a tough ball to untangle,” he said. (Some types of measures of meaningful use, like the provision of personal health record information to patients and the ability to exchange information with other providers, are common to pediatric and adult care, but other measures—like quality measures—can be quite different, Dr. Schneider said.)

EHR vendors have catered more to the larger market of adult patient populations in designing their systems thus far, and “if states end up with varying meaningful use definitions and definitions that are significantly different from Medicare's, then the EHR vendors will probably ignore pediatric needs [even more],” Dr. Schneider said.

At various points in time, the AAP has urged Congress to include the Children's Health Insurance Program in the EHR incentive process, to repeal the ability of state Medicaid programs to modify the definition of meaningful use from a national standard, and to lower the threshold for Medicaid as far as possible in order to provide incentive payments to as many Medicaid providers as possible.

Now, Dr. Schneider said, the goals of the AAP's COCIT and its new Child Health Informatics Center include working with the states to minimize variation in definitions of meaningful use, and working with the new regional extension centers to “provide a common approach to helping pediatricians” select and implement EHRs that are friendly to their patient populations and their workflow. Surveys done in 2006 showed that one-third of office-based pediatric practices had no plans to implement an EHR system; 70% of these were solo practitioners.

Will the Recovery Act's incentives and technical assistance programs change their minds, or spur on those who are teetering? Ms. Marchibroda said she hopes so, though the goals, she admits, are high. “Congress's intention in the Recovery Act is to grow the numbers to 90% adoption by physicians and 70% by hospitals,” she said. “So we have a long way to go.”

The organization that Ms. Marchibroda led until earlier this year—the eHealth Initiative—is a multidisciplinary nonprofit organization whose members include employers and purchasers, accrediting groups, physician groups, and patient and consumer groups.

WASHINGTON — The attention and funding given to electronic health records under the Recovery Act means that “it's time for pediatricians to get involved,” said Janet Marchibroda, former chief executive officer of the eHealth Initiative.

Wider adoption of health IT “is definitely going to happen now—we're there,” Ms. Marchibroda told attendees at the annual meeting of the American Academy of Pediatrics.

Outside of the meeting halls, however, there was skepticism that enough pediatricians would be candidates for the financial incentives provided through the Recovery Act to make a significant difference.

In an interview, Dr. Joseph H. Schneider, chairperson of the AAP's Council on Clinical Information Technology (COCIT), said that requirements that practices demonstrate specific case mix thresholds in order to qualify for Medicaid EHR incentives mean that “for many pediatricians, this offer of money is really a hollow promise.”

The Recovery Act—formally known as the American Recovery and Reinvestment Act of 2009—set aside almost $45 billion of stimulus money to encourage the adoption of electronic health records through Medicare and Medicaid incentives that will be offered to providers who purchase a certified EHR system and make “meaningful use” of the technology, Ms. Marchibroda explained at the meeting.

Another $564 million will support statewide “Health Information Exchange (HIE) Cooperative Agreements” that will “help build HIE capacity,” she said, and $643 million will support approximately 70 health IT “regional extension centers” that will help health care providers select and implement E technology. States and nonprofit organizations applied for grants for these programs this fall; both efforts should be underway this month, she said.

“A lot will be happening in your communities,” said Ms. Marchibroda, now chief health care officer at IBM. “It's time to start a conversation with all the organizations with which you interact [from hospital systems to health plans and labs].”

Opportunities to purchase EHRs with Medicaid incentive money will come later, however—and only for those non–hospital-based pediatricians who have at least a 30% Medicaid patient volume or those who practice predominantly in federally qualified health centers or rural health clinics and have at least 30% of the patient volume attributable to “needy” patients.

Pediatricians with a 20% Medicaid volume will be eligible to receive two-thirds of the incentives, but even this lower threshold will exclude many pediatricians, said Dr. Schneider, who practices pediatrics in Dallas.

This means that pediatricians with at least 30% Medicaid volume could receive up to $63,750 over a 5-year period under the Recovery Act, he said. And those with at least 20% Medicaid volume could receive up to $42,500 over a 5-year period.

For those who do qualify, Ms. Marchibroda explained after the meeting, Medicaid will pay up to 85% of the costs related to EHR adoption and operations.

Another problem for pediatricians, Dr. Schneider said, lies with the “meaningful use” requirements. Such requirements will be defined nationally for incentives provided through the Medicare program, but for Medicaid-provided incentives, states have the ability under the Recovery Act to define their own meaningful use standards.

At least some states have been discussing the possibility of developing common definitions, and some have been waiting to see the draft Medicare regulations defining meaningful use that were expected from the Centers for Medicare and Medicaid Services last month. (A final rule will be issued in spring 2010.)

By tying funds to Medicaid, “Congress has left us with a tough ball to untangle,” he said. (Some types of measures of meaningful use, like the provision of personal health record information to patients and the ability to exchange information with other providers, are common to pediatric and adult care, but other measures—like quality measures—can be quite different, Dr. Schneider said.)

EHR vendors have catered more to the larger market of adult patient populations in designing their systems thus far, and “if states end up with varying meaningful use definitions and definitions that are significantly different from Medicare's, then the EHR vendors will probably ignore pediatric needs [even more],” Dr. Schneider said.

At various points in time, the AAP has urged Congress to include the Children's Health Insurance Program in the EHR incentive process, to repeal the ability of state Medicaid programs to modify the definition of meaningful use from a national standard, and to lower the threshold for Medicaid as far as possible in order to provide incentive payments to as many Medicaid providers as possible.

Now, Dr. Schneider said, the goals of the AAP's COCIT and its new Child Health Informatics Center include working with the states to minimize variation in definitions of meaningful use, and working with the new regional extension centers to “provide a common approach to helping pediatricians” select and implement EHRs that are friendly to their patient populations and their workflow. Surveys done in 2006 showed that one-third of office-based pediatric practices had no plans to implement an EHR system; 70% of these were solo practitioners.

Will the Recovery Act's incentives and technical assistance programs change their minds, or spur on those who are teetering? Ms. Marchibroda said she hopes so, though the goals, she admits, are high. “Congress's intention in the Recovery Act is to grow the numbers to 90% adoption by physicians and 70% by hospitals,” she said. “So we have a long way to go.”

The organization that Ms. Marchibroda led until earlier this year—the eHealth Initiative—is a multidisciplinary nonprofit organization whose members include employers and purchasers, accrediting groups, physician groups, and patient and consumer groups.

