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The investigators randomly assigned patients with dementia and their caregivers to usual care or to a coordinated system of care. In the coordinated system, care managers regularly assessed patient and caregiver pairs and coordinated guideline-recommended provision of services by health care providers and community agencies using computerized information systems. Patient-caregiver pairs cared for in the coordinated system received higher-quality health care and more assistance than those who received usual care.

In this study, the investigators randomly assigned Hispanic, black, and white dementia caregivers to receive a control intervention (written educational materials) or an intensive intervention to improve caregiver quality of life. The specific interventions were determined by caregivers, were delivered via trained personnel and telephone support groups, and targeted several dimensions of need. The study found that quality of life improved for Hispanic and white caregivers and for spouse caregivers who were black in the intervention group but not in the control group. The intervention had no detectable effect on the number of institutionalized care recipients.

The authors studied the care received for non–ST-segment elevation acute coronary syndromes by 37 345 patients younger than age 65 years and 59 550 patients age 65 years or older. Compared with privately insured patients, Medicaid patients received fewer guideline-recommended services at admission or discharge and experienced greater delays in receiving invasive procedures. Differences for Medicare patients were fewer and smaller, although delays were common. The in-hospital mortality rate was higher in Medicaid patients but not Medicare patients.

Most internal medicine residents in the United States make career plans during the course of their 3-year training program; however, little is known about the stability of career choice decisions among internal medicine residents. This study examined changes in expressed career preferences in a national cohort of categorical internal medicine residents as they progressed through 3 years of residency training. Career decisions changed late into residency training, and enthusiasm for careers in general internal medicine remained low.

The Update in Pulmonary Medicine features notable publications in pulmonary medicine from 2005 that cover such topics as pneumonia, asthma, chronic obstructive pulmonary disease, pulmonary embolism, lung cancer, and interstitial lung disease. Changes to clinical practice emerging from these articles are also discussed.

Pharmacogenomics holds considerable promise of contributing to our understanding of the mechanisms underlying variability in responses to drug therapy. Indeed, studies have discovered new biological mechanisms and have identified molecules that enhance drug safety. Many challenges remain to be overcome in the implementation of pharmacogenomic vision in clinical practice However, potential solutions are also evolving rapidly.

A new epidemic strain of Clostridium difficile is associated with increased frequency and severity of enteric disease and resistance to fluoroquinolones. Although methods to detect the new strain are not standard practice in most microbiology laboratories, an epidemic strain should be suspected if there is an increased rate of infection and high rates of serious complications, including toxic megacolon, leukemoid reactions, requirement for colectomy, shock, or death.

The vast majority of patients with dementia receive their care in primary care settings. Clinicians find it challenging to provide optimal care for these patients and their often-stressed and overly burdened caregivers because current reimbursement mechanisms do not support the kinds of practical, time-intensive, team-based processes of care that have been associated with improved outcomes in these settings. In this issue, Vickrey and colleagues present in a randomized trial the results of a novel disease management program for the primary care of dementia; Belle and colleagues tested a multicomponent intervention to improve quality of life in distressed caregivers. These articles make it clear that the medical profession must advocate for patients with dementia.

We have known for some time that fewer medical students and internal medicine residents are deciding on careers in primary care. As we try to transform primary care into a desirable career choice, we need to know more about when students and residents make their decisions and why they choose primary care (or why they do not). An article in this issue by West and colleagues helps fill this important gap and allows us to follow the career preferences of a large cohort of residents in each of the 3 years of residency.

The development of varenicline reflects new understanding of how nicotine acts to increase craving for cigarettes. Two studies recently published in the Journal of the American Medical Association evaluated the effects of varenicline on quitting. These studies showed that, although varenicline improves quit rates relative to bupropion, it is not a magic bullet. Regardless, even a small increase in sustained quit rates will yield health benefits that far exceed any other clinical intervention.

More than anything Mas'uda reminds me of the wicked witch from Hansel and Gretel, only her house is not made of chocolate and candy.