Acute interstitial nephritis associated with vancomycin therapy.

Nephrotoxicity due to vancomycin is relatively uncommon and usually occurs in patients receiving concomitant therapy with an aminoglycoside or in patients with preexisting renal disease receiving prolonged courses of therapy and who exhibited excessive serum levels. We treated a healthy young woman who developed acute interstitial nephritis and moderate reversible azotemia associated with intravenous vancomycin hydrochloride therapy.

Low fractional excretion of sodium with contrast media-induced acute renal failure.

Risk factors, clinical courses, and urinary indices were examined in 12 consecutive patients with contrast media-induced acute renal failure. A high prevalence of preexisting renal disease, diabetes, vascular disease, and compromised cardiac output was observed. All patients had transient oliguria one to four days in duration, and all patients had return of renal function to their baseline values within five to ten days. Consistently low urinary sodium concentration and fractional excretion of sodium (FENa) were seen during the oliguric phase of the acute renal failure. Fractional excretion of sodium of less than 1% persisted for up to five days despite unequivocal renal function deterioration. The findings raise the possibility that acute renal failure secondary to contrast media may be mediated either by decreases in renal perfusion or by acute tubular obstruction.

Initiating the firm system at a community teaching hospital.

The Medical Center of Central Massachusetts-Memorial, a 350-bed private community teaching hospital, initiated a firm system for multiple reasons: to improve teaching, improve physician nursing relations, improve discharge planning, and to improve quality assurance/utilization review activities. In this system, private physician groups were randomized to four geographic medical wards, each of which had a distinctive subspecialty identity: oncology, cardiology, nephrology, and diabetes. Primary care internists became the Firm Directors, and subspecialists, already identified with those geographic wards, became Associate Firm Directors. The new system has produced several exciting successes; better bedside teaching and a project to shorten the length of stay of common diagnoses are two examples. Problems remain: resident complaints about imbalanced admissions and an increased census are two issues that we must overcome.

Toxicity after self-poisoning by ingestion of potassium chloroplatinite.

A 31 year-old man ingested 10 mL of a photographic toning solution containing 600 mg of potassium chloroplatinite in a suicide attempt. Subsequent toxic effects included acute oliguric renal failure, metabolic acidosis, fever, muscle cramps, gastroenteritis and rhabdomyolysis. Laboratory abnormalities included mildly elevated liver enzymes and elevated peripheral blood neutrophil and eosinophil counts. All symptoms and signs of toxicity resolved over a six day hospital stay with supportive medical management only; thereafter he was lost to medical follow-up. A spot serum platinum concentration was 245 mcg/dL and a spot urine platinum concentration was 4200 mcg/L.

Assessing clinical skills of residents with standardized patients.

Current techniques do not provide a reproducible, reliable, or valid basis for assessing clinical skills. The need for large-scale direct observation and standardized assessment procedures has precluded development of better techniques. A project using standardized patients presenting with common clinical problems evaluated the skills of 336 internal medicine residents at 14 New England residency programs in 1289 standardized patient and resident encounters. Results indicated that reproducible assessment of the clinical skills could be achieved in approximately 1 day of testing time using standardized patients. Resident performance improved with years of training, and senior residents and those from programs with stronger reputations performed better and were more homogeneous in ability. Low correlations between standardized-patient-based measures of clinical skills and other evaluation techniques suggested that standardized patients provided unique information. Reactions of residents and faculty to standardized-patient-based evaluations were favorable.