Steven J. Peitzman

Spontaneous Hypoglycemia in End-Stage Renal Failure

Five men with end-stage renal failure had spontaneous hypoglycemia during lengthy hospitalizations. Four were cachectic, and all five had weight loss and poor caloric intake. Malnutrition were seen also in some of the ten previous case reports of hypoglycemia in renal failure. Impaired renal gluconeogenesis may allow hypoglycemia in such patients.

Creation and assessment of a structured review course in physical diagnosis for medical residents

AbstractObjective: To evaluate the effects of a course in physical diagnosis on the knowledge, skills, and attitudes of internal medicine trainees. Design: A controlled, prospective assignment of housestaff to a yearlong curricular program, linked to a set of pre- and posttests. House-officers who could not attend the teaching sessions functioned as control subjects. Setting: An internal medicine training program at an urban medical school. Subjects: 56 (86.1%) of 65 eligible internal medicine housestaff (postgraduate years 1 through 3) participated in the intervention and assessment. A comparison group of 14 senior medical students participated in the pretest. Intervention: 12 monthly lectures emphasizing skills useful in emergencies or validated by the literature. Measurements: The pre- and posttests included: 1) a multiple-choice questionnaire to assess knowledge; 2) professional standardized patients to assess selected skills; and 3) Likert-type questionnaires to assess self-motivated learning and attitude toward diagnosis not based on technology. Main results: The residents expressed interest in the program and on a six-point scale rated the usefulness of lectures and standardized patients as 3.5±1.3 and 4.3±1, respectively. For no system tested, however, did they achieve more than 55.2% correct answers (range: 24.2%–55.2%, median =41.04), and their performance did not differ from that of the fourth-year medical students. There was no significant difference in pre/posttest improvement between the control and intervention groups. Conclusions: These data confirm the deficiencies of physical diagnostic skills and knowledge among physicians in training. These deficiencies were not corrected by the classroom lecture series. Improvement in these skills may require a more intense experiential program made part of residency requirements.

Comparison of "Fact-Recall" with "Higher-Order" Questions in Multiple-Choice Examinations as Predictors of Clinical Performance of Medical Students.

No abstract available.

Chronic Dialysis and Dialysis Doctors in the United States: A Nephrologist-Historian's Perspective

In an earlier article in Seminars in Dialysis (9:276–281, 1996), the author described the invention of clinical hemodialysis for acute renal failure and its initially equivocal reception by the emerging specialty of nephrology in the United States. A similar story of blunted enthusiasm played out following the invention of the Quinton–Scribner shunt (whose idea “came in the night”), which allowed maintenance treatment for chronic renal failure. Few centers at first could match Belding Scribners early successes, and some physiology‐oriented university nephrologists envisioned how routine dialysis might swamp other activities. Nonetheless, increasingly complex and successful inventions appeared and prevailed: the chronic dialysis unit, the national dialysis chain. A unique federal entitlement program fostered the spread of maintenance dialysis, but so did the emergence of disposable off‐the‐shelf supplies and many new nephrologists trained in academia but seeking positions in practice. Indeed, the spread of end‐stage renal disease (ESRD) care transformed American nephrology. The essay concludes by considering what nephrologists of the ESRD era share with their patients.

Performance in physical examination on the USMLE Step 2 Clinical Skills examination.

Purpose To provide descriptive information about history-taking (HX) and physical examination (PE) performance for U.S. medical students as documented by standardized patients (SPs) during the Step 2 Clinical Skills (CS) component of the United States Medical Licensing Examination. The authors examined two hypotheses: (1) Students perform worse in PE compared with HX, and (2) for PE, students perform worse in the musculoskeletal system and neurology compared with other clinical domains. Method The sample included 121,767 student–SP encounters based on 29,442 examinees from U.S. medical schools who took Step 2 CS for the first time in 2011. The encounters comprised 107 clinical presentations, each categorized into one of five clinical domains: cardiovascular, gastrointestinal, musculoskeletal, neurological, and respiratory. The authors compared mean percent-correct scores for HX and PE via a one-tailed paired-samples t test and examined mean score differences by clinical domain using analysis of variance techniques. Results Average PE scores (59.6%) were significantly lower than average HX scores (78.1%). The range of scores for PE (51.4%–72.7%) was larger than for HX (74.4%–81.0%), and the standard deviation for PE scores (28.3) was twice as large as the HX standard deviation (14.7). PE performance was significantly weaker for musculoskeletal and neurological encounters compared with other encounters. Conclusions U.S. medical students perform worse on PE than HX; PE performance was weakest in musculoskeletal and neurology clinical domains. Findings may reflect imbalances in U.S. medical education, but more research is needed to fully understand the relationships among PE instruction, assessment, and proficiency.

Science, Inventors, and the Introduction of the Artificial Kidney in the United States

Dialysis was a largely European invention induced by the new awareness of the reversible acute renal failure syndrome (1, 2, 3, 4). Sporadic attempts at clinical dialysis occurred in the 1920s, but those that proved fruitful began in the 1940s, when war and sulfa drugs made cases of sudden renal shutdown plentiful. Four indviduals or groups , working almost simultaneously, rightly may claim credit: Nils Alwall in Sweden, Willem Kolff in the Netherlands, Gordon Murray in Canada, and Leonard Skeggs and Jack Leonards in the United States (Cleveland). Simultaneous invention is a common phenomenon: early American examples include the steamboat and the telegraph (5). Such a concurrence suggests that a need is apparent, and that some set of conditions has appeared to meet the need. For hemodialysis in the 1940% two necessary elements had surfaced in the previous decades: a cheap semi-permeable membrane, cellophane; and heparin, an effective and reasonably safe anticoagulant.

