Rachel L. Perlman

Blood content of asymmetric dimethylarginine: new insights into its dysregulation in renal disease

BACKGROUND Plasma asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, is significantly elevated in patients with kidney disease and is a potential risk factor for cardiovascular disease. Here, we tested whether human whole blood (WB), as in rodent blood, can accumulate free ADMA and whether this accumulation is a function of disease burden. METHODS In 16 healthy control subjects (CO), 18 patients with ESRD and 18 matched hypertensive patients with normal renal function (HTN), we compared using high-pressure liquid chromatography baseline plasma and WB supernatant (WBSUP) ADMA and symmetrical dimethylarginine (SDMA) concentrations and accumulation during a 5-h incubation. We measured protein turnover in incubated WBSUP to determine if proteolytic processes drive ADMA accumulation. RESULTS Elevated plasma ADMA was confirmed in ESRD and HTN populations while basal WBSUP ADMA was significantly higher in ESRD subjects than controls (P = 0.05 versus CO; P = 0.02 versus HTN). Plasma SDMA followed a similar pattern. Incubation of WBSUP resulted in ADMA release from protein-incorporated stores while SDMA was unaffected. ADMA accumulation in ESRD samples was significantly greater than that in HTN (P = 0.03). CO and HTN men showed significantly greater ADMA accumulation than women (P = 0.01 and P = 0.003, respectively) but no gender difference was observed in the ESRD group (P = 0.26). ADMA accumulation correlated with ex vivo protein turnover (R = 0.76, P < 0.0001). CONCLUSIONS Human blood is capable of releasing physiologically significant quantities of ADMA via proteolytic pathways. Dysregulated ADMA release from WB reservoirs may contribute to the distinctly high plasma ADMA levels in ESRD populations.

The impact of facilitation of small-group discussions of psychosocial topics in medicine on faculty growth and development.

Purpose To use qualitative analysis of interview transcripts with clinician–educators who facilitate small-group discussions on psychosocial themes—including doctoring—to answer the question, “What impact does facilitating small-group discussions of the patient’s experience with chronic illness, the doctor–patient relationship, and doctoring have on faculty instructors’ attitudes regarding their roles as clinicians and teachers?” Method In 2006, in-depth, face-to-face interviews using an open-ended question format were conducted with individual faculty small-group instructors teaching in the Family Centered Experience and Longitudinal Case Studies courses at the University of Michigan Medical School. Interview transcripts were analyzed using grounded theory methodology to identify emerging themes. Accuracy of interpretations and saturation of themes was confirmed by repeated contextual reading of the transcripts. Results Several major thematic codes emerged from the data. Facilitation of small-group discussions of psychosocial topics and doctoring fostered reflective approaches to patient care and teaching; enhanced interpersonal relationships between facilitators and their students, colleagues, and patients; and acted as a source of fulfillment and renewal among faculty facilitators. Conclusions Small-group teaching of the art of doctoring may stimulate personal and professional growth among faculty facilitators and renewed interest in teaching and patient care.

Understanding the medical marriage: Physicians and their partners share strategies for success

Purpose Physicians and their spouses experience challenges to their relationships, some of which are shared with the general population and others of which are unique to the field of medicine. Trainees and junior faculty members remain curious about how they will balance their careers alongside marriage and family obligations. This study explores the challenges and strengths of dual- and single-physician relationships. Method In 2009, using appreciative inquiry as a theoretical framework, the authors conducted in-depth qualitative interviews with 25 individuals: 12 women and 13 men; 10 from dual-physician and 15 from single-physician relationships. A phenomenological analytic approach was used to arrive at the final themes. Results Four themes emerged during the interviews: “We rely on mutual support in our relationships,” “We recognize the important roles of each family member,” “We have shared values,” and “We acknowledge the benefit of being a physician to our relationships.” Conclusions These findings illustrate that physicians identify strategies to navigate the difficult aspects of their lives. Learn ing from others’ best practices can assist in managing personal relationships and work–life balance. These data can also be useful when counseling physicians on successful relationship strategies. As systems are developed that improve wellness and focus on role models for work–life balance, it will be important for this topic to be integrated into formal curricula across the continuum of medical education.

The interpretive project: a creative educational approach to fostering medical students’ reflections and advancing humanistic medicine

There are emerging links between reflection and humanistic, patient‐centered practice. We created the Family Centered Experience (FCE) to help students understand the experience of illness from the patient’s perspective. The FCE centers on students’ reflections of their conversations with their volunteer patients and families – these conversations and reflections are at the core of small group activities. The FCE Interpretive Project provides students with a chance to reflect on their volunteer’s illness experience. Students reflect on how the volunteer’s experience has influenced the way they understand the unique experience of illness and its impact on individuals, families and friends. Projects have included poems, songs, collages, paintings, quilts, sculptures, books, slide presentations, and games. By carrying forward into clerkships what they have learned from their patients and in their discussions, students are better equipped to handle the challenges of the hidden curriculum and to preserve the values of humanistic medicine espoused in the FCE.

