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Job burnout is highly prevalent in graduate medical trainees. Numerous demands and stressors drive the development of burnout in this population, leading to significant and potentially tragic consequences, not only for trainees but also for the patients and communities they serve. The literature on interventions to reduce resident burnout is limited but suggests that both individual- and system-level approaches are effective. Work hours limitations and mindfulness training are each likely to have modest benefit. Despite concerns that physician trainee wellness programs might be costly, attention to physician wellness may lead to important benefits such as greater patient satisfaction, long-term physician satisfaction, and increased physician productivity. A collaborative of medical educators, academic leaders, and researchers recently formed with the goal of improving trainee well-being and mitigating burnout. Its first task is outlining this framework of initial recommendations in a call to action. These recommendations are made at the national, hospital, program, and nonwork levels and are meant to inform stakeholders who have taken up the charge to address trainee well-being. Regulatory bodies and health care systems need to be accountable for the well-being of trainees under their supervision and drive an enforceable mandate to programs under their charge. Programs and individuals should develop and engage in a "menu" of wellness options to reach a variety of learners and standardize the effort to ameliorate burnout. The impact of these multilevel changes will promote a culture where trainees can learn in settings that will sustain them over the course of their careers.

A 66-year-old man presented with malaise, weakness, hypercalcemia, and acute kidney injury. CT of the abdomen and pelvis revealed no evidence of cancer; CT of the chest revealed a sclerotic lesion of the eighth rib. Additional tests were performed, and a diagnosis was made.

Serum osmolality may fluctuate with neurohormonal activation and in response to certain therapeutics in patients with heart failure (HF). The clinical relevance of osmolality in patients with HF has not been defined. In this post hoc analysis of the Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan trial, we analyzed serum osmolality measured at discharge in 3,744 patients hospitalized for HF and reduced ejection fraction (EF ≤40%). Median follow-up was 9.9 months. The association between discharge osmolality and all-cause mortality (ACM) and composite cardiovascular mortality or HF hospitalization was nonlinear; and thus, patients were divided into low (≤284), normal (285 to 300), and high (≥300 mOsm/kg) osmolality. Median serum osmolality at discharge was 297 (290 to 304) mOsm/kg. Patients in the low osmolality group (n = 454,12.1%) were more likely to be younger, men, have lower rates of hypertension, coronary artery disease, chronic kidney disease, diabetes, and have lower serum sodium, creatinine, systolic blood pressure, and EF (all p0.001). Low discharge osmolality was associated with higher ACM (low 29.3%; normal 23.6%; high 25.2%; p = 0.04) and the composite endpoint (low 45.6%; normal 39.3%; high 41.8%; p = 0.04). After risk adjustment, a 15 mOsm/kg decrease in osmolality was predictive of higher ACM (hazard ratio 1.61, 95% CI 1.19 to 2.17) and the composite endpoint (hazard ratio 1.37, 95% CI 1.06 to 1.75) in the low osmolality group. These associations were not seen in patients with normal or high osmolality. Interaction analyses for tolvaptan treatment were nonsignificant (p0.4). In conclusion, low discharge serum osmolality was independently predictive of worse postdischarge mortality and readmission. Further study is required to clarify the clinical utility of serum osmolality in hospitalized patients with HF.

A 61-year-old woman was admitted to the hospital because of vomiting, diarrhea, anemia, and acute kidney injury. Physical examination was normal. Laboratory testing and a diagnostic procedure were performed.