Ticrynafen and probenecid in hyperuricemic, hypertensive men

In a double‐blind crossover study of ticrynafen (TCN) and probenecid (PBC), 9 hypertensive, hyperuricemic men completed 12‐wk courses of each drug. With a TCN dose of 125 mg daily, the fall in serum uric acid was prompt, dramatic, and lasting; it was equal to that after PBC, 500 or 1,000 mg daily. There was a small but significant early weight loss (diuresis) after TCN but no antihypertensive effect. Twelve days after resuming TCN for a proposed additional extension study 1 patient suffered acute, reversible bilateral ureteral obstruction, probably caused by sudden urinary uric acid precipitation.

Medical Students’ Assessment of Eduard Pernkopf’s Atlas: Topographical Anatomy of Man

INTRODUCTION To date, there has been no study examining the perceptions of first-year medical students regarding Eduard Pernkopfs atlas, particularly during their study of gross anatomy and prior to coursework in medical ethics. We present a discussion of Pernkopfs Atlas: Topographical Anatomy of Man from the perspective of U.S. medical students, and sought to determine whether medical students view Pernkopfs Topographical Anatomy of Man as a resource of greater accuracy, detail, and potential educational utility as compared to Netters Atlas of Human Anatomy. METHODS The entire first-year class at Drexel University College of Medicine (265 students) was surveyed at approximately the midpoint of their gross anatomy course and 192 responses were collected (72% response rate). RESULTS Of these, 176 (95%) were unaware of the existence of Pernkopfs atlas. Another 71% of students found the Pernkopf atlas more likely complete and accurate, whereas 76% thought the Netter atlas more useful for learning (p<.001). When presented with a hypothetical scenario in which the subjects used in creating Pernkopfs atlas were donated, or unclaimed, but with knowledge that Pernkopf was an active member of the Nazi party, 133 students (72%) retained their original position (p=.001). About 94% desired discussion of Pernkopf within a medical school bioethics course. The relationship between level of self-reported knowledge and whether or not students would advocate removal of the atlas was statistically significant (p=.013). CONCLUSION Discussing ethical violations in medical history, especially the Pernkopf atlas, must attain a secure place in medical school curricula, and more specifically, within a bioethics course.

Care of Elderly Patients in a Special Hypertension Clinic

In a special hypertension clinic, 35 hypertensive elderly men (mean age, 72 years) and 29 hypertensive younger men (mean age, 45 years) were studied. In the clinic, nurse‐clinicians evaluated and treated the patients under physician supervision, and compared the findings in the two groups. The same success in blood pressure control was achieved in both groups. Syncope or serious dizziness was uncommon in either group. A slight rise in the serum creatinine level over time was observed in both the older and the younger patients, but was greater in the elderly (mean increment 0.27 mg/dl, elderly; 0.096 mg/dl, younger). Compliances with medication schedules (diuretics, or a diuretic and methyldopa) were equally good in the two groups. The rates of required clinic visits were the same, but the elderly had a better attendance record. It is concluded that the treatment of elderly hypertensive patients is feasible and may be carried out in a focused “hypertension clinic.” Including older persons in such programs can be expected to result in their protection from cardiovascular complications, as well as other indirect health benefits.

From Bright’s Disease to Chronic Kidney Disease

In the 1820s and 1830s, Richard Bright of Guy’s Hospital in London showed that dropsy (edema) when associated with heat-coagulable urine (albuminuria) predicted one or another form of pathologically altered kidneys at autopsy. His first cases were of hospitalized patients, but he later recognized and described indolent cases, what we would call chronic disease. Subsequent pathologists created classification schemes for chronic renal disease. In the late 19th century, a movement called “functional diagnosis” turned attention to the kidney’s “power” in health and disease, using tests of excretion and concentration. Here arose terms such as “chronic renal failure” which persisted into the 1990s. The notion of renal “work” led to attempts to “rest” the presumably overworking nephrons of impaired kidneys with the low-protein diet. Key figures were Thomas Addis in the period 1920s–1940s, and Barry Brenner in the later decades of the 20th century. Meanwhile, clinicians identified various causes of chronic kidney disease, only in recent decades including diabetes. Treatment from Bright’s time onward aimed at reducing symptoms, such as edema, until concepts of hyper-filtration and injurious effects of proteinuria prompted therapies (beyond diet) aimed at slowing progression. With a sense that the course of chronic renal disease if identified early might be favorably influenced (particularly by inhibition of the renal-angiotensin-aldosterone axis), nephrologists in the United States and elsewhere through their organizations effected changes in nomenclature (e.g. “kidney” not “renal”) and other measures to de-mystify and raise awareness of kidney disease. The hope was that earlier detection might allow interventions to slow progression and thus avoid or delay the need for renal replacement therapy.