Frazier T. Stevenson

Determinants of albumin concentration in hemodialysis patients

Hypoalbuminemia predicts mortality in hemodialysis patients with end-stage renal disease and is assumed to result from malnutrition. To investigate a possible alternative cause, we evaluated the relationships between serum albumin (Salb) and serum levels of two positive acute-phase proteins: C-reactive protein (CRP) and serum amyloid A (SAA). We also examined the relationship between Salb and dialysis dose delivered (Kt/V) and normalized protein catabolic rate (PCRn) measured during 3 consecutive months in a group of 115 patients. Serum albumin was measured monthly for 5 months. SAA levels were not increased in the majority of patients, despite its low molecular weight (8 kd), and predialysis concentrations were independent of residual renal function, compatible with a nonrenal site of metabolism. Both CRP and SAA levels correlated negatively with Salb both by linear regression and by multiple regression analysis (P < 0.001). CRP correlated with fibrinogen (P < 0.005). Salb also correlated positively with PCRn (P = 0.001), but not with Kt/V. The Kt/V did not correlate with PCRn. While CRP and SAA correlated with one another, neither variable correlated with PCRn. When either SAA or CRP was high, Salb was low regardless of PCRn. Thus, there are two separate independent factors predicting Salb--markers of inflammation and protein intake--but high concentrations of acute-phase proteins have a greater impact on Salb than does low PCRn. Activity of the acute-phase response is an important predictor of low Salb in hemodialysis patients independently of nutritional factors.

Comparing problem-based learning with case-based learning: Effects of a major curricular shift at two institutions

Purpose Problem-based learning (PBL) is now used at many medical schools to promote lifelong learning, open inquiry, teamwork, and critical thinking. PBL has not been compared with other forms of discussion-based small-group learning. Case-based learning (CBL) uses a guided inquiry method and provides more structure during small-group sessions. In this study, we compared faculty and medical students’ perceptions of traditional PBL with CBL after a curricular shift at two institutions. Method Over periods of three years, the medical schools at the University of California, Los Angeles (UCLA) and the University of California, Davis (UCD) changed first-, second-, and third-year Doctoring courses from PBL to CBL formats. Ten months after the shift (2001 at UCLA and 2004 at UCD), students and faculty who had participated in both curricula completed a 24-item questionnaire about their PBL and CBL perceptions and the perceived advantages of each format Results A total of 286 students (86%–97%) and 31 faculty (92%–100%) completed questionnaires. CBL was preferred by students (255; 89%) and faculty (26; 84%) across schools and learner levels. The few students preferring PBL (11%) felt it encouraged self-directed learning (26%) and valued its greater opportunities for participation (32%). From logistic regression, students preferred CBL because of fewer unfocused tangents (59%, odds ration [OR] 4.10, P = .01), less busy-work (80%, OR 3.97, P = .01), and more opportunities for clinical skills application (52%, OR 25.6, P = .002). Conclusions Learners and faculty at two major academic medical centers overwhelmingly preferred CBL (guided inquiry) over PBL (open inquiry). Given the dense medical curriculum and need for efficient use of student and faculty time, CBL offers an alternative model to traditional PBL small-group teaching. This study could not assess which method produces better practicing physicians.

Calculation of the Estimated Creatinine Clearance in Avoiding Drug Dosing Errors in the Older Patient