Oncogenic osteomalacia, a paraneoplastic syndrome associated with hypophosphatemia due to increased urinary phosphate excretion, is caused by excessive synthesis and secretion of fibroblast growth factor 23 (FGF23), a phosphaturic hormone that is normally produced by osteocytes. Most cases of oncogenic osteomalacia have been associated with benign tumors of bone or soft tissue; however, whether malignant neoplasms can also produce and secrete FGF23 is currently unknown.The aim was to determine whether a malignant neoplasm could cause oncogenic osteomalacia through excessive production and secretion of FGF23.We describe an 80-year-old woman with stage IV colon adenocarcinoma who presented with severe hypophosphatemia (0.4 mg/dL; reference, 2.6-4.5 mg/dL).Fractional excretion of phosphate was 34% (reference,5% in the setting of hypophosphatemia), and plasma levels of FGF23 were highly elevated at 674 RU/mL (reference,180 RU/mL). Immunohistochemical analysis of the patient's tumor showed strong staining for FGF23. Genetic analyses revealed a point mutation in the KRAS gene.We present the first case in which a malignant neoplasm is documented to produce and secrete FGF23, leading to renal phosphate-wasting. Oncogenic osteomalacia should be considered in the differential diagnosis for patients with a malignant tumor who present with hypophosphatemia.

William Iobst, MD, is Vice President of Academic Affairs, American Board of Internal Medicine; Eve Aagaard, MD, is Associate Professor of Medicine, University of Colorado School of Medicine; Hasan Bazari, MD, is Program Director, Internal Medicine Residency Program, Massachusetts General Hospital, and Associate Professor of Medicine, Harvard Medical School; Timothy Brigham, MDiv, PhD, is Chief of Staff and Senior Vice President, Department of Education, Accreditation Council for Graduate Medical Education; Roger W. Bush, MD, is Attending Physician, Virginia Mason Medical Center; Kelly Caverzagie, MD, is Assistant Professor of Medicine and Associate Vice Chair for Quality and Physician Competence, Department of Internal Medicine, University of Nebraska Medical Center; Davoren Chick, MD, is Clinical Assistant Professor of Medicine, Department of Internal Medicine, University of Michigan Medical School; Michael Green, MD, is Professor of Medicine, Yale University School of Medicine; Kevin Hinchey, MD, is Associate Professor, Tufts University School of Medicine, and Chief Academic Officer, Baystate Medical Center; Eric Holmboe, MD, is Chief Medical Officer, American Board of Internal Medicine; Sarah Hood, MS, is Director of Academic Affairs, American Board of Internal Medicine; Gregory Kane, MD, is Professor of Medicine, Interim Chairman of the Department of Medicine, Jefferson Medical College; Lynne Kirk, MD, is Professor of Internal Medicine, University of Texas Southwestern Medical Center; Lauren Meade, MD, is Assistant Professor of Medicine, Tufts University School of Medicine, and Associate Program Director for Internal Medicine, Baystate Medical Center, and Chair of Educational Research Outcomes Collaborative–Internal Medicine; Cynthia Smith, MD, is Senior Medical Associate for Content Development, American College of Physicians, and Adjunct Associate Professor, Perelman School of Medicine; and Susan Swing, PhD, is Vice President, Outcome Assessment, Accreditation Council for Graduate Medical Education.

Important safety concerns have recently emerged regarding the use of sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin commonly used for the treatment of hyperkalemia. We implemented an electronic alert system at a tertiary care academic medical center to warn providers of the safety concerns of Kayexalate. We assessed the number of Kayexalate prescriptions per month, as well as the number of grams of Kayexalate ordered per month, one year before versus one year after implementing the alert. The mean (±SD) number of Kayexalate orders decreased from 123 (±12) to 76 (±14) orders/month (38% absolute reduction, p

A 77-year-old man was transferred to this hospital because of edema, hematuria, and acute renal failure. A renal biopsy had shown crescentic glomerulonephritis. Diagnostic test results were received, and management decisions were made.

