Gregory W. Rutecki

The Influence of Controllable Lifestyle and Sex on the Specialty Choices of Graduating U.s. Medical Students, 1996–2003

Purpose To determine whether the preferences of female medical students are sufficient to explain the recent trend of U.S. medical students choosing specialties with controllable lifestyles. Method Specialty choice for graduating U.S. medical students by sex was determined from the responses to the Association of American Medical Colleges’ 1996–2003 Medical School Graduation Questionnaires. Using earlier research, specialties were classified as having an uncontrollable or controllable lifestyle. Log-linear models were constructed to assess the strength of association among trends in specialty choice, controllable lifestyle, and sex. Results The percentage of women choosing specialties with controllable lifestyles increased from 18% in 1996 to 36% in 2003. For men, the percentage grew from 28% to 45%. The change in preference for controllable lifestyle specialties accounted for a large proportion of the variability in specialty choices for both women and men from 1996–2003 (&khgr;2 for changes common to women and men = 920, 1 df, p < .0001). The difference between women and men in the trend toward controllable lifestyle specialties was small relative to the common changes (&khgr;2for differences = 12, 1 df, p = .0005). Conclusion Controllable lifestyle was strongly associated with the recent trends in specialty choice for both women and men and could not be explained solely by the specialty preferences of women.

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.

Chronic lymphocytic leukemia–associated membranous glomerulopathy: Remission with fludarabine

In some individuals, chronic lymphocytic leukemia (CLL) may be associated with glomerular disease from membranous nephropathy with resultant nephrotic syndrome. CLL is characterized by abnormal immunoregulation with a malignant clonal proliferation of lymphocytes. The association between the abnormal clone and nephrotic syndrome is suggested in some cases by the remission of proteinuria with a reduction in abnormal lymphocyte number after treatment with antineoplastic agents. For the first time, we describe a patient with CLL and associated membranous glomerulopathy whose nephrotic syndrome remitted after treatment with fludarabine, a new purine analogue used in the treatment of refractory CLL.

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...

Reversible acute renal failure as an atypical presentation of ischemic nephropathy

Ischemic nephropathy (IN) is defined as a clinically significant reduction in glomerular filtration rate in patients with hemodynamically significant obstruction to renal artery flow in a solitary functioning kidney or with bilateral renal artery stenosis (RAS). Ischemic nephropathy typically has a subacute to chronic course that may lead to end-stage renal disease. Acute anuric renal failure, which occurs less commonly with IN, is usually associated with moderately severe hypertension and has been attributed to certain risk factors: angiotensin-converting enzyme inhibition, a reduction in blood pressure secondary to antihypertensives or volume contraction, and exposure to contrast media. We present a series of six patients with IN and acute, anuric renal failure without either moderately severe hypertension or the previously defined risk factors. Of these six patients, four had RAS in a solitary kidney and two were found by ultrasound to have disparity in kidney size and bilateral RAS. Within 1 week of surgery, three patients developed renal failure that did not involve the kidney(s) responsible for the anuria and thus mimicked postoperative acute renal failure. Creatinine levels pre-anuria (1.2 to 2.1 mg/dL), during renal failure (5.0 to 12.8 mg/dL), and postrecovery (1.6 to 2.8 mg/dL) showed recovery of renal function, with renal artery bypass in four patients (sustained at 1 year). Two patients refused surgery and are on chronic dialysis. Acute renal failure in IN may occur postoperatively or spontaneously, and emergent intervention (ultrasound, angiography, angioplasty, and/or surgery) in this setting may lead to the correction of RAS and preservation of renal function.

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.

A Subtherapeutic International Normalized Ratio Despite Increasing Doses of Warfarin: Could This Be Malabsorption?

OBJECTIVE To describe a case of warfarin resistance apparently caused by malabsorption and to review the literature regarding warfarin resistance. CASE SUMMARY A 28-year-old renal transplant patient with systemic lupus erythematosus was admitted for upper extremity thrombophlebitis. Resistance to oral warfarin was demonstrated. Potential causes were investigated. The trapezoidal rule was used to compare the area under the curve for intravenous versus oral dosing of warfarin. The usual bioavailability of warfarin should be 100%. In this patient, warfarin bioavailability after oral dosing was 1.5%. Three potential causes, malabsorption (FF), enzymatic degradation (FG), and first-pass extraction in the portal circulation (FH), are discussed. CONCLUSION This case demonstrates resistance to warfarin presumably caused by malabsorption.

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.