WASHINGTON — The newer topical retinoid adapalene is often the best front-line agent for the management of mild to moderate acne because it can be applied along with benzoyl peroxide, according to Dr. Richard J. Antaya.

Adapalene (Differin) “is a much more stable molecule, so you can apply it with other medications like benzoyl peroxide,” said Dr. Antaya, director of pediatric dermatology at Yale University in New Haven, Conn. “Retin-A gets broken down much more easily.”

Although a topical retinoid alone is effective for mild acne that is primarily comedonal, benzoyl peroxide (a topical antibacterial) should be added when the acne has a papulopustular component, he explained at the annual meeting of the American Academy of Pediatrics.

A topical antibiotic also should be part of the regimen if the acne is more severe at presentation or if it does not improve in 6-12 weeks of treatment with a retinoid and benzoyl peroxide.

Moisturizers are a critical part of acne management since all medications cause some degree of erythema, drying, or peeling. “With Tazorac [tazarotene, another newer-generation topical retinoid], because it's so irritating, we've actually realized that if you put moisturizer on before the Tazorac, it actually slows the [drug's] absorption and softens the blow so you get less irritation,” he noted.

Dr. Antaya said that he has had no financial relationships in the past year with any manufacturers of these products.

WASHINGTON — The newer topical retinoid adapalene is often the best front-line agent for the management of mild to moderate acne because it can be applied along with benzoyl peroxide, according to Dr. Richard J. Antaya.

Adapalene (Differin) “is a much more stable molecule, so you can apply it with other medications like benzoyl peroxide,” said Dr. Antaya, director of pediatric dermatology at Yale University in New Haven, Conn. “Retin-A gets broken down much more easily.”

Although a topical retinoid alone is effective for mild acne that is primarily comedonal, benzoyl peroxide (a topical antibacterial) should be added when the acne has a papulopustular component, he explained at the annual meeting of the American Academy of Pediatrics.

A topical antibiotic also should be part of the regimen if the acne is more severe at presentation or if it does not improve in 6-12 weeks of treatment with a retinoid and benzoyl peroxide.

Moisturizers are a critical part of acne management since all medications cause some degree of erythema, drying, or peeling. “With Tazorac [tazarotene, another newer-generation topical retinoid], because it's so irritating, we've actually realized that if you put moisturizer on before the Tazorac, it actually slows the [drug's] absorption and softens the blow so you get less irritation,” he noted.

Dr. Antaya said that he has had no financial relationships in the past year with any manufacturers of these products.

WASHINGTON — The newer topical retinoid adapalene is often the best front-line agent for the management of mild to moderate acne because it can be applied along with benzoyl peroxide, according to Dr. Richard J. Antaya.

Adapalene (Differin) “is a much more stable molecule, so you can apply it with other medications like benzoyl peroxide,” said Dr. Antaya, director of pediatric dermatology at Yale University in New Haven, Conn. “Retin-A gets broken down much more easily.”

Although a topical retinoid alone is effective for mild acne that is primarily comedonal, benzoyl peroxide (a topical antibacterial) should be added when the acne has a papulopustular component, he explained at the annual meeting of the American Academy of Pediatrics.

A topical antibiotic also should be part of the regimen if the acne is more severe at presentation or if it does not improve in 6-12 weeks of treatment with a retinoid and benzoyl peroxide.

Moisturizers are a critical part of acne management since all medications cause some degree of erythema, drying, or peeling. “With Tazorac [tazarotene, another newer-generation topical retinoid], because it's so irritating, we've actually realized that if you put moisturizer on before the Tazorac, it actually slows the [drug's] absorption and softens the blow so you get less irritation,” he noted.

Dr. Antaya said that he has had no financial relationships in the past year with any manufacturers of these products.

WASHINGTON — Incorporating preparticipation screening into routine health supervision visits for all youth—not just those playing competitive sports—is one of the recommendations in an updated monograph being published by the American Academy of Pediatrics, Dr. David T. Bernhardt announced at the AAP's annual meeting.

The new recommendations, slated for released in the spring of 2010, also will weigh in on the use of ECGs and other tests to screen athletes for causes of sudden cardiac death, saying that such testing would be impractical, too costly, and challenged by false-positive test results, he said.

The new emphasis on wider, more routine use of the evaluation is in keeping with the growing emphasis on sports and other activities for good health, said Dr. Bernhardt, coeditor of the monograph, who is with the department of pediatrics and the division of sports medicine at the University of Wisconsin, Madison.

“Think about the kid playing a club sport, where there's no demand or regulation for a [signed preparticipation card], or kids skiing or playing at recess,” he said. “They may be playing tag or hula-hoop with just as much vigor as the older kids who are participating … for a scholarship.”

The overarching goal of the preparticipation evaluation, to promote the health and safety of athletes, “should be the same for every youngster coming into your clinic,” he emphasized.

Incorporating an additional set of questions into the well-child visit will require some thought, Dr. Bernhardt said in an interview. “If we want to be uniform in asking the right questions, we should use the [health] form in the visits … but realistically, this won't happen,” he said.

Asking families to complete the form before the visit, or incorporating at least parts of the form into the practice's overall history forms, could work, especially among practices using technology and electronic health records, he noted.

The issue of cardiovascular screening, and how best to prevent sudden cardiac death during intense physical activity, has become increasingly controversial since the last monograph on preparticipation screenings was published in 2004. The International Olympic Committee began endorsing ECGs for screening that year, and the European Society of Cardiology followed suit in 2005.

Although rare, sudden deaths of young competitive athletes have been reported more frequently in recent years and have been highly publicized. “More families have access to the Internet and read about [these tragedies] and what others are doing to screen” for sudden cardiac death, making it important for pediatricians and other physicians to be able to discuss the limitations of widespread screening with ECGs and other tests, Dr. Bernhardt said in the interview.

The European recommendations stem from a unique experience in Italy in which all athletes aged 12-35 years have been required for more than 25 years to obtain medical clearance—based on history, physical examination, and a 12-lead ECG—by certified physicians at designated screening centers. Italian investigators reported that the annual incidence of sudden cardiac death decreased by 89% in screened athletes in the Veneto region of Italy since the state-subsidized screening program was implemented (JAMA 2006;296:1593-601).