Background Residency is an intense period. Challenges, including burnout, arise as new physicians develop their professional identities. Residency programs provide remediation, but emotional support for interns is often limited. Professional development coaching of interns, regardless of their performance, has not been reported. Objective Design, implement, and evaluate a program to support intern professional development through positive psychology coaching. Methods We implemented a professional development coaching program in a large residency program. The program included curriculum development, coach-intern interactions, and evaluative metrics. A total of 72 internal medicine interns and 26 internal medicine faculty participated in the first year. Interns and coaches were expected to meet quarterly; expected time commitments per year were 9 hours (per individual coached) for coaches, 5 1/2 hours for each individual coachee, and 70 hours for the director of the coaching program. Coaches and interns were asked to complete 2 surveys in the first year and to participate in qualitative interviews. Results Eighty-two percent of interns met with their coaches 3 or more times. Coaches and their interns assessed the program in multiple dimensions (participation, program and professional activities, burnout, coping, and coach-intern communication). Most of the interns (94%) rated the coaching program as good or excellent, and 96% would recommend this program to other residency programs. The experience of burnout was lower in this cohort compared with a prior cohort. Conclusions There is early evidence that a coaching program of interactions with faculty trained in positive psychology may advance intern development and partially address burnout.

A 22-year-old woman was admitted because of blurred vision and acute renal failure. One week earlier, pain and blurred vision had developed in the right eye. Valacyclovir, leucovorin, prednisone, sulfadiazine, and pyrimethamine were prescribed. Dark urine, nausea, and vomiting developed.

A 49-year-old man was admitted to this hospital because of perinephric collections of fluid and acute renal failure. Seven years earlier, routine testing revealed an elevated hematocrit; regular phlebotomy was begun. Ten months before admission to this hospital, dyspnea on exertion developed; imaging studies showed pleural effusions and bilateral perinephric cystic lesions. One month before admission, left-flank pain developed suddenly, and the left perinephric collection of fluid had enlarged; a drain was placed, and acute renal failure developed. A diagnostic procedure was performed.

A 46-year-old woman was seen by a rheumatology consultant because of stiffness of the joints and skin. She had been well until 7 years earlier, when an episode of group A streptococcal pneumonia complicated by septic shock left her with chronic kidney disease and a painful peripheral neuropathy. Three years later, gradually progressive stiffness of the skin of her hands and feet developed, with pain and stiffness of the joints; renal failure worsened, and respiratory distress and congestive heart failure developed. A diagnostic procedure was performed.

A 59-year-old woman with diabetic renal disease was admitted to the hospital because of nonhealing painful ulcers on the right leg and foot. An ulcer on the heel had developed 6 years earlier and persisted despite local treatment, with development of osteomyelitis refractory to antibiotic therapy. A few months before admission, new painful ulcers developed on the right hip and thigh. A procedure was performed.

Internal medicine (IM) residents commonly develop job burnout, which may lead to poor academic performance, depression, and medical errors. The extent to which duty hours restrictions (DHRs) can mitigate job burnout remains uncertain. The July 2011 DHRs created an opportunity to measure the impact of decreased work hours on developing burnout in IM residents.A survey was administered twice to first-year IM residents at three academic medical centers between June 2011 and July 2012. To estimate the impact of the 2011 DHRs, data from this cohort, including demographics, sleepiness, hospital-based patient service characteristics, and burnout measures, were compared with data from 2008-2009 from first-year IM residents at the same institutions.Of eligible residents, 128/188 (68%) from the 2011-2012 cohort and 111/180 (62%) from the 2008-2009 cohort completed both surveys. Year-end burnout prevalence (92/123 [75%] versus 91/108 [84%], P = .08) and incidence (59/87 [68%] versus 55/68 [81%], P = .07) did not differ significantly between cohorts. There was no difference in year-end prevalence of excessive Epworth sleepiness (72/122 [59%] versus 71/108 [66%], P = .29) between cohorts; however, a greater percentage of residents who developed burnout in the 2011-2012 cohort reported caring for8 patients on their service (2011-2012 versus 2008-2009) (29/59 [49%] versus 5/34 [15%], P.01).Job burnout and self-reported sleepiness in IM resident physicians were unchanged after the 2011 DHRs at three academic institutions. Further investigation into the determinants of burnout can inform effective interventions.