Faculty reflections on the implementation of socio‐cultural eportfolio assessment tool

Electronic portfolios (eportfolios) are increasingly used to assess student development. The degree to which faculty in North American medical schools are confident in their ability to evaluate such materials and their perceptions of the utility of eportfolios are unclear. Thirteen medical educators developed skills necessary to critically assess students’ reflective essays. Qualitative methods were used to explore faculty experiences with a socio‐cultural eportfolio. Despite self‐perceptions of being novice users, faculty were willing to engage with the eportfolio and assume an unfamiliar role in guiding medical students’ personal reflections. Additionally, we uncovered unique faculty expectations regarding the quality of students’ essays and their thoughts about the utility of an eportfolio as an assessment tool. Our findings indicate that given adequate time and training, faculty will use an eportfolio. They believe it is an effective method for both longitudinal assessment of student learning and achieving curricular objectives. Our findings also illustrate the numerous unintended ethical challenges faculty encounter as they engage in student assessment.

Quality of life of older patients undergoing renal transplantation: finding the right immunosuppressive treatment.

Kidney transplantation is currently the best treatment for end-stage renal disease, both in terms of mortality benefit and quality of life (QOL). Elderly patients are a rapidly growing subset of the kidney transplant waiting list. While it is clear that elderly individuals have a mortality benefit from kidney transplant, it is less clear how to make sure these individuals benefit from optimal QOL following transplant. Several studies demonstrate superiority of some immunosuppressive regimens over others in the QOL domain. Tacrolimus has been shown to be associated with better QOL than cyclosporine (ciclosporin), as has corticosteroid-free immunosuppressive regimens. Similarly, patients on drug regimens, which tend to lessen the side effects, report better QOL. However, these studies are observational or cross-sectional and not focused exclusively on the elderly patient. More studies are needed to determine optimal immunosuppression regimens for elderly individuals. Additionally, further studies on determinants of QOL in elderly kidney transplant recipients are also needed.

A successful faculty development program for implementing a sociocultural ePortfolio assessment tool.

Portfolios are emerging as a tool for documenting learning progression and assessing competency. ePortfolios are appealing as a portable and fluid means of documenting both learning and relevant experiences in a large number of students. Competence and learning can be especially difficult to document in important aspects of education and training, such as patient-centeredness, the cultural context of disease, and social determinants of health that do not lend themselves to fact-based assessment methods. Successful implementation of a method such as an ePortfolio requires explicit faculty development, as many faculty members have limited expertise with modern educational assessment technology. As part of the authors’ introduction of a Sociocultural ePortfolio Assessment Tool in the undergraduate medical curriculum, three faculty development workshops were held to expand faculty skills in using this technology. In addition to gaining comfort using a new Web-based technology, faculty members also needed to develop skills with providing mentored feedback and stimulating student reflection. Workshops were modeled after other successful programs reported in the literature and allowed faculty to develop a structured format for evaluating student content. Faculty members were given multiple opportunities to practice their newly developed skills providing mentored reflections using an ePortfolio. The workshop evaluations were positive, suggesting that faculty participation in the workshops were a necessary component for them to develop sufficient assessment skills for providing mentored reflection. Faculty members who participated in this program—whether or not they had content expertise in sociocultural medicine—valued the hands-on faculty development program.

Syndrome of Inappropriate Antidiuretic Hormone in Association with Amiodarone Therapy: A Case Report and Review of Literature

Background: Amiodarone is a class III antiarrhythmic agent that is widely used in the treatment of a variety of arrhythmias. Several different systemic side effects are reported after use of this medication. In this article, we report a case that had developed syndrome of inappropriate antidiuretic hormone (SIADH) after starting treatment with this agent. Case report: The patient is a 66-year-old male with past medical history of hypertension, hyperlipidemia, coronary artery disease, and class III New York Heart Association congestive heart failure who presented with monomorphic nonsustained ventricular tachycardia. A loading dose of amiodarone followed by maintenance dose was started. Baseline serum sodium of 138 mmol/L on admission decreased to 119 mmol/L by day 7, and a diagnosis of SIADH was made. The patient was not taking any other medication known to cause SIADH, nor had any such comorbidity to explain it. Serum sodium increased to 133 and 138 mmol/L, respectively, after 16 and 33 days from discontinuation of amiodarone. Conclusion: SIADH is a rare but serious side effect of amiodarone and practicing physicians should be aware of this complication, particularly after loading dose of the medication.

Outcomes of an Erythropoietic Growth Factor Interchange Program in Hospitalized Chronic Hemodialysis Patients

Background The substantial cost of erythropoietic growth factors (EGFs), darbepoetin alfa and epoetin alfa, has led many institutions to evaluate EGF usage and costs in the hospital setting. The primary objectives of this study were to determine the clinical impact on hemoglobin (Hb) concentration, postdischarge epoetin alfa dose requirements, and the economic impact of a darbepoetin alfa for epoetin alfa therapeutic interchange program in hospitalized hemodialysis patients. Methods A retrospective review was conducted in 79 patients (43 during a control period and 36 during the interchange period). The control group consisted of chronic hemodialysis patients admitted to the hospital before the therapeutic interchange program was implemented (September 2002 through September 2003); the interchange group included patients admitted after implementation of the interchange program (October 2003 through October 2004). Clinical parameters including Hb concentration, concomitant iron therapy, packed red blood cell (PRBC) transfusions, EGF dose and cost were collected beginning 2 months prior to hospitalization, during hospitalization, through 2 months post hospital discharge. Results No differences were observed between groups in baseline demographics. There was a greater decrease in Hb concentration in the control group compared to the interchange group, but this did not achieve statistical significance (0.5 g/dL vs 0.3 g/dL, respectively; P = 0.67). EGF dose requirements did not differ between the two groups, nor did the total EGF cost per patient admission before and after hospitalization. Total cost per patient during hospitalization was

Having It All: Medicine and a Family

164 ± 144 in the control group and