Background: The population of hospitalized older patients is increasing. We investigated whether clinicians accurately detected renal insufficiency in older patients and chose correct doses of commonly prescribed antibiotics. Methods: We conducted a retrospective chart review of 1044 patients >80 years admitted to the University of California Davis Medical Center between January and December 1997 with a diagnosis of infection. Inclusion criteria included data necessary to calculate creatinine clearance using the Cockroft‐Gault equation and administration of any of the study antibiotics. Patients with unstable renal function, defined as an increase in creatinine of ≥1.0 mg/dL/day were excluded. Administered dosages of each study drug were compared with the appropriate adjusted doses. We examined the variables of age, weight, serum creatinine, and sex to determine whether any were individually predictive of dosing errors. Results: Dosing errors were identified in all of the antibiotics studied, and the overall dosing error rate was 34%. The factors that were predictive of dosage errors were advanced age and low body weight. Serum creatinine and sex were not statistically significant factors. Conclusions: Widespread errors in medication dosing are made in elderly hospitalized patients. The Cockroft‐Gault equation reveals significant renal insufficiency requiring dose adjustments in most elderly patients studied, especially those>85 years of age and with low body weight. Estimation of glomerular filtration rate should be performed routinely on all admitted patients older than 80 and in any patient with low lean body mass.

A fatal case of iatrogenic hypercalcemia after calcium channel blocker overdose.

We report a case of a 61-year-old woman treated for a suspected verapamil overdose with continuous calcium chloride infusion, resulting in severe hypercalcemia of 32.3 mg/dL (8.07 mmol/L) with a normal range of 8.6–10.5 mg/dL (2.15–2.63 mmol/L). Treatment with acute hemodialysis rapidly normalized the serum calcium level, but the patient later died of vasoconstrictive complications of hypercalcemia.

Paired basic science and clinical problem-based learning faculty teaching side by side: do students evaluate them differently?

Introduction  Many studies have evaluated the desirability of expert versus non‐expert facilitators in problem‐based learning (PBL), but performance differences between basic science and clinical facilitators has been less studied. In a PBL course at our university, pairs of faculty facilitators (1 clinician, 1 basic scientist) were assigned to student groups to maximise integration of basic science with clinical science.

The Doctoring Curriculum at the University of California, Davis School of Medicine: Leadership and Participant Roles for Psychiatry Faculty.

ObjectiveThe authors describe in detail the 3-year model of the Doctoring curriculum plus an elective fourth-year Doctoring course at University of California, Davis School of Medicine (UCDSOM) and University of California Los Angeles (UCLA) School of Medicine and the critical role for psychiatry faculty leadership and participation.MethodsThe authors present a review of curricular materials and course operations for the different Doctoring courses for first-, second-, third-, and fourth-year curriculum. The authors describe the role of psychiatry faculty in both leadership and in group facilitation.ResultsThe Doctoring curriculum offers case-based, small-group learning that relies heavily on standardized patients to teach core content around doctor-patient communication, ethics behavioral medicine and counseling approaches. There are frequent psychosocial issues woven in to these encounters. Psychiatry faculty members and other mental health professionals are well-prepared by virtue of their training to lead small group discussions and facilitate the supportive elements of the small groups in medical education.ConclusionThe Doctoring curriculum is both a biopsychosocial educational endeavor and a high-visibility leadership opportunity for the Department of Psychiatry. Other medical schools and departments of psychiatry may wish to pursue similar roles in their didactic programs.

Inflammation and End‐Stage Renal Disease: Recent Insights

Increasing evidence supports the theory that chronic inflammation plays an important role in the early morbidity and mortality of some dialysis patients. Inflammation and immune suppression represent opposite ends of a spectrum of recognized immunologic disorders in endstage renal disease (ESRD) patients. These disorders may manifest as abnormalities in leukocyte function, as altered synthesis of immunomodulatory substances (cytokines, growth factors, glucocorticoids, acute phase reactants), or as a disordered response to underlying infection. The analysis of these disorders in ESRD patients is complicated by immune alterations induced by the dialysis process itself. Considerable literature has attempted to clarify how different types of hemodialysis membranes, continuous ambulatory peritoneal dialysis (CAPD), and the uremic state may induce inflammation or reduce the appropriate inflammatory response to infection. These studies have frequently yielded conflicting results, usually attributed to differing methodologies and patient populations and to the notoriously heterogeneous nature of the ESRD population. This review will discuss some recent advances in efforts to understand the modulation of the inflammatory response in the ESRD population and to point out the inherent difficulties in immunologic studies of this type, which will continue to make this a challenging goal.