A 47-year-old man was transferred to the emergency department because of altered mental status and acute renal failure. Approximately 13 hours earlier, lethargy had developed that progressed to unresponsiveness. The airway had been intubated and acidosis and an elevated creatinine level noted. A generalized tonic–clonic seizure occurred; the results of toxicologic screening of the serum and urine were negative, and a urine specimen contained numerous needle-shaped crystals.

Objectives: While acute kidney injury (AKI) can be diagnosed based on specified increases in a patient’s plasma creatinine level, standard creatinine reporting methods typically only flag creatinine results as abnormal when outside the reference range and often fail to identify rising creatinine values indicative of AKI. Here, we evaluate the impact of this limitation in standard creatinine reporting and develop and implement an enhanced creatinine reporting algorithm. Methods: We evaluated 59,712 plasma creatinine results collected over approximately 3 months, using computational simulations and statistical analyses. Results: Our analyses demonstrated that 29% of creatinine results substantially increased over the patient’s baseline and concerning for AKI remained within the normal reference range. These concerning results would not be flagged as abnormal using standard reporting. Likewise, we found that simple delta checks are also insensitive at AKI detection. To improve creatinine reporting, we developed and implemented an algorithm within our laboratory information system to alert clinicians to rising creatinine results, which we describe in this report. Conclusion: While both creatinine reference limits and simple delta checks are insensitive for AKI identification, a simple algorithm can be implemented within a common laboratory information system to enhance AKI identification.

Contrast-induced nephropathy (CIN) is a common complication of cardiac catheterization, reported to result in a 15% incidence of acute renal failure. Convincing evidence supports the prophylactic use of prehydration and low volumes of contrast medium. Recently, the antioxidant acetylcysteine has been shown to have a potential preventive role. The aim of this study was to examine the hypothesis that acetylcysteine prevents CIN. Patients undergoing cardiac catheterization with a serum creatinine ≥ 1.5 mg/dl were prospectively randomized to receive acetylcysteine or placebo. A total of five doses of acetylcysteine 600 mg b.i.d. or placebo was administered, commencing on the day of the procedure. All patients were prehydrated with 0.45% saline and during the catheterization a nonionic low-osmolality contrast medium was used. Serum creatinine and urea were measured at 24, 48, and 72 hr postprocedure. A total of 43 patients were studied. There was no significant difference between the groups in terms of baseline characteristics, including baseline renal function. No adverse events were experienced with acetylcysteine treatment. Serum creatinine levels at 48 and 72 hr remained largely unchanged in the acetylcysteine group but continued to rise at 48 and 72 hr in the placebo group. By 72 hr, the incidence of CIN, defined as a 25% increase in baseline creatinine, was significantly lower in the acetylcysteine arm compared to placebo (5% for acetylcysteine vs. 32% for placebo; P = 0.046). In patients with mild to moderate renal impairment undergoing cardiac catheterization, prophylactic treatment with oral acetylcysteine reduces the incidence of contrast-induced nephropathy. Catheter Cardiovasc Interv 2003;60:458–461. © 2003 Wiley-Liss, Inc.

Presentation of Case A 75-year-old man was admitted to the hospital because of acute renal failure. He had undergone cystoprostatectomy and urethrectomy with construction of an ileal conduit five months earlier because of prostatic adenocarcinoma and urethral papillary transitional-cell carcinoma. The postoperative course was complicated by three weeks of paralytic ileus. Eighteen days before admission, laboratory tests were performed (Table 1). Two weeks before admission, malaise, low-grade fever, chills, and anorexia developed. Ofloxacin was prescribed, but the patient took it only sporadically. The symptoms did not improve. During an outpatient evaluation, a urographic examination (Figure 1) disclosed faint opacification of . . .

Hematuria and proteinuria are common problems encountered in medicine that may be benign conditions or be harbingers of severe systemic illness and require vigorous evaluation and treatment. This chapter is categorized into conditions that are defined by the presence of hematuria alone, conditions limited to proteinuria alone, or those in which proteinuria is combined with hematuria. The evaluation and therapy of conditions that combine both is dealt with in the latter part of the chapter.

