Asghar Rastegar

Short-Term Global Health Research Projects by US Medical Students: Ethical Challenges for Partnerships

Recent interest in global health among medical students has grown drastically, and many students now spend time abroad conducting short-term research projects in low-resource settings. These short-term stints in developing countries present important ethical challenges to US-based students and their medical schools as well as the institutions that host such students abroad. This paper outlines some of these ethical issues and puts forth recommendations for ethically mindful short-term student research.

Chronic renal failure in Iranian children

Abstract We investigated chronic renal failure (CRF) in 166 Iranian children (95 boys and 71 girls) from July 1991 to June 1999. The mean age at onset of CRF was 7.9±4.5 years. The most common cause of CRF was congenital urological malformations (78 cases). The second most common cause of CRF was hereditary nephropathy (21%). Glomerular diseases accounted for only 10% of children who later went on to develop renal failure. High rates of cystinosis and primary hyperoxaluria were seen, and these elevated rates could be due to a high prevalence of parental consanguinity. Eighty-six patients required renal replacement therapy, of whom the majority underwent hemodialysis. The prevalence of primary reflux as a cause of CRF was high compared with reports from western countries. Earlier diagnosis and management of urinary tract infections in this group could reduce the prevalence of reflux as a cause of CRF in this population.

A Patient With Severe Hyponatremia and Hypokalemia: Osmotic Demyelination Following Potassium Repletion

evere hyponatremia is a rare, but important, omplication of thiazide diuretics. This often is ssociated with hypokalemia and other metaolic abnormalities, including hypophosphatemia nd metabolic alkalosis. Treatment of hyponatreia requires in-depth understanding of the mechaisms leading to these metabolic disorders, espeially the role of hypokalemia in the development f hyponatremia. We present a challenging paient with severe hyponatremia and hypokalemia ho, despite careful management, developed osotic demyelinating syndrome. We review the athophysiologic characteristics of this disorder nd lessons learned from this unfortunate incience.

Lactic Acidosis in the Setting of Antiretroviral Therapy for the Acquired Immunodeficiency Syndrome

Type B lactic acidosis, a rare but often fatal disorder, has been reported in 21 AIDS patients on antiretroviral therapy (ART). We present an AIDS patient with severe and prolonged lactic acidosis on stavudine and lamivudine. The lactic acidosis occurred in the absence of mitochondrial myopathy, hepatomegaly, or liver failure. This is the second report of lactic acidosis in a patient on stavudine and lamivudine. This patient recovered after aggressive supportive therapy including intravenous alkali and fluid administration as well as continuous venovenous hemodiafiltration. A single dose of dichloroacetate (DCA) was associated with a decrease in the serum lactate level by 20%, which persisted for more than 24 h. Seventeen months after recovery, the patient was rechallenged with ART without recurrence of lactic acidosis. We review and summarize all reported cases of patients with ART-associated lactic acidosis reported in the English literature.

Use of the ∇AG/∇HCO3- ratio in the diagnosis of mixed acid-base disorders

When a strong acid is added to plasma, one expects a quantitative relationship between excess anion gap (AG) and bicarbonate deficit (HCO3 ) with the AG/HCO3 ratio close to unity. If true, then this ratio could be used to diagnose mixed acid-base disorders in patients with metabolic acidosis. Although the mean ratio in selected patients is close to unity, this ratio also has a wide range, making its use in individual patients problematic. The ratio should therefore be used cautiously in making a diagnosis of mixed acid-base disorders.

The Craft of Writing: A Physician‐Writer's Workshop for Resident Physicians

AbstractINTRODUCTION: How can residency programs help trainees address conflicting emotions about their professional roles and cultivate a curiosity about their patients’ lives beyond their diseases? We drew on the medical humanities to address these challenges by creating an intensive writing workshop for internal medicine residents. AIM: To help participants become better physicians by reflecting on their experiences and on what gives meaning to work and life. This paper describes the workshop and how residents were affected by the focus on the craft of writing. SETTING: A group of 15 residents from 3 training programs affiliated with 1 institution. PROGRAM DESCRIPTION: We engaged the expertise of physician-writer Abraham Verghese in planning and facilitating the 2 and one-half day workshop. Residents’ submissions were discussed with a focus on the effectiveness of the writing. We also conducted a focus group with participants to evaluate the workshop. PROGRAM EVALUATION: Themes in the writing included dysphoria, impotence of the physician, and the healing power of compassion. Our focus group data suggested that this workshop served as a creative outlet from the rigors of medicine, created a sense of community among participants, enhanced both self-awareness and awareness of their patients’ lives, and increased intra-institutional and extra-institutional interest in writing and the residency program. DISCUSSION: Teaching creative writing to residents in an intensive workshop may deepen interactions with peers and patients, improve writing skills, and increase interest in writing and the residency program.

