Frederick C. Whittier

Dialysis leg cramps : efficacy of quinine Versus vitamin E

A controlled randomized double-blind study was done to determine the frequency and severity of leg cramps in 40 patients on dialysis with a history of leg cramps. All patients entered a 2 month placebo washout and were randomized into a 2 month double-dummy phase of quinine 325 mg at bedtime versus vitamin E 400 IU at bedtime. Of the 29 patients completing the study, 16 received quinine and 13 vitamin E. During placebo washout, the vitamin E group had a mean of 10.4 leg cramps per month, and the quinine group had a mean of 10.9. The vitamin E and quinine groups had a 1 month reduction in leg cramps to 3.3 and 3.6, respectively (p < 0.0005 for both groups combined); this was sustained at 2 months. A severity of pain index showed a statistically significant decrease for both groups. The 95% confidence interval for the difference between the number of leg cramps after vitamin E versus quinine treatment (95% confidence interval, -3.8, +3.2) suggests similar efficacy. Quinine and vitamin E were effective treatments for leg cramps in these patients. Considering the potential toxicity of quinine, vitamin E is recommended as the initial treatment of choice for patients on dialysis with leg cramps.

Spontaneous vertebral artery dissection as a complication of autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) may be associated with a variety of cardiovascular complications, including intracranial saccular aneurysms. In ADPKD, intracranial saccular aneurysms tend to rupture more frequently and earlier than the sporadic variety with a tendency to cluster in families. In contrast, dissecting intracranial aneurysms are rarely associated with either intracranial saccular aneurysms or ADPKD. We describe an ADPKD-1 patient whose course was complicated by a spontaneous dissection of a vertebral artery aneurysm. This particular patient had previously experienced three episodes of ascending aortic dissection with cystic medial necrosis. Intracranial vascular and aneurysmal dissection may occur in select ADPKD patients with familial clusters.

ASPERGILLUS DISCITIS WITH ACUTE DISC ABSCESS

Study Design Aspergillus Osteomyelitis of the vertebral body and disc space is rare. This report discusses a case that occured in an immunosuppressed 29-year-old man and reviews the pertinent medical literature. Objectives To review the management and treatment of Aspergillus osteomyelitis of the vertebral body and disc space. Summary of Background Data The patient presented with acute neurologic compromise resulting from L5-S1 discitis and a large epidural soft tissue component secondary to the Aspergillus infection. Results The patient underwent aggressive surgical debridement along with treatment with amphotericin B and had a complete clinical recovery. Conclusions The authors recommend a combined medical-surgical approach in most cases of vertebral Aspergillus osteomyelitis. Early surgery with vigorous surgical debridement along with antifungal treatment seems to yield a good outcome.

Acquired inhibitor to factor VIII in small cell lung cancer: a case report and review of the literature

Abstractu2002Acquired hemophilia (antibodies or inhibitors to factor VIII) is the most common acquired disease affecting clotting factors. It has been described in association with autoimmune disease, malignancy, dermatologic disorders, in the postpartum period, and with drug interactions. Factor VIII inhibitors have been previously described with lung cancer, three with squamous cell and one with adenocarcinoma. A 54-year-old woman presented with weight loss and shoulder pain. A chest X-ray revealed a right hilar mass, confirmed by computed tomography (CT) scan and biopsy revealed small cell lung cancer. Coagulation panel prior to bronchoscopy showed an increased partial thromboplastin time (aPTT). The presence of factor VIII inhibitor was demonstrated at 5u2009Bethesda units. The patient was treated with fresh frozen plasma twice for hemorrhagic episodes, and six cycles of chemotherapy were begun with carboplatin and etoposide 16. Eight months after the diagnosis, her aPTT was normal and the factor VIII inhibitor titer was undetectable. This is the first case report of small cell lung cancer and acquired hemophilia. A causal relationship between the malignancy and the presence of factor VIII inhibitors is suggested by the response to therapy.

A comparison of interactive computerized medical education software with a more traditional teaching format

Background: Computer‐assisted instruction in medicine appears to facilitate learning, but it has not been compared prospectively to more traditional teaching methods. Purpose: To compare the efficacy of computer‐assisted instruction to a more traditional format in medical students’ acquisition of clinical acid‐base problem‐solving skills. Methods: 2nd‐year medical students at Northeastern Ohio Universities College of Medicine (N = 82) were randomized into 2 groups. Thirty‐seven received computer‐assisted instruction in acid‐base problem‐solving skills, and 45 were enrolled in a teacher‐supervised workshop. Preinstruction and postinstruction questionnaires, as well as a 25‐question test, were administered to all students. Results: Analysis of the preinstruction questionnaire demonstrated that the students’ preferred method of learning was the teacher supervised workshop (50%) followed by reading (39.5%). Fifty‐eight percent of the students did not use computers at all. Of the remaining 42%, average compute...