Patients with renal failure undergoing percutaneous coronary intervention (PCI) experience reduced procedural success rates and increased in-hospital and long-term follow-up major adverse cardiac events. This study was designed to determine whether the severity of preprocedural renal failure influences the outcomes of patients with renal failure undergoing PCI. We compared the immediate and long-term outcomes of 192 patients with mild renal failure (creatinine 1.6 to 2.0 mg/dl, mean 1.76) with those of 131 patients with severe renal failure (creatinine >2.0 mg/dl, mean 2.90), selected from 3,334 consecutive patients undergoing PCI between 1994 and 1997. Although the overall population with renal failure represents a high-risk group, the severe renal failure cohort had a higher incidence of hypertension, multivessel disease, prior coronary bypass surgery, vascular disease, and congestive heart failure (all p values

Background —Patients with end-stage renal disease undergoing conventional balloon angioplasty have reduced procedural success and increased complication rates. This study was designed to determine the immediate and long-term outcomes of patients with varying degrees of renal failure undergoing percutaneous coronary intervention in the current device era. Methods and Results —We compared the immediate and long-term outcomes of 362 renal failure patients (creatinine >1.5 mg/dL) with those of 2972 patients with normal renal function who underwent percutaneous coronary intervention between 1994 and 1997. Patients with renal failure were older and had more associated comorbidities. They had reduced procedural success (89.5% versus 92.9%, P =0.007) and greater in-hospital combined major event (death, Q-wave myocardial infarction, emergent CABG; 10.8% versus 1.8%; P P P P Conclusions —Although patients with renal failure can be treated with a high procedural success rate in the new device era, they have an increased rate of major events both in hospital and at long-term follow-up. Nevertheless, utilization of stenting and debulking techniques improves immediate and long-term outcomes.

Purpose: Contrast arteriography is the accepted gold standard for diagnosis and treatment planning in patients with atherosclerotic renovascular disease (RVD). In this study, the results of a selective policy of surgical renal artery reconstruction (RAR) with magnetic resonance angiography (MRA) as the sole preoperative imaging modality are reviewed. Methods: From May 1993 to May 1998, 25 patients underwent RAR after clinical evaluation, and aortic/renal MRA performed with a gadolinium-enhanced and 3-dimensional phase contrast technique. Clinical presentations suggested severe RVD in all patients and included poorly controlled hypertension (16 patients), hospitalization for hypertensive crises and/or acute pulmonary edema (13), and deterioration of renal function within one year of operation (15). Thirteen patients had associated aortic pathologic conditions (12 aneurysms, 1 aortoiliac occlusive disease), and eight of these patients also underwent noncontrast computed tomography scans. Significant renal dysfunction (serum creatinine level, ≥2.0 mg/dL) was present in all but 4 patients with 14 of 25 patients having extreme (creatinine level, ≥3.0 mg/dL) dysfunction. Results: Hemodynamically significant RVD in the main renal artery was verified at operation in 37 of 38 reconstructed main renal arteries (24/25 patients). A single accessory renal artery was missed by MRA. RAR was comprehensive (bilateral or unilateral to a single-functioning kidney) in 21 of 25 patients and consisted of hepatorenal bypass graft (3 patients), combined aortic and RAR (13 patients), isolated transaortic endarterectomy (8 patients), and aortorenal bypass graft (1 patient). Early improvement in both hypertension control and/or renal function was noted in 21 of 25 patients without operative deaths or postoperative renal failure. Sustained favorable functional results at follow-up, ranging from 5 months to 4 years, were noted in 19 of 25 patients. Conclusion: MRA is an adequate preoperative imaging modality in selected patients before RAR. This strategy is best applied in circumstances where the clinical presentation suggests hemodynamically significant bilateral RVD and/or in patients at substantial risk of complications from contrast angiography. (J Vasc Surg 1999;29:1012-21.)

Cardiobacterium hominis, an uncommon cause of bacterial endocarditis, is rarely implicated in infections outside the vascular system. We report the isolation of C. hominis from the peritoneal fluid of a patient on continuous ambulatory peritoneal dialysis with a presentation suggestive of peritonitis but no evidence of infective endocarditis.