The effect of a bidirectional exchange on faculty and institutional development in a global health collaboration.

Purpose The MUYU Collaboration is a partnership between Mulago Hospital-Makerere University College of Health Sciences (M-MakCHS), in Kampala, Uganda, and the Yale University School of Medicine. The program allows Ugandan junior faculty to receive up to 1 year of subspecialty training within the Yale hospital system. The authors performed a qualitative study to assess the effects of this program on participants, as well as on M-MakCHS as an institution. Methods Data was collected via semi-structured interviews with exchange participants. Eight participants (67% of those eligible as of 4/2012) completed interviews. Study authors performed data analysis using standard qualitative data analysis techniques. Results Analysis revealed themes addressing the benefits, difficulties, and opportunities for improvement of the program. Interviewees described the main benefit of the program as its effect on their fund of knowledge. Participants also described positive effects on their clinical practice and on medical education at M-MakCHS. Most respondents cited financial issues as the primary difficulty of participation. Post-participation difficulties included resource limitations and confronting longstanding institutional and cultural habits. Suggestions for programmatic improvement included expansion of the program, ensuring appropriate management of pre-departure expectations, and refinement of program mentoring structures. Participants also voiced interest in expanding post-exchange programming to ensure both the use of and the maintenance of new capacity. Conclusions The MUYU Collaboration has benefitted both program participants and M-MakCHS, though these benefits remain difficult to quantify. This study supports the assertion that resource-poor to resource-rich exchanges have the potential to provide significant benefits to the resource-poor partner.

Pathophysiology of Renal Tubular Acidosis: Core Curriculum 2016

Metabolic acidosis results from either the gain of an acid or the loss of a base. The former is due to exogenous or endogenous acid loads resulting in anion gap metabolic acidosis. The latter is due to the loss of a base from either the gastrointestinal or genitourinary tract, producing nonanion gap or hyperchloremic metabolic acidosis. Renal tubular acidosis (RTA) arises from the kidney’s inability to excrete enough acid or retain enough bicarbonate (HCO3 - ), resulting in a clinical syndrome characterized by nongap metabolic acidosis, hyperchloremia, and impaired urinary acidification. In this Core Curriculum, we briefly summarize the role of the kidney in acid-base homeostasis and discuss clinical presentations, diagnoses, and treatments of RTA. OVERVIEW OF RENAL ACID-BASE HOMEOSTASIS Total-Body Acid-Base Homeostasis Metabolism of food particles generates both volatile carbonic acid, which is excreted by the lung, and fixed acid, which is generated primarily from metabolism of proteins. On a Western diet containing high levels of animal protein, an adult generates 15,000 mEq of volatile acid derived from fat and carbohydrate combustion and w1 mEq of fixed acid per kilogram of body weight from metabolism of proteins. This latter is initially neutralized by the body buffers, including HCO3 - , and then excreted by the kidney. The kidney is therefore responsible for the regeneration of lost buffers through excretion of 1 mEq of hydrogen ion (H 1 ) per kilogram of body by the reabsorption of all filtered HCO3 - and the regeneration of HCO3 - lost through metabolism of food particles. Both processes involve secretion of H 1 , initially to reabsorb filtered HCO3 - and then to generate new HCO3 - . The secreted H 1 would either combine with filtered HCO3 - , resulting in HCO3 reabsorption, or combine with urinary buffers in the tubular fluid to be excreted as titratable acids and ammonium ion (NH4 1 ), thus leading to HCO3 regeneration. Net acid excretion (NAE) by the kidney equals the sum of titratable acids and ammonium amounts minus the amount of HCO3 - :

Approach to the Diagnosis and Treatment of Hyponatremia in Pregnancy

Hyponatremia is the most commonly encountered electrolyte abnormality. Severe hyponatremia in pregnancy poses diagnostic and therapeutic challenges. Pregnancy involves changes in physiology that affect water and sodium homeostasis. Knowledge of these complex physiologic alterations during pregnancy is critical to managing dysnatremias in pregnancy. This teaching case describes a woman with chronic hyponatremia who presented during pregnancy with worsening hyponatremia. She had an activating vasopressin receptor mutation, which was passed on to her child, and her diagnostic workup is described.

Attending Rounds: Patient with Hypokalemia and Metabolic Acidosis

Hypokalemic paralysis represents a medical emergency requiring both rapid diagnosis and treatment. In this Attending Rounds a patient with hypokalemia and metabolic acidosis is presented to emphasize the role of routine laboratory studies in the assessment of such patients so that a correct diagnosis can be made and appropriate treatment can be initiated promptly.