The screening program was predicated on an unusually high incidence of arrhythmogenic right ventricular dysplasia (ARVD) in the region, however, and the 89% drop reported in the JAMA study brings the rate of sudden cardiac death in the region “to about what we see in our country,” Dr. Bernhardt said at the AAP meeting.

An analysis of sudden deaths in U.S. athletes since 1980 showed that about 4% of the sudden cardiac deaths in athletes under 35 since 1980 have been caused by ARVD, he noted (Circulation 2009;119:1085-92). The most common cause, reportedly responsible for about 36% of the sudden cardiac deaths, was hypertrophic cardiomyopathy. (Cardiovascular sudden deaths occurred at a rate of less than 80/year, according to the study.)

The incidence of sudden cardiac death is about 1 in 75,000 competitive athletes, Dr. Bernhardt said, so “you're truly trying to find a needle in a haystack.”

Studies of ECG abnormalities in athletes have clearly shown that borderline or false-positive results are common. In one Italian study, investigators determined that the test's sensitivity was 51%, its specificity 61%, its positive predictive value 7%, and its negative predictive value 96%, he said.

The potential for false-positive results, combined with the size of the U.S. population, limited financial resources, and limited numbers of trained physicians, make the routine use of tests such as ECGs unwise in this country, Dr. Bernhardt added.

The AAP and its monograph cosponsors recommend a thorough personal and family history and physical exam as the best screening strategy. The monograph will incorporate the American Heart Association's recommendations for cardiovascular screening, along with questions about unexplained seizure and whether any family member or relative has died of sudden infant death syndrome, Dr. Bernhardt said.

The monograph will recommend that evaluations be performed in a primary care physician's office for better continuity of care, “rather than in station-based formats at schools or drugstores,” he said.

The new recommendations will also address legal concerns such as the ability of primary care or team physicians to rescind participation clearance based on changes in an athlete's health status, he said.

The AAP, along with the American Academy of Family Physicians and several sports medicine associations, has been a sponsoring organization of previous versions of the Preparticipation Physical Evaluation monograph. The new monograph will be sold, but the updated history and physical exam forms contained in the book will be available free of charge through sponsoring organizations.

WASHINGTON — Incorporating preparticipation screening into routine health supervision visits for all youth—not just those playing competitive sports—is one of the recommendations in an updated monograph being published by the American Academy of Pediatrics, Dr. David T. Bernhardt announced at the AAP's annual meeting.

The new recommendations, slated for released in the spring of 2010, also will weigh in on the use of ECGs and other tests to screen athletes for causes of sudden cardiac death, saying that such testing would be impractical, too costly, and challenged by false-positive test results, he said.

The new emphasis on wider, more routine use of the evaluation is in keeping with the growing emphasis on sports and other activities for good health, said Dr. Bernhardt, coeditor of the monograph, who is with the department of pediatrics and the division of sports medicine at the University of Wisconsin, Madison.

“Think about the kid playing a club sport, where there's no demand or regulation for a [signed preparticipation card], or kids skiing or playing at recess,” he said. “They may be playing tag or hula-hoop with just as much vigor as the older kids who are participating … for a scholarship.”

The overarching goal of the preparticipation evaluation, to promote the health and safety of athletes, “should be the same for every youngster coming into your clinic,” he emphasized.

Incorporating an additional set of questions into the well-child visit will require some thought, Dr. Bernhardt said in an interview. “If we want to be uniform in asking the right questions, we should use the [health] form in the visits … but realistically, this won't happen,” he said.

Asking families to complete the form before the visit, or incorporating at least parts of the form into the practice's overall history forms, could work, especially among practices using technology and electronic health records, he noted.

The issue of cardiovascular screening, and how best to prevent sudden cardiac death during intense physical activity, has become increasingly controversial since the last monograph on preparticipation screenings was published in 2004. The International Olympic Committee began endorsing ECGs for screening that year, and the European Society of Cardiology followed suit in 2005.

Although rare, sudden deaths of young competitive athletes have been reported more frequently in recent years and have been highly publicized. “More families have access to the Internet and read about [these tragedies] and what others are doing to screen” for sudden cardiac death, making it important for pediatricians and other physicians to be able to discuss the limitations of widespread screening with ECGs and other tests, Dr. Bernhardt said in the interview.

The European recommendations stem from a unique experience in Italy in which all athletes aged 12-35 years have been required for more than 25 years to obtain medical clearance—based on history, physical examination, and a 12-lead ECG—by certified physicians at designated screening centers. Italian investigators reported that the annual incidence of sudden cardiac death decreased by 89% in screened athletes in the Veneto region of Italy since the state-subsidized screening program was implemented (JAMA 2006;296:1593-601).

The screening program was predicated on an unusually high incidence of arrhythmogenic right ventricular dysplasia (ARVD) in the region, however, and the 89% drop reported in the JAMA study brings the rate of sudden cardiac death in the region “to about what we see in our country,” Dr. Bernhardt said at the AAP meeting.

An analysis of sudden deaths in U.S. athletes since 1980 showed that about 4% of the sudden cardiac deaths in athletes under 35 since 1980 have been caused by ARVD, he noted (Circulation 2009;119:1085-92). The most common cause, reportedly responsible for about 36% of the sudden cardiac deaths, was hypertrophic cardiomyopathy. (Cardiovascular sudden deaths occurred at a rate of less than 80/year, according to the study.)

The incidence of sudden cardiac death is about 1 in 75,000 competitive athletes, Dr. Bernhardt said, so “you're truly trying to find a needle in a haystack.”

Studies of ECG abnormalities in athletes have clearly shown that borderline or false-positive results are common. In one Italian study, investigators determined that the test's sensitivity was 51%, its specificity 61%, its positive predictive value 7%, and its negative predictive value 96%, he said.

The potential for false-positive results, combined with the size of the U.S. population, limited financial resources, and limited numbers of trained physicians, make the routine use of tests such as ECGs unwise in this country, Dr. Bernhardt added.

The AAP and its monograph cosponsors recommend a thorough personal and family history and physical exam as the best screening strategy. The monograph will incorporate the American Heart Association's recommendations for cardiovascular screening, along with questions about unexplained seizure and whether any family member or relative has died of sudden infant death syndrome, Dr. Bernhardt said.

The monograph will recommend that evaluations be performed in a primary care physician's office for better continuity of care, “rather than in station-based formats at schools or drugstores,” he said.