Purpose: We reviewed a 13-year experience with an emphasis on long-term survival and renal function response when renal artery reconstruction (RAR) was performed primarily for the preservation or restoration of renal function in patients who had atherosclerotic renovascular disease.Methods: From January 1, 1980, to June 30, 1993, 139 patients underwent RAR for renal function salvage and were retrospectively reviewed. Inclusion criteria were either preoperative serum creatinine level >2.0 mg/dl (67% of patients) or RAR to the entire functioning renal mass irrespective of baseline renal function. Patient survival was calculated by life-table methods. Cox regression analysis was used to determine relative risk (RR) estimates for the late outcomes of continued deterioration of renal function and late survival after RAR. A logistic regression model was used to evaluate variables associated with perioperative complications.Results: Clinical characteristics of the cohort were notable for advanced cardiac (history of congestive heart failure, 27%; angina, 22%; previous myocardial infarction, 19%) and renal disease (serum creatinine level 3.0 mg/dl, 27%). Cardiac disease was the principle cause of early (6 of 11 operative deaths) and late death. Operative management consisted of aortorenal bypass in 47%, extraanatomic bypass in 45%, and endarterectomy in 8%; 45% of patients required combined aortic and RAR. The operative mortality rate was 8%; significant perioperative renal dysfunction occurred in 10%. Major operative morbidity was associated with increasing azotemia (RR = 2.1; p = 0.001; 95% confidence interval [CI], 1.3 to 4.7 for each 1.0 mg/dl increase in baseline creatinine level). Of those patients who had a baseline creatinine level ≥2.0 mg/dl, 54% had ≥20% reduction in creatinine level after RAR. Late follow-up data were available for 87% of operative survivors at a mean duration of 4 years (range, 6 weeks to 12.6 years). Actuarial survival at 5 years was 52% ± 5%. Continued deterioration in renal function occurred in 24% of patients who survived operation, and eventual dialysis was required in 15%. Deterioration of renal function after RAR was associated with increasing levels of preoperative creatinine (RR = 1.6; 95% CI, 1.2 to 1.8; p = 0.001 for each 1.0 mg/dl increment in baseline creatinine level), and inversely related to early postoperative improvement in creatinine level (RR = 0.41; 95% CI, 0.2 to 0.9; p = 0.04).Conclusions: Intervention before major deterioration in renal function and an aggressive posture toward the frequently associated coronary artery disease are necessary to improve long-term results when RAR is performed for renal function salvage. (J Vasc Surg 1996;24:371-82.)

Atheromatous plaque material containing cholesterol crystals may dislodge and cause distal ischemia. To characterize atheroembolic renal failure, we retrospectively evaluated all patients at the Massachusetts General Hospital from 1981 to 1990 with both renal failure and histologically proven atheroembolism after angiography or cardiovascular surgery. Over the 10-year period, 52 patients were identified. They tended to be elderly men with a history of hypertension (81%), coronary artery disease (73%), peripheral vascular disease (69%), and current smoking (50%). Within 30 days of their procedure, only 50% of patients had cutaneous signs of atheroembolism, and 14% had documented blood eosinophilia. Urinalysis was often abnormal. Hemodynamically unstable patients died shortly after their procedure, yet renal function in the remainder continued to decline over 3 to 8 weeks. Patients who received dialysis had a higher baseline serum creatinine than those who did not (168 +/- 44 mumol/L versus 133 +/- 18 mumol/L, p = 0.02), with dialysis starting a median of 29 days after the procedure. Patients with renal failure due to atheroembolism alone, as opposed to multiple renal insults, were more likely to recover renal function (24% versus 3%, p = 0.03) and had a lower risk of death during the 6 months after their procedure (log-rank p = 0.002). Renal failure due to procedure-induced AE is characterized by a decline in renal function over 3 to 8 weeks. This time course is not consistent with most other iatrogenic causes of renal failure, such as radiocontrast or nephrotoxic medications, which present earlier and often resolve within 2 to 3 weeks after appropriate intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

