Gail Morrison

Risk factors and outcome of hospital-acquired acute renal failure: Clinical epidemiologic study:

In order to evaluate potential risk factors for the development of hospital-acquired acute renal failure, a case-control study was performed, comparing patients with hospital-acquired acute renal failure with control subjects matched on age, sex, hospital, service of admission, and baseline renal function. The same patients were then reanalyzed utilizing a cohort study design to investigate outcomes from this syndrome. The following elevated odds ratios (95 percent confidence interval) were found while simultaneously adjusting for possible confounding variables using logistic regression: volume depletion, 9.4 (2.1 to 42.8); aminoglycoside use, 5.6 (1.3 to 23.7); congestive heart failure 9.0 (2.1 to 38.9); radiocontrast exposure, 4.9 (1.2 to 19.7); and septic shock, approached infinity, p less than 0.0001. The effect of volume depletion was markedly accentuated in those with diabetes (odds ratio = 1.9) (p less than 0.05). The risk from aminoglycoside use markedly increased with increasing age (p less than 0.002). Finally, the development of hospital-acquired acute renal failure was associated with a marked increase in the risk of dying--the relative risk (95 percent confidence interval) was 6.2 (2.6 to 14.9)--and a marked increase in length of stay, from a median of 13 days in control subjects to a median of 23 days in case subjects (p = 0.005). In conclusion, hospital-acquired acute renal failure is a serious illness. Attempts to prevent it should focus on proved risk factors.

Superiority of demeclocycline over lithium in the treatment of chronic syndrome of inappropriate secretion of antidiuretic hormone.

We evaluated demeclocycline and lithium therapy in 10 patients with the syndrome of inappropriate secretion of antidiuretic hormone. Despite severe water restriction, all patients had hyponatremia (mean +/- S.E.M. serum sodium of 122 +/- 1.1 meq per liter) and elevated urine osmolality (744 +/- 59 mOsm per kilogram) before treatment. Demeclocycline (600 to 1200 mg daily) restored serum sodium concentration to 139 +/- 1.1 meq per liter within five to 14 days, permitting unrestricted water intake in all patients. In three patients given lithium carbonate (900 mg daily) the serum sodium concentration, urine osmolality and urine volume were unchanged; since two patients had adverse central-nervous-system symptoms during lithium therapy, further study of this agent was abandoned. A patient with an unusual 22-year history of the syndrome was unresponsive to lithium, whereas long-term treatment with demeclocyline was markedly effective. Demeclocycline is superior to lithium in the treatment of the syndrome and may obviate the need for severe water restriction.

Drug Therapy in Renal Failure: Dosing Guidelines for Adults: Part I: Antimicrobial Agents, Analgesics

Data are presented in tabular form that provide guidelines for drug use in adult patients with renal insufficiency. The data are derived from the current medical literature. If specific information about a drug is unavailable or conflicting, emphasis is given to normal pharmacokinetic variables in arriving at recommendations for therapy. Nephrotoxicity or adverse effects in patients with renal disease are noted and adjustments for dialysis suggested.

Team Training of Medical Students in the 21st Century: Would Flexner Approve?

As the 100-year anniversary of the Flexner Report approaches us, the physician workforce in the 21st century faces a radically different health care environment. To function effectively in this environment, future physicians, including medical students, will need educational programs that incorporate the theory and practice of teams and teamwork. Medical school graduates will be expected to understand how teams function and be capable themselves of functioning in a team. They will need to be competent in the knowledge, skills, and attitudes of teams and teamwork. Numerous reports during the past 10 years from national oversight and safety institutes and agencies have supported the need for team training in the health care environment, especially as a means to decrease errors and increase patient safety. Hospital training programs have begun implementing interdisciplinary team training around high-risk scenarios for their trainees and staff. However, for most medical schools, competence in team training has not been an instructional objective of educating medical students. Most instruction has been individual learning (i.e., lectures) or group learning (i.e., team-based or problem-based learning) even though there is strong evidence for team learning to be effective. With the ongoing changes in health care, it is argued that Flexner would concur that team training is necessary for medical students.

Drug Therapy in Renal Failure: Dosing Guidelines for Adults: Part II: Sedatives, Hypnotics, and Tranquilizers; Cardiovascular, Antihypertensive, and Diuretic Agents; Miscellaneous Agents

Data providing guidelines for drug use in adult patients with renal insufficiency are presented in tabular form with supporting references. The data are derived from the current medical literature. If specific information about a drug is unavailable or conflicting, emphasis is given to normal pharmacokinetic variables in arriving at recommendations for therapy. Nephrotoxicity or adverse effects in patients with renal disease are noted and adjustments for dialysis suggested.

