Tom A. Hutchinson

Predicting Survival in Adults with End-Stage Renal Disease: An Age Equivalence Index

To quantify prognosis in patients with end-stage renal disease, we evaluated pretreatment clinical state and ascertained the outcome of all 220 patients who began therapy at two hospitals from 1970 to 1975. Each of three pretreatment characteristics made a statistically significant independent contribution to the relative risk of death: age (relative risk for 10-year increments = 2.2, p less than 0.001); duration of diabetes (relative risk for 10-year increments = 2.2, p less than 0.001); and left-sided heart failure (relative risk = 2.0, p less than 0.001). We combined the effects of these factors in an age-equivalence index that showed a strong gradient in survival rates from lower to higher values; the 5-year survival rate differed between 92% in patients with a score of 30 or less and 6% in patients with a score over 70. This index, which is simple to use, should prove helpful in patient care and can improve the scientific validity of therapeutic comparisons in patients with end-stage renal disease by identifying and adjusting for the selection biases that occur in the allocation of different treatments.

Frequency, severity and risk factors for adverse drug reactions in adult out-patients: A prospective study

To provide information on the frequency of adverse drug reactions in ambulatory patients we used intensive telephone surveillance to detect suspected reactions in 1026 patients seen at an internal medicine group practice over a 1-year period. Two hundred and ninety-two suspected reactions were detected. The majority of suspected reactions were mild, causing predominantly worry or discomfort. We used a published algorithm to assess the suspected reactions for drug causation with the following results: 40 (14%) unlikely; 193 (66%) possible; 56 (19%) probable; and 3 (1%) definite. The rate of probable or definite reactions was 49/1026 (5%) per patient and 58/3330 (2%) per drug course. Surprisingly, neither the age of the patient nor the number of other drugs he was taking modified the risk of a reaction to an individual newly-started drug. Our data suggest that fear of adverse reaction should not usually be a major factor in therapeutic decision making for an ambulatory patient even when the patient is old or already on multiple drugs.

Teaching mindfulness in medical school: where are we now and where are we going?

Mindfulness has the potential to prevent compassion fatigue and burnout in that the doctor who is self‐aware is more likely to engage in self‐care activities and to manage stress better. Moreover, well doctors are better equipped to foster wellness in their patients. Teaching mindfulness in medical school is gaining momentum; we examined the literature and related websites to determine the extent to which this work is carried out with medical students and residents.

Adverse drug reactions in general pediatric outpatients

We used a recently developed diagnostic adverse drug reaction (ADR) algorithm and an intensive telephone surveillance program to monitor all courses of prescription and nonprescription drug therapy in a general pediatric group practice for 1 year. A total of 3181 different children visited the practice during the year and received 4244 separate courses of drug therapy. Adverse symptoms were noted in 473 (11.1%) of these courses of therapy. Of 534 total adverse symptoms, however, only 24 scored as definite and 176 as probable ADRs. The main ADRs noted were antibiotic-associated gastrointestinal complaints and rashes, and various manifestations of CNS stimulation with bronchodilators. Sociodemographic variables significantly associated with the risk of a definite or probable ADR were socioeconomic status (P less than 0.0001), ethnic origin (P = 0.0015), and age (P less than 0.05). Treatment-related risk factors included treatment by a practitioner outside the study practice (usually during nonoffice hours) (P less than 0.001) and administration of a dosage above the range recommended by the manufacturer (P less than 0.001). Half the ADRs were judged as inconsequential by the childrens parents, and most of the remainder resulted in only minor morbidity. Half were judged to be highly or probably preventable. Our results suggest that ADRs do not occur commonly in general pediatric outpatients and that most are mild and self-limited.

Hyperapobetalipoproteinemia: the major dyslipoproteinemia in patients with chronic renal failure treated with chronic ambulatory peritoneal dialysis

In the present study, plasma cholesterol, triglyceride, low density lipoprotein (LDL)-cholesterol, high density lipoprotein (HDL)-cholesterol, and the major protein in LDL, apoB, were measured in 28 patients with chronic renal failure treated with hemodialysis and in 28 patients with chronic renal failure treated with chronic ambulatory peritoneal dialysis (CAPD). Elevated plasma triglycerides and reduced HDL cholesterol were frequent in both the hemodialysis and CAPD patients. However LDL levels were significantly higher in the CAPD patients as evident both by LDL cholesterol and LDL apoB. Even so, only one of the CAPD patients was hypercholesterolemic whereas 14 (or 50%) had hyperapobetalipoproteinemia (HyperapoB). Insulin-dependent diabetes was more frequent in the CAPD group but only 2 of the 9 insulin-dependent diabetics in this group had HyperapoB, and therefore, diabetes mellitus cannot account for the difference between the 2 groups. Thus HyperapoB appears to be a prevalent dyslipoproteinemia in CAPD patients and as such might be another factor which places CAPD patients at particularly increased risk of atherosclerosis.

Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice.

Recent calls for an expanded perspective on medical education and training include focusing on complexities of professional identity formation (PIF). Medical educators are challenged to facilitate the active constructive, integrative developmental process of PIF within standardized and personalized and/or formal and informal curricular approaches. How can we best support the complex iterative PIF process for a humanistic, resilient health care professional? How can we effectively scaffold the necessary critical reflective learning and practice skill set for our learners to support the shaping of a professional identity? The authors present three pedagogic innovations contributing to the PIF process within undergraduate and graduate medical education (GME) at their institutions. These are (1) interactive reflective writing fostering reflective capacity, emotional awareness, and resiliency (as complexities within physician–patient interactions are explored) for personal and professional development; (2) synergistic teaching modules about mindful clinical practice and resilient responses to difficult interactions, to foster clinician resilience and enhanced well-being for effective professional functioning; and (3) strategies for effective use of a professional development e-portfolio and faculty development of reflective coaching skills in GME. These strategies as “bridges from theory to practice” embody and integrate key elements of promoting and enriching PIF, including guided reflection, the significant role of relationships (faculty and peers), mindfulness, adequate feedback, and creating collaborative learning environments. Ideally, such pedagogic innovations can make a significant contribution toward enhancing quality of care and caring with resilience for the being, relating, and doing of a humanistic health care professional.

Reasons for disagreement in the standardized assessment of suspected adverse drug reactions.

Clinical Pharmacology and Therapeutics (1983) 34, 421–426; doi:10.1038/clpt.1983.192

Left ventricular hypertrophy in end-stage renal disease on peritoneal dialysis

Abstract Cardiovascular diseases account for the greatest number of deaths among uremic patients.1,2 Most attention has focused on atherosclerosis, with opinion divided as to whether it is accelerated by uremia.3,4 Although a “uremic dilated cardiomyopathy” has been reported, its cause and prevalence remain obscure.5 In contrast, concentric left ventricular (LV) hypertrophy is known to occur more often in patients treated with dialysis, although apparently little attention has been paid to its possible clinical significance.6,7 This report was designed to (1) determine the prevalence of LV hypertrophy in patients treated with dialysis, (2) examine the clinical factors that may be responsible for its presence, and (3) determine whether LV hypertrophy was associated with increased mortality. Because blood pressure (BP) is likely to be involved in the pathogenesis of LV hypertrophy, the study was conducted in patients treated with continuous ambulatory peritoneal dialysis because such patients are free of the marked swings in BP that frequently accompany the relatively rapid intravascular volume changes with hemodialysis, and accurate tracking of BP is therefore possible.

Whole person care: encompassing the two faces of medicine

“I would go without shirt or shoe Friend, tobacco or bread, Sooner than lose for a minute the two Separate sides of my head!” — Rudyard Kipling, The Two-Sided Man ![Figure][1] FIGURE. Janus, the Roman god of doorways, looks in 2 directions.

Transplantation versus Dialysis in Diabetic Patients With Renal Failure

Studies suggesting that transplantation is better than dialysis for diabetic patients with renal failure may be biased by the more favorable pretreatment prognosis of transplanted patients. Therefore, to provide a fairer comparison we controlled for pretreatment clinical state, categorized treatment received, and assessed mortality, major morbid events, and hospitalization in 51 diabetic patients who began therapy between 1970 and 1980. Fourteen patients were treated by transplantation and 37 by dialysis. The mean waiting period for transplantation was 5 months. The average age of transplanted patients was 40.9 years and of dialyzed patients 59.6 years. When we controlled for this age disparity and other factors (duration of diabetes and heart failure) that affect prognosis in end-stage renal disease (ESRD), the mortality with both transplantation and dialysis was similar to that expected from the overall mortality rate of the 51 study patients. Treatment received had no effect on mortality; the observed deaths compared with deaths expected from pretreatment status were 8 and 7.3 for transplantation and 30 and 30.7 for dialysis. We also compared major morbid events (blindness, amputation, stroke, severe heart failure, and myocardial infarction) and hospitalization in transplanted patients with the 24 dialyzed patients who survived long enough (5 months) to be eligible for transplantation. The number of major morbid events was 2.7 per 10 patient-years in the transplanted group and 3.4 in the dialyzed group. Hospitalization was 151.3 d/yr in transplanted patients and 55.6 d/yr in dialyzed patients (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)