We studied the renal arteries prospectively in 16 patients with renal insufficiency using a combination of two-dimensional and three-dimensional time of flight magnetic resonance angiography (MRA). Results were compared with conventional angiography. All renal arteries were identified by MRA. Accuracy for classifying renal arteries into patent, moderately (30–70%) stenotic, severely (>70%) stenotic, or occluded was 91%. With regard to the presence or absence of severe occlusive disease (>70% stenosis or occlusion) the sensitivity was 100%, with a specificity of 93%.

The card, with its picture of a bouquet of flowers, was on my desk when I arrived at the hospital on Monday morning. I opened it, assuming it was a thank-you note from an interviewee for our residency program. But the handwriting was that of an elderly person who had taken the pains to write, with slants and slopes necessitated by decreased mobility. Under the printed lines, “A little ray to brighten your day. Thinking of you,” the sender had written, “My mother, Mary Louise Kelly, '83–'84, would be pleased with your role at MGH. Please remember to wear a . . .

BACKGROUND: Hospital discharges are vulnerable periods for patient safety, especially in teaching hospitals where discharges are done by residents with competing demands. We sought to assess whether embedding a nurse practitioner on a medical team to help physicians with the discharge process would improve communication, patient follow-up, and hospital reutilization. METHODS: A 5-month randomized controlled trial was conducted on the medical service at an academic tertiary-care hospital. A nurse practitioner was randomly assigned to 1 resident team to complete discharge paperwork, arrange follow-up appointments and prescriptions, communicate discharge plans with nursing and primary care physicians, and answer questions from discharged patients. RESULTS: Intervention patients had more discharge summaries completed within 24 hours (67% vs 47%, P < 0.001). Similarly, they had more follow-up appointments scheduled by the time of discharge (62% vs 36%, P < 0.0001) and attended those appointments more often within 2 weeks (36% vs 23%, P < 0.0002). Intervention patients knew whom to call with questions (95% vs 85%, P = 0.003) and were more satisfied with the discharge process (97% vs 76%, P < 0.0001). Attending rounds on the intervention team finished on time (45% vs 31%, P = 0.058), and residents signed out on average 46 minutes earlier each day. There was no significant difference between the groups in 30-day emergency department visits or readmissions. CONCLUSIONS: Helping resident physicians with the discharge process improves many aspects of discharge communication and patient follow-up, and saves residents' time, but had no effect on hospital reutilization for a general medicine population. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Villin is a multidomain protein that severs, caps, and bundles actin filaments. We employed a chemical modification/cleavage strategy to identify residues whose chemical reactivities are reduced when villin is complexed with actin. We found that actin protects 3 methionine residues, Met125, Met379, and Met711 from oxidation by N-chlorosuccinimide. Because Met125 lies within the actin-severing domain of villin (44T), we probed this region for actin binding sites using a series of overlapping peptides each with an additional cysteine residue at their C terminus. Each peptide, as a disulfide-bonded dimer, was examined for actin cross-linking activity by electron microscopy and light scattering. Our results with M3R suggest this region contains an F-actin binding site and are consistent with proteolysis and deletion mutagenesis studies of gelsolin. Single substitution of the basic residues modulated actin severing but not capping activity of 44T. Circular dichroism and protease digestions did not detect alterations in secondary structure or conformational changes in the mutants, although some are cleaved more rapidly, thereby suggesting a change in the packing of the domains. Our results highlight that basic residues comprise part of the F-actin binding site that is involved in the actin severing activity of villin.

In December 2008, the Institute of Medicine released a report (www.iom.edu/residenthours) on the Accreditation Council for Graduate Medical Education's current duty hour regulations for medical residents. The following two articles address the report's recommendations from the perspectives of the medical residency program and GI fellowship.