The new recommendations will also address legal concerns such as the ability of primary care or team physicians to rescind participation clearance based on changes in an athlete's health status, he said.

The AAP, along with the American Academy of Family Physicians and several sports medicine associations, has been a sponsoring organization of previous versions of the Preparticipation Physical Evaluation monograph. The new monograph will be sold, but the updated history and physical exam forms contained in the book will be available free of charge through sponsoring organizations.

WASHINGTON — Incorporating preparticipation screening into routine health supervision visits for all youth—not just those playing competitive sports—is one of the recommendations in an updated monograph being published by the American Academy of Pediatrics, Dr. David T. Bernhardt announced at the AAP's annual meeting.

The new recommendations, slated for released in the spring of 2010, also will weigh in on the use of ECGs and other tests to screen athletes for causes of sudden cardiac death, saying that such testing would be impractical, too costly, and challenged by false-positive test results, he said.

The new emphasis on wider, more routine use of the evaluation is in keeping with the growing emphasis on sports and other activities for good health, said Dr. Bernhardt, coeditor of the monograph, who is with the department of pediatrics and the division of sports medicine at the University of Wisconsin, Madison.

“Think about the kid playing a club sport, where there's no demand or regulation for a [signed preparticipation card], or kids skiing or playing at recess,” he said. “They may be playing tag or hula-hoop with just as much vigor as the older kids who are participating … for a scholarship.”

The overarching goal of the preparticipation evaluation, to promote the health and safety of athletes, “should be the same for every youngster coming into your clinic,” he emphasized.

Incorporating an additional set of questions into the well-child visit will require some thought, Dr. Bernhardt said in an interview. “If we want to be uniform in asking the right questions, we should use the [health] form in the visits … but realistically, this won't happen,” he said.

Asking families to complete the form before the visit, or incorporating at least parts of the form into the practice's overall history forms, could work, especially among practices using technology and electronic health records, he noted.

The issue of cardiovascular screening, and how best to prevent sudden cardiac death during intense physical activity, has become increasingly controversial since the last monograph on preparticipation screenings was published in 2004. The International Olympic Committee began endorsing ECGs for screening that year, and the European Society of Cardiology followed suit in 2005.

Although rare, sudden deaths of young competitive athletes have been reported more frequently in recent years and have been highly publicized. “More families have access to the Internet and read about [these tragedies] and what others are doing to screen” for sudden cardiac death, making it important for pediatricians and other physicians to be able to discuss the limitations of widespread screening with ECGs and other tests, Dr. Bernhardt said in the interview.

The European recommendations stem from a unique experience in Italy in which all athletes aged 12-35 years have been required for more than 25 years to obtain medical clearance—based on history, physical examination, and a 12-lead ECG—by certified physicians at designated screening centers. Italian investigators reported that the annual incidence of sudden cardiac death decreased by 89% in screened athletes in the Veneto region of Italy since the state-subsidized screening program was implemented (JAMA 2006;296:1593-601).

The screening program was predicated on an unusually high incidence of arrhythmogenic right ventricular dysplasia (ARVD) in the region, however, and the 89% drop reported in the JAMA study brings the rate of sudden cardiac death in the region “to about what we see in our country,” Dr. Bernhardt said at the AAP meeting.

An analysis of sudden deaths in U.S. athletes since 1980 showed that about 4% of the sudden cardiac deaths in athletes under 35 since 1980 have been caused by ARVD, he noted (Circulation 2009;119:1085-92). The most common cause, reportedly responsible for about 36% of the sudden cardiac deaths, was hypertrophic cardiomyopathy. (Cardiovascular sudden deaths occurred at a rate of less than 80/year, according to the study.)

The incidence of sudden cardiac death is about 1 in 75,000 competitive athletes, Dr. Bernhardt said, so “you're truly trying to find a needle in a haystack.”

Studies of ECG abnormalities in athletes have clearly shown that borderline or false-positive results are common. In one Italian study, investigators determined that the test's sensitivity was 51%, its specificity 61%, its positive predictive value 7%, and its negative predictive value 96%, he said.

The potential for false-positive results, combined with the size of the U.S. population, limited financial resources, and limited numbers of trained physicians, make the routine use of tests such as ECGs unwise in this country, Dr. Bernhardt added.

The AAP and its monograph cosponsors recommend a thorough personal and family history and physical exam as the best screening strategy. The monograph will incorporate the American Heart Association's recommendations for cardiovascular screening, along with questions about unexplained seizure and whether any family member or relative has died of sudden infant death syndrome, Dr. Bernhardt said.

The monograph will recommend that evaluations be performed in a primary care physician's office for better continuity of care, “rather than in station-based formats at schools or drugstores,” he said.

The new recommendations will also address legal concerns such as the ability of primary care or team physicians to rescind participation clearance based on changes in an athlete's health status, he said.

The AAP, along with the American Academy of Family Physicians and several sports medicine associations, has been a sponsoring organization of previous versions of the Preparticipation Physical Evaluation monograph. The new monograph will be sold, but the updated history and physical exam forms contained in the book will be available free of charge through sponsoring organizations.

WASHINGTON — Given growing concerns about propylthiouracil-related liver toxicity, “it may be that we should be weighing the relative risks” of this drug and methimazole for the treatment of Graves' disease during pregnancy, Dr. Susan J. Mandel said.

Propylthiouracil (PTU) has been the preferred therapy for Graves' disease during pregnancy, especially during first-trimester organogenesis, because methimazole (MMI) and carbimazole have been associated with aplasia cutis and rare embryopathy including choanal atresia, esophageal atresia, tracheoesophageal fistula, and athelia.

None of these congenital anomalies has been reported with the use of PTU, Dr. Mandel said at an American Thyroid Association-sponsored meeting. Dr. Mandel is associate chief of the division of endocrinology, diabetes, and metabolism at the University of Pennsylvania, Philadelphia.

Last month, the Food and Drug Administration issued a warning about the risk of severe liver injury associated with the use of PTU with the treatment of Graves' disease. “After analyzing adverse event reports, the FDA has identified an increased risk of liver injury with propylthiouracil, compared with an alternative treatment for Graves' disease, methimazole,” Dr. Amy Egan, deputy director for safety, division of metabolism and endocrinology products, FDA Center for Drug Evaluation and Research, said in a statement.