Evaluation of a National Curriculum Reform Effort for the Medicine Core Clerkship

BACKGROUND: In 1995, the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM) developed and disseminated a new model curriculum for the medicine core clerkship that was designed to enhance learning of generalist competencies and increase interest in general internal medicine.OBJECTIVE: To evaluate the dissemination and use of the resulting SGIM/CDIM Core Medicine Clerkship Curriculum Guide.DESIGN: Survey of internal medicine clerkship directors at the 125 medical schools in the United States.MEASUREMENTS AND MAIN RESULTS: The questionnaire elicited information about the use and usefulness of the Guide and each of its components, barriers to effective use of the Guide, and outcomes associated with use of the Guide. Responses were received from 95 clerkship directors, representing 88 (70%) of the 125 medical schools. Eighty-seven (92%) of the 95 respondents were familiar with the Guide, and 80 respondents had used it. The 4 components used most frequently were the basic generalist competencies (used by 83% of those familiar with the Guide), learning objectives for these competencies (used by 83%), learning objectives for training problems (used by 70%), and specific training problems (used by 67%); 74% to 85% of those using these components found them moderately or very useful. The most frequently identified barriers to use of the Guide were insufficient faculty time, insufficient number of ambulatory care preceptors and training sites, and need for more faculty development. About 30% or more of those familiar with the Guide reported that use of the Guide was associated with improved ability to meet clerkship accreditation criteria, improved performance of students on the clerkship exam, and increased clerkship time devoted to ambulatory care.CONCLUSION: This federally supported initiative that engaged the collaborative efforts of the SGIM and the CDIM was successful in facilitating significant changes in the medicine core clerkship across the United States.

Medical Student Performance Evaluations in 2005: An Improvement Over the Former Dean's Letter?

Purpose To collect information regarding preparation, content, and format of Medical Student Performance Evaluations (MSPEs) and evaluate a sample of 2005 MSPEs to assess compliance with the 2002 Association of American Medical Colleges-issued MSPE guidelines. Method Cross-sectional survey with all 126 U.S. allopathic medical schools. Associate deans of students affairs were sent an eight-item questionnaire in June 2006 and asked to submit a sample of redacted MSPEs for 2005 graduates, choosing one from each tertile of the class. Survey data are summarized. MSPEs were abstracted, and results are presented descriptively. Results The survey response rate was 84%. Most associate deans (71%) reported having primary responsibility for composing MSPEs; 78% adhered to the format and content guidelines three fourths of the time. The abstraction of 293 MSPEs (78%) showed that more than 80% adhered to format recommendations. However, only 70% to 80% stated grades clearly, avoided the word recommendation, and stated whether the student had completed remediation. Fewer than 70% indicated whether the student had had any adverse actions or provided adequate comparative data. Strikingly, only 17% provide comparative data in the summary paragraph. Overall, 75% of the MSPEs were judged to be “adequate.” Conclusions MSPEs are somewhat variable in terms of which specific items are included. There has been steady quality improvement since prior surveys, primarily in formatting and labeling. However, a sizable minority of writers are still using the MSPE as a recommendation, and too few are providing helpful comparative data.

Oxaprozin disposition in renal disease

Effects of renal disease on the disposition kinetics of oxaprozin, a nonsteroidal antiinflammatory analgesic, were assessed in 15 subjects who were normal, renally impaired, or who had been undergoing hemodialysis. Oral dose clearance (Cloral), volume of distribution at steady‐state (Vssd), and elimination half‐life (tl/2) did not substantially differ among the three groups. Mean fraction unbound oxaprozin in plasma (fup) increased from 0.08% in the normal group to 0.18% and 0.28% in the two azotemic groups. Consequently, unbound drug kinetic parameters, including intrinsic clearance (Clint) and Vssdu of unbound drug were reduced from 2.9 l/hr/kg and 193 l/kg in normal subjects to approximately 1.6 l/hr/kg and 91 l/kg in azotemic patients. The smaller volume of distribution is consistent with a decrease in oxaprozin tissue binding in azotemia. The decreased plasma and tissue binding and lower Clint suggest that, in the treatment of azotemic patients with rheumatoid arthritis, the dose of oxaprozin should begin at 600 mg once a day.

Development of a case-based integrated nutrition curriculum for medical students

The Nutrition Education and Prevention Program at the University of Pennsylvania School of Medicine is a successful program that can be used as a model for the development and implementation of a case-based nutrition curriculum across the 4-y medical school experience. This article gives a broad overview of the development, implementation, evaluation, and dissemination processes used by the Nutrition Education and Prevention Program administration and core faculty group at the University of Pennsylvania School of Medicine. Beginning in 1990, the nutrition curriculum was initiated with the assistance of several funding sources. The program was structured using a multidisciplinary faculty group of physicians and registered dietitians from multiple departments, centers, and institutes. The outcome of this process is a textbook, Medical Nutrition and Disease, currently required by numerous medical schools, residency programs, and other health professional programs across the nation. With the use of data from the Association of American Medical Colleges All Schools Survey of Graduating Medical Students, perceptions of the adequacy of nutrition education were tracked over time. In 1991, 80% of University of Pennsylvania medical students felt that nutrition coverage was inadequate compared with 10% of medical students in 1998, a significant change resulting from the nutrition programs effect. The University of Pennsylvania School of Medicine has developed and implemented a successful nutrition curriculum, despite national trends. The case-based integrated curricular model presented in Medical Nutrition and Disease and on our Web site, www.med.upenn.edu/nutrimed, can be used by medical institutions and other health professionals.

The 3-Year Medical School — Change or Shortchange?

Shortening medical school to 3 years, some observers argue, would increase the supply of physicians and reduce the cost of medical training. Data from many years of experiments in shortening medical education, however, suggest that doing so is unwise.