A rare cause of high anion gap acidosis is 5-oxoproline (pyroglutamic acid), an organic acid intermediate of the gamma-glutamyl cycle. Acetaminophen and several other drugs have been implicated in the development of transient 5-oxoprolinemia in adults. We report the case of a patient with lymphoma who was admitted for salvage chemotherapy. The patient subsequently developed fever and neutropenia and was administered 20.8 g of acetaminophen during 10 days. During this time, anion gap increased from 14 to 30 mEq/L (14 to 30 mmol/L) and altered mental status developed. After usual causes of high anion gap acidosis were ruled out, a screen for urine organic acids showed 5-oxoproline levels elevated at 58-fold greater than normal values. Predisposing factors in this case included renal dysfunction and sepsis. Clinicians need to be aware of this unusual cause of anion gap acidosis because it may be more common than expected, early discontinuation of the offending agent is therapeutic, and administration of N -acetylcysteine could be beneficial.

Skin ulceration is a well-characterized thrombotic complication of the heparin-induced thrombocytopenia (HIT) syndrome. We present the case of a 73-year-old diabetic woman nearing end-stage renal failure who developed extensive upper thigh, abdominal and buttock ulceration following initiation of subcutaneous heparin for prophylaxis against deep vein thrombosis. A preliminary diagnosis of calciphylaxis was made based on the classical distribution and macroscopic appearance of the ulceration in a patient with end-stage renal failure and secondary hyperparathyroidism. However skin biopsy showed complete absence of calcium deposits in the dermal microvasculature. The presence of extensive microthrombi within dermal vessels prompted serologic testing to detect a prothrombotic state. We identified the combined presence of heparin-dependent platelet activating (HIT) antibodies and functional protein S deficiency. To our knowledge this is the first reported case of a dialysis patient presenting with skin ulceration induced by heparin and protein S deficiency. This case highlights the importance of a skin biopsy and testing for a hypercoaguable state in patients with end-stage renal disease and skin ulceration. We suggest that HIT antibodies should be requested in all dialysis patients presenting with skin ulceration.

The authors reviewed results of digital subtraction vena cavography with a gadolinium-based contrast agent in 14 patients with serum creatinine levels greater than or equal to 1.5 mg/dL (133 mumol/L). All cavograms were diagnostic. In 11 patients, there was no impairment of renal function. In three patients, a rise in serum creatinine level of greater than or equal to 0.5 mg/dL (44 mumol/L) was attributable to concurrent medical problems. Gadolinium-based contrast agents may be suitable for digital subtraction vena cavography in patients with renal insufficiency.

We report the case of a 51-year-old man who presented with diarrhea and was found to have Campylobacter fetus bacteremia and related aortitis and monoarticular arthritis. This case report highlights the clinical presentation and vascular tropism of C. fetus in an immunocompetent host.

The purpose of this study was to compare dynamic gadolinium-enhanced three-dimensional spoiled gradient-recalled MR angiography with conventional arteriography in the evaluation of proximal renal artery stenosis (RAS).MR angiography and conventional arteriographic examinations of 30 patients evaluated for RAS were analyzed retrospectively. Three-dimensional MR angiography was performed with an RF spoiled gradient-recalled imaging sequence acquired during the dynamic i.v. injection of gadolinium (0.2-0.3 mmol/kg), MR data and conventional arteriograms were independently evaluated for the number and location of renal arteries and the degree and location of stenoses. The patients had a mean age of 70 years old and a mean serum creatinine level of 2.9 mg/dl, reflecting a population in whom atherosclerotic RAS was the primary concern.Gadolinium-enhanced MR angiography revealed 100% of main renal arteries. For RAS of 50% or greater occlusion, the technique was 100% sensitive and 71% specific; the negative predictive value was 100%. The technique was 100% sensitive and 71% specific for RAS of 75% or greater occlusion.Dynamic gadolinium-enhanced three-dimensional spoiled gradient-recalled MR angiography has a high sensitivity for revealing proximal RAS and is a quick and reliable technique for obtaining helpful anatomic information.