“Health care professionals should carefully consider which drug to initiate in a patient recently diagnosed with Graves' disease. If PTU therapy is chosen, the patient should be closely monitored for symptoms and signs of liver injury, especially during the first 6 months after initiating therapy.”

The FDA is advising health care professionals to reserve PTU for patients in their first trimester of pregnancy or those who are intolerant of or allergic to methimazole.

The FDA statement, posted on the agency's MedWatch Web site, said that 32 cases of serious liver injury were reported to the FDA from 1969, when the agency's adverse event reporting program was established, through October 2008. Of these cases, 22 were in adults, and included 12 fatalities and 5 liver transplants. Among the 10 pediatric cases, there were 6 reports of liver transplants and 1 fatality, according to the statement.

On the basis of an analysis of these reports, the FDA has determined that the risk of hepatotoxicity is greater with PTU than with MMI. The FDA received only five reports of serious liver injury associated with MMI, which was approved in 1950.

The FDA announced plans to change the prescribing information for PTU to reflect the hepatotoxicity warning

Concerns about PTU's hepatotoxicity have come largely from the pediatric community. Last year, the National Institute of Child Health and Human Development (NICHD) held a conference on “hepatic toxicity following treatment for pediatric Graves' disease.” And most recently, Dr. Scott A. Rivkees of Yale University, New Haven, Conn., and Dr. Donald R. Mattison of NICHD called for an end to the use of PTU in children.

In a letter to the editor published in the April 9 issue of the New England Journal of Medicine (2009;360:1574-5), Dr. Rivkees and Dr. Mattison said that PTU-induced liver failure may occur in 1 in 2,000 to 1 in 4,000 treated children, with nearly 10 times that range developing reversible PTU-induced liver injury.

In the context of Graves' disease in pregnancy, Dr. Mandel said, “it may be that we should be rethinking, what are the relative risks of hepatotoxicity with PTU versus the very rare embryopathy reported with methimazole [and carbimazole].”

Because the changes apparently caused by MMI “all occur by 8-10 weeks' gestation, and some even earlier, there may be a rationale” to using PTU into early pregnancy and then switching to methimazole afterwards,” added Dr. Mandel, also professor of medicine and radiology at the University of Pennsylvania.

The original recommendations to use PTU in pregnancy—before the teratogenic effects of MMI were reported—came from studies suggesting that PTU was less likely to cross the placenta. More recent data acquired through the use of newer measurement techniques have challenged this, demonstrating a similar degree of transplacental passage with both drugs, she noted.

WASHINGTON — Given growing concerns about propylthiouracil-related liver toxicity, “it may be that we should be weighing the relative risks” of this drug and methimazole for the treatment of Graves' disease during pregnancy, Dr. Susan J. Mandel said.

Propylthiouracil (PTU) has been the preferred therapy for Graves' disease during pregnancy, especially during first-trimester organogenesis, because methimazole (MMI) and carbimazole have been associated with aplasia cutis and rare embryopathy including choanal atresia, esophageal atresia, tracheoesophageal fistula, and athelia.

None of these congenital anomalies has been reported with the use of PTU, Dr. Mandel said at an American Thyroid Association-sponsored meeting. Dr. Mandel is associate chief of the division of endocrinology, diabetes, and metabolism at the University of Pennsylvania, Philadelphia.

Last month, the Food and Drug Administration issued a warning about the risk of severe liver injury associated with the use of PTU with the treatment of Graves' disease. “After analyzing adverse event reports, the FDA has identified an increased risk of liver injury with propylthiouracil, compared with an alternative treatment for Graves' disease, methimazole,” Dr. Amy Egan, deputy director for safety, division of metabolism and endocrinology products, FDA Center for Drug Evaluation and Research, said in a statement.

“Health care professionals should carefully consider which drug to initiate in a patient recently diagnosed with Graves' disease. If PTU therapy is chosen, the patient should be closely monitored for symptoms and signs of liver injury, especially during the first 6 months after initiating therapy.”

The FDA is advising health care professionals to reserve PTU for patients in their first trimester of pregnancy or those who are intolerant of or allergic to methimazole.

The FDA statement, posted on the agency's MedWatch Web site, said that 32 cases of serious liver injury were reported to the FDA from 1969, when the agency's adverse event reporting program was established, through October 2008. Of these cases, 22 were in adults, and included 12 fatalities and 5 liver transplants. Among the 10 pediatric cases, there were 6 reports of liver transplants and 1 fatality, according to the statement.

On the basis of an analysis of these reports, the FDA has determined that the risk of hepatotoxicity is greater with PTU than with MMI. The FDA received only five reports of serious liver injury associated with MMI, which was approved in 1950.

The FDA announced plans to change the prescribing information for PTU to reflect the hepatotoxicity warning

Concerns about PTU's hepatotoxicity have come largely from the pediatric community. Last year, the National Institute of Child Health and Human Development (NICHD) held a conference on “hepatic toxicity following treatment for pediatric Graves' disease.” And most recently, Dr. Scott A. Rivkees of Yale University, New Haven, Conn., and Dr. Donald R. Mattison of NICHD called for an end to the use of PTU in children.

In a letter to the editor published in the April 9 issue of the New England Journal of Medicine (2009;360:1574-5), Dr. Rivkees and Dr. Mattison said that PTU-induced liver failure may occur in 1 in 2,000 to 1 in 4,000 treated children, with nearly 10 times that range developing reversible PTU-induced liver injury.

In the context of Graves' disease in pregnancy, Dr. Mandel said, “it may be that we should be rethinking, what are the relative risks of hepatotoxicity with PTU versus the very rare embryopathy reported with methimazole [and carbimazole].”

Because the changes apparently caused by MMI “all occur by 8-10 weeks' gestation, and some even earlier, there may be a rationale” to using PTU into early pregnancy and then switching to methimazole afterwards,” added Dr. Mandel, also professor of medicine and radiology at the University of Pennsylvania.

The original recommendations to use PTU in pregnancy—before the teratogenic effects of MMI were reported—came from studies suggesting that PTU was less likely to cross the placenta. More recent data acquired through the use of newer measurement techniques have challenged this, demonstrating a similar degree of transplacental passage with both drugs, she noted.