Practicing and resident physicians' views on pharmaceutical companies

&NA; We studied the perception of residents and practicing physicians regarding interaction with pharmaceutical companies and their representatives. We focused on the concept that the pharmaceutical industry is considered to have an undue influence on physician prescribing habits and assessed the effect of pharmaceutical education efforts on physician education. The study consisted of an anonymous 22‐item questionnaire sent to 511 Northeastern Ohio primary care practicing physicians and 265 primary care residents. We obtained a 67% response rate. Only 13% of the practicing physicians and 8% of the residents believed that the pharmaceutical industry had a negative influence on conferences. Eighty‐nine percent of the physicians believed that they had sufficient training to interpret information from the pharmaceutical companies. Residents believed that they needed more training for the private detailing of representatives (39% had adequate training) versus 61% of the practicing physicians (p < .0001). Both physician groups felt that, as the value of a gift incneased, the less appropriate it was. Factors that were not perceived as having influence on prescribing included lunches, dinners, and gifts. Provision of free samples did affect the choice of writing a prescription. We analyzed five constructs of a history of receipt of gifts, attitudes toward gifts, attitudes toward information, influence on prescription, and assessment of prior training. We found the correlations among those constructs to be low. This implies that physicians attitudes and behaviors cannot be treated globally. In the call for changes in the practices of the pharmaceutical companies, an assumption is made that such changes will diminish unwarranted influence on physicians. Our results indicated that pharmaceutical gifts and influence on conferences have no apparent effect on prescribing habits. They also indicated that various attitudes and behaviors of physicians toward pharmaceutical companies are independent constructs, such that changing one has little, if any, influence on another. Physicians seem more discerning than the calls for change suggest.

Sex differences in extracellular and intracellular calcium-mediated vascular reactivity to vasopressin in rat aorta

In rat thoracic aorta, contractile responses to arginine vasopressin are two-fold higher in females than in males. To determine the roles of extracellular and intracellular Ca2+ in this sexual dimorphism in vascular function, vascular reactivity and Ca2+ channel function were examined in thoracic aortae of male and female rats. In the presence of diltiazem (10 microM), maximal contraction to vasopressin was reduced to a greater extent in male (65+/-2%) than in female aortae (38+/-1%). Maximal contractile responses to KCl and Bay K 8644 were similar in male and female aortae. Sensitivity to KCI was slightly but significantly higher in male than in female aorta; in contrast, sensitivity to Bay K 8644 was nearly three-fold higher in males than in females. Removal of the endothelium enhanced sensitivity to KCl similarly in male and female aortae. In the presence of simvastatin (60 microM; an inhibitor of intracellular Ca2+ release), reactivity to vasopressin was reduced substantially in female (42+/-1%) but unaltered in male aortae. Removal of the endothelium enhanced the inhibitory effect of simvastatin in both female (73+/-2%) and male aortae (41+/-2%). These findings demonstrate that male aortae depend more upon extracellular Ca2+ influx, whereas female aortae depend more upon intracellular Ca2+ release for vasopressin-induced contraction.

Enterovesical fistula presenting as life-threatening normal anion gap metabolic acidosis

Enterovesical fistula is a rare complication of a variety of inflammatory and neoplastic diseases. It usually presents with pneumaturia, fecaluria, urinary tract infections, or irritable bladder symptoms in the setting of either diverticulitis or malignancy. For the first time, we describe a patient with an enterovesical fistula who presented with a life-threatening normal anion gap metabolic acidosis. The direction of flow through the fistula, ie, bladder to intestine, was contingent on a spastic bladder and was responsible for the atypical presentation.

End of Life Issues in ESRD: A Study of Three Decision Variables That Affect Patient Attitudes

The substantial end-stage renal disease (ESRD) mortality rate reflects an older population, worsening comorbidity, and increased cardiovascular disease. Advance directives in ESRD may simplify issues such as cardiopulmonary resuscitation (CPR) and dialysis discontinuation. However, ESRD patients with advance directives may change their mind or allow surrogate leeway for override of end-of-life decisions. Three decision variables (requesting CPR, discontinuation of dialysis with depression, or discontinuation with dementia) were studied in 141 ESRD patients through a 47 item questionnaire. Duration of dialysis (> or = 4 years) (P = 0.002) and prior CPR experience (P = 0.02) increased the probability of refusing CPR by 12 times. The use of surrogates and substituted judgement for dialysis discontinuation with depression was more likely in women (P = 0.0006) and in patients with higher levels of education (P = 0.003). The odds of deciding to discontinue given dementia were three times greater for hemodialysis than peritoneal dialysis patients (P = 0.03). Eighty-three percent of the patients requested that physicians periodically check with them to determine if their advance directives had changed. The authors conclude that advance directives may assist ESRD patients, families, and staff with end-of-life decisions. Three end-of-life decision variables are significantly affected by duration and type of dialysis, previous CPR, gender, and level of education.

Acute Effects of Nifedipine on Renal Electrolyte Excretion in Normal and Hypertensive Subjects

ABSTRACT: The role of renal calcium handling in the hypotensive response to calcium channel blockers has not been investigated previously. The acute vasodilatory effect of calcium channel blockers may be accompanied by changes in renal electrolyte handling that are important in producing the hypotensive response seen with these agents. Nifedipine has been shown to cause acute and chronic natriuresis and diuresis, which are important in the ability to use nifedipine chronically in essential hypertension. We prospectively investigated the acute effect of 10 mg of nifedipine orally on renal cation handling in normotensive and untreated essential hypertensive subjects during a standard oral water load. At baseline there was no difference between normotensives and hypertensives in serum ionized calcium or magnesium, or in the urinary fractional excretion of these two cations. Oral nifedipine acutely increased the fractional excretion of sodium without changing the fractional excretion of calcium or magnesium. Nifedipine did not alter the serum concentrations of sodium, calcium, or magnesium. Augmented sodium excretion may play a role in the acute hypotensive response to oral nifedipine. The acute hypotensive response does not seem to be caused by altered renal handling of calcium or magnesium. Counterbalancing effects of nifedipine on proximal and distal nephron calcium handling may explain the disassociation of augmented sodium excretion and no net change in calcium excretion.