WASHINGTON — Given growing concerns about propylthiouracil-related liver toxicity, “it may be that we should be weighing the relative risks” of this drug and methimazole for the treatment of Graves' disease during pregnancy, Dr. Susan J. Mandel said.

Propylthiouracil (PTU) has been the preferred therapy for Graves' disease during pregnancy, especially during first-trimester organogenesis, because methimazole (MMI) and carbimazole have been associated with aplasia cutis and rare embryopathy including choanal atresia, esophageal atresia, tracheoesophageal fistula, and athelia.

None of these congenital anomalies has been reported with the use of PTU, Dr. Mandel said at an American Thyroid Association-sponsored meeting. Dr. Mandel is associate chief of the division of endocrinology, diabetes, and metabolism at the University of Pennsylvania, Philadelphia.

Last month, the Food and Drug Administration issued a warning about the risk of severe liver injury associated with the use of PTU with the treatment of Graves' disease. “After analyzing adverse event reports, the FDA has identified an increased risk of liver injury with propylthiouracil, compared with an alternative treatment for Graves' disease, methimazole,” Dr. Amy Egan, deputy director for safety, division of metabolism and endocrinology products, FDA Center for Drug Evaluation and Research, said in a statement.

“Health care professionals should carefully consider which drug to initiate in a patient recently diagnosed with Graves' disease. If PTU therapy is chosen, the patient should be closely monitored for symptoms and signs of liver injury, especially during the first 6 months after initiating therapy.”

The FDA is advising health care professionals to reserve PTU for patients in their first trimester of pregnancy or those who are intolerant of or allergic to methimazole.

The FDA statement, posted on the agency's MedWatch Web site, said that 32 cases of serious liver injury were reported to the FDA from 1969, when the agency's adverse event reporting program was established, through October 2008. Of these cases, 22 were in adults, and included 12 fatalities and 5 liver transplants. Among the 10 pediatric cases, there were 6 reports of liver transplants and 1 fatality, according to the statement.

On the basis of an analysis of these reports, the FDA has determined that the risk of hepatotoxicity is greater with PTU than with MMI. The FDA received only five reports of serious liver injury associated with MMI, which was approved in 1950.

The FDA announced plans to change the prescribing information for PTU to reflect the hepatotoxicity warning

Concerns about PTU's hepatotoxicity have come largely from the pediatric community. Last year, the National Institute of Child Health and Human Development (NICHD) held a conference on “hepatic toxicity following treatment for pediatric Graves' disease.” And most recently, Dr. Scott A. Rivkees of Yale University, New Haven, Conn., and Dr. Donald R. Mattison of NICHD called for an end to the use of PTU in children.

In a letter to the editor published in the April 9 issue of the New England Journal of Medicine (2009;360:1574-5), Dr. Rivkees and Dr. Mattison said that PTU-induced liver failure may occur in 1 in 2,000 to 1 in 4,000 treated children, with nearly 10 times that range developing reversible PTU-induced liver injury.

In the context of Graves' disease in pregnancy, Dr. Mandel said, “it may be that we should be rethinking, what are the relative risks of hepatotoxicity with PTU versus the very rare embryopathy reported with methimazole [and carbimazole].”

Because the changes apparently caused by MMI “all occur by 8-10 weeks' gestation, and some even earlier, there may be a rationale” to using PTU into early pregnancy and then switching to methimazole afterwards,” added Dr. Mandel, also professor of medicine and radiology at the University of Pennsylvania.

The original recommendations to use PTU in pregnancy—before the teratogenic effects of MMI were reported—came from studies suggesting that PTU was less likely to cross the placenta. More recent data acquired through the use of newer measurement techniques have challenged this, demonstrating a similar degree of transplacental passage with both drugs, she noted.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

"We're asking ourselves: What should we take on in the next 3-5 years, and how can we as medical school leaders maximize our value and contribution?" Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

"Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity," said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of over 3 million jobs. "That's 1 out of 48 wage earners in the U.S.," said Dr. Reece.

In their meetings with legislators and national leaders, Dr. Reece and his colleagues from other medical schools emphasized the "ripple effect" of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research and slows the amount and pace of such research.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and more than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before a retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans involve "maximizing the impact of research" and better preparing graduates for the future.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

"We're asking ourselves: What should we take on in the next 3-5 years, and how can we as medical school leaders maximize our value and contribution?" Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

"Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity," said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of over 3 million jobs. "That's 1 out of 48 wage earners in the U.S.," said Dr. Reece.

In their meetings with legislators and national leaders, Dr. Reece and his colleagues from other medical schools emphasized the "ripple effect" of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research and slows the amount and pace of such research.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and more than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before a retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans involve "maximizing the impact of research" and better preparing graduates for the future.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

"We're asking ourselves: What should we take on in the next 3-5 years, and how can we as medical school leaders maximize our value and contribution?" Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

"Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity," said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of over 3 million jobs. "That's 1 out of 48 wage earners in the U.S.," said Dr. Reece.

In their meetings with legislators and national leaders, Dr. Reece and his colleagues from other medical schools emphasized the "ripple effect" of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research and slows the amount and pace of such research.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and more than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before a retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans involve "maximizing the impact of research" and better preparing graduates for the future.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece, chair of the AAMC Council of Deans, said upgrading primary care's status and emphasis is “definitely on the agenda.” ©RICHARD LIPPENHOLZ

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece, chair of the AAMC Council of Deans, said upgrading primary care's status and emphasis is “definitely on the agenda.” ©RICHARD LIPPENHOLZ

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece, chair of the AAMC Council of Deans, said upgrading primary care's status and emphasis is “definitely on the agenda.” ©RICHARD LIPPENHOLZ

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Deans have played a “very active role” in securing more biomedical research funding, Dr. John E. Prescott, chief academic officer at the AAMC, said in an interview. They are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Deans have played a “very active role” in securing more biomedical research funding, Dr. John E. Prescott, chief academic officer at the AAMC, said in an interview. They are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Deans have played a “very active role” in securing more biomedical research funding, Dr. John E. Prescott, chief academic officer at the AAMC, said in an interview. They are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers being responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners” in the United States, said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act (formally, the American Recovery and Reinvestment Act of 2009) directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine, a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention. A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group. Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers being responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners” in the United States, said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act (formally, the American Recovery and Reinvestment Act of 2009) directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine, a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention. A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group. Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers being responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners” in the United States, said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act (formally, the American Recovery and Reinvestment Act of 2009) directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine, a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention. A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group. Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care use and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview.

The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation–a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion in 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, who also serves as the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the ripple effect of declining funding–the way in which it thwarts the careers of young scientists and physicians who are interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funding to the NIH–equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine–a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans–questions that could drive the choice of issues for new or renewed focus–involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies–including one published recently in Health Affairs–also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, who serves as chief academic officer at the AAMC.

Medical school deans have played a “very active role” in securing more biomedical research funding, Dr. Prescott said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece is concerned about the ripple effect of declining funding. ©Richard Lippenholz

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care use and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview.

The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation–a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion in 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, who also serves as the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the ripple effect of declining funding–the way in which it thwarts the careers of young scientists and physicians who are interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funding to the NIH–equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine–a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans–questions that could drive the choice of issues for new or renewed focus–involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies–including one published recently in Health Affairs–also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, who serves as chief academic officer at the AAMC.

Medical school deans have played a “very active role” in securing more biomedical research funding, Dr. Prescott said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece is concerned about the ripple effect of declining funding. ©Richard Lippenholz

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care use and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview.

The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation–a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion in 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, who also serves as the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the ripple effect of declining funding–the way in which it thwarts the careers of young scientists and physicians who are interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funding to the NIH–equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine–a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans–questions that could drive the choice of issues for new or renewed focus–involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies–including one published recently in Health Affairs–also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, who serves as chief academic officer at the AAMC.

Medical school deans have played a “very active role” in securing more biomedical research funding, Dr. Prescott said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece is concerned about the ripple effect of declining funding. ©Richard Lippenholz

WASHINGTON — Preliminary analyses of a national registry of patients with the “understudied” condition of acute severe hypertension paint a picture of surprisingly high morbidity and mortality, and striking differences in physician management practices.

The STAT (Studying the Treatment of Acute Hypertension) registry, now closed, collected data from more than 1,580 patients in 25 hospitals—up to 120 consecutive patients in each hospital—in an effort to better understand the condition of acute hypertension that is managed in a critical care setting and treated with intravenous antihypertensive drugs, reported Dr. Kurt C. Kleinschmidt at the annual meeting of the Society of Academic Emergency Medicine.

Estimates are that up to 25% of patients in busy urban emergency departments (EDs) suffer from acute hypertension. Other than small retrospective studies, however, there are limited data available to guide physicians in the evaluation and management of these patients, said Dr. Kleinschmidt of the emergency medicine department at the University of Texas Southwestern Medical School, Dallas.

The STAT registry includes nonpregnant patients with at least one blood pressure reading greater than 180 mm Hg systolic and/or greater than 110 mm Hg diastolic, as well as patients with subarachnoid hemorrhage if they had a BP reading greater than 140 mm Hg systolic and/or greater than 90 mm Hg diastolic. All patients had to have been treated with an intravenous agent given as at least two boluses within 24 hours of hospital arrival and/or as a continuous infusion.

Initial analyses of the registry shed light on the patient population, patterns of care, and outcomes.

“It's a much sicker population than we'd anticipated … and there is an amazing collection of management strategies,” Dr. Kleinschmidt said.

Patients enrolled in the registry, managed by the Center for Outcomes Research at the University of Massachusetts, Worcester, had a mean age of 58 years. Most had a history of chronic hypertension (89%), and many (25%) were nonadherent to medications (25%). Almost 27% had had a prior admission for acute hypertension. The patients were almost equally men and women; 56% were black.

In nearly 80% of cases, intravenous antihypertensives were started in the ED. Management practices varied substantially with respect to the initial agent selected, the use of subsequent antihypertensives, and the timing of therapy.

Labetalol was the most commonly used first-line intravenous antihypertensive (31.5%), followed by metoprolol (17.4%), nitroglycerin (15.2%), hydralazine (14.8%), other antihypertensives (8.2%), nicardipine (7.6%), and sodium nitroprusside (5.2%). None of these medications was effective alone; all were followed by the addition of at least two other intravenous antihypertensives, “suggesting that none of the initial IV medications is particularly effective,” Dr. Kleinschmidt said in an interview.

Nicardipine was the least likely to be followed by other agents, he said, while sodium nitroprusside was most frequently followed by other medications. Therapy was initiated within 1 hour after acute severe hypertension was detected in about 47% of cases. In almost 11.5% of the cases, it took more than 6 hours. The median duration of intravenous therapy was 7.7 hours.

For patients without subarachnoid hemorrhage (1,419 of the more than 1,580 patients), the median time to achieve a systolic BP of less than 160 mm Hg was 4 hours. About 53% of patients had a re-elevation to greater than 180 mm Hg after initial control, and roughly 4% developed hypotension that required intervention.

For those patients who presented with subarachnoid hemorrhage, a systolic BP less than 140 mm Hg was reached in a median of 1.8 hours, and about 4% developed hypotension.

Overall, there was “considerable variability” in BP response over time, based on the initial antihypertensive agent selected, reported Dr. Kleinschmidt, also associate medical director of emergency services at Parkland Memorial Hospital, Dallas.

Nearly 60% of patients had evidence of target-organ injury associated with their hypertensive episodes. In-hospital mortality was almost 7%—a rate that is largely attributed to those patients with intracerebral hemorrhage.

WASHINGTON — Preliminary analyses of a national registry of patients with the “understudied” condition of acute severe hypertension paint a picture of surprisingly high morbidity and mortality, and striking differences in physician management practices.

The STAT (Studying the Treatment of Acute Hypertension) registry, now closed, collected data from more than 1,580 patients in 25 hospitals—up to 120 consecutive patients in each hospital—in an effort to better understand the condition of acute hypertension that is managed in a critical care setting and treated with intravenous antihypertensive drugs, reported Dr. Kurt C. Kleinschmidt at the annual meeting of the Society of Academic Emergency Medicine.

Estimates are that up to 25% of patients in busy urban emergency departments (EDs) suffer from acute hypertension. Other than small retrospective studies, however, there are limited data available to guide physicians in the evaluation and management of these patients, said Dr. Kleinschmidt of the emergency medicine department at the University of Texas Southwestern Medical School, Dallas.

The STAT registry includes nonpregnant patients with at least one blood pressure reading greater than 180 mm Hg systolic and/or greater than 110 mm Hg diastolic, as well as patients with subarachnoid hemorrhage if they had a BP reading greater than 140 mm Hg systolic and/or greater than 90 mm Hg diastolic. All patients had to have been treated with an intravenous agent given as at least two boluses within 24 hours of hospital arrival and/or as a continuous infusion.

Initial analyses of the registry shed light on the patient population, patterns of care, and outcomes.

“It's a much sicker population than we'd anticipated … and there is an amazing collection of management strategies,” Dr. Kleinschmidt said.

Patients enrolled in the registry, managed by the Center for Outcomes Research at the University of Massachusetts, Worcester, had a mean age of 58 years. Most had a history of chronic hypertension (89%), and many (25%) were nonadherent to medications (25%). Almost 27% had had a prior admission for acute hypertension. The patients were almost equally men and women; 56% were black.

In nearly 80% of cases, intravenous antihypertensives were started in the ED. Management practices varied substantially with respect to the initial agent selected, the use of subsequent antihypertensives, and the timing of therapy.

Labetalol was the most commonly used first-line intravenous antihypertensive (31.5%), followed by metoprolol (17.4%), nitroglycerin (15.2%), hydralazine (14.8%), other antihypertensives (8.2%), nicardipine (7.6%), and sodium nitroprusside (5.2%). None of these medications was effective alone; all were followed by the addition of at least two other intravenous antihypertensives, “suggesting that none of the initial IV medications is particularly effective,” Dr. Kleinschmidt said in an interview.

Nicardipine was the least likely to be followed by other agents, he said, while sodium nitroprusside was most frequently followed by other medications. Therapy was initiated within 1 hour after acute severe hypertension was detected in about 47% of cases. In almost 11.5% of the cases, it took more than 6 hours. The median duration of intravenous therapy was 7.7 hours.

For patients without subarachnoid hemorrhage (1,419 of the more than 1,580 patients), the median time to achieve a systolic BP of less than 160 mm Hg was 4 hours. About 53% of patients had a re-elevation to greater than 180 mm Hg after initial control, and roughly 4% developed hypotension that required intervention.

For those patients who presented with subarachnoid hemorrhage, a systolic BP less than 140 mm Hg was reached in a median of 1.8 hours, and about 4% developed hypotension.

Overall, there was “considerable variability” in BP response over time, based on the initial antihypertensive agent selected, reported Dr. Kleinschmidt, also associate medical director of emergency services at Parkland Memorial Hospital, Dallas.

Nearly 60% of patients had evidence of target-organ injury associated with their hypertensive episodes. In-hospital mortality was almost 7%—a rate that is largely attributed to those patients with intracerebral hemorrhage.

WASHINGTON — Preliminary analyses of a national registry of patients with the “understudied” condition of acute severe hypertension paint a picture of surprisingly high morbidity and mortality, and striking differences in physician management practices.

The STAT (Studying the Treatment of Acute Hypertension) registry, now closed, collected data from more than 1,580 patients in 25 hospitals—up to 120 consecutive patients in each hospital—in an effort to better understand the condition of acute hypertension that is managed in a critical care setting and treated with intravenous antihypertensive drugs, reported Dr. Kurt C. Kleinschmidt at the annual meeting of the Society of Academic Emergency Medicine.

Estimates are that up to 25% of patients in busy urban emergency departments (EDs) suffer from acute hypertension. Other than small retrospective studies, however, there are limited data available to guide physicians in the evaluation and management of these patients, said Dr. Kleinschmidt of the emergency medicine department at the University of Texas Southwestern Medical School, Dallas.

The STAT registry includes nonpregnant patients with at least one blood pressure reading greater than 180 mm Hg systolic and/or greater than 110 mm Hg diastolic, as well as patients with subarachnoid hemorrhage if they had a BP reading greater than 140 mm Hg systolic and/or greater than 90 mm Hg diastolic. All patients had to have been treated with an intravenous agent given as at least two boluses within 24 hours of hospital arrival and/or as a continuous infusion.

Initial analyses of the registry shed light on the patient population, patterns of care, and outcomes.

“It's a much sicker population than we'd anticipated … and there is an amazing collection of management strategies,” Dr. Kleinschmidt said.

Patients enrolled in the registry, managed by the Center for Outcomes Research at the University of Massachusetts, Worcester, had a mean age of 58 years. Most had a history of chronic hypertension (89%), and many (25%) were nonadherent to medications (25%). Almost 27% had had a prior admission for acute hypertension. The patients were almost equally men and women; 56% were black.

In nearly 80% of cases, intravenous antihypertensives were started in the ED. Management practices varied substantially with respect to the initial agent selected, the use of subsequent antihypertensives, and the timing of therapy.

Labetalol was the most commonly used first-line intravenous antihypertensive (31.5%), followed by metoprolol (17.4%), nitroglycerin (15.2%), hydralazine (14.8%), other antihypertensives (8.2%), nicardipine (7.6%), and sodium nitroprusside (5.2%). None of these medications was effective alone; all were followed by the addition of at least two other intravenous antihypertensives, “suggesting that none of the initial IV medications is particularly effective,” Dr. Kleinschmidt said in an interview.

Nicardipine was the least likely to be followed by other agents, he said, while sodium nitroprusside was most frequently followed by other medications. Therapy was initiated within 1 hour after acute severe hypertension was detected in about 47% of cases. In almost 11.5% of the cases, it took more than 6 hours. The median duration of intravenous therapy was 7.7 hours.

For patients without subarachnoid hemorrhage (1,419 of the more than 1,580 patients), the median time to achieve a systolic BP of less than 160 mm Hg was 4 hours. About 53% of patients had a re-elevation to greater than 180 mm Hg after initial control, and roughly 4% developed hypotension that required intervention.

For those patients who presented with subarachnoid hemorrhage, a systolic BP less than 140 mm Hg was reached in a median of 1.8 hours, and about 4% developed hypotension.

Overall, there was “considerable variability” in BP response over time, based on the initial antihypertensive agent selected, reported Dr. Kleinschmidt, also associate medical director of emergency services at Parkland Memorial Hospital, Dallas.

Nearly 60% of patients had evidence of target-organ injury associated with their hypertensive episodes. In-hospital mortality was almost 7%—a rate that is largely attributed to those patients with intracerebral hemorrhage.