Association between pregnancy-related changes in serum creatinine and preeclampsia diagnosis.

BACKGROUND: Preeclampsia is a leading cause of maternal and neonatal morbidity and mortality, affecting 2-8% of all pregnancies. Typically, the increased glomerular filtration rate of pregnancy results in a decrease in serum creatinine. It is unknown if women without the expected decrease in serum creatinine during pregnancy are more likely to be diagnosed with preeclampsia. OBJECTIVE: We sought to determine if the absence of a pregnancy-related decrease in serum creatinine was associated with the development of preeclampsia in patients deemed to be at high risk for developing preeclampsia. We hypothesized that the absence of the expected decrease in serum creatinine may be a marker of impaired renal function and therefore may be associated with increased risk of preeclampsia in this cohort. STUDY DESIGN: We conducted a retrospective cohort study of deliveries between November 2, 2017 and June 30, 2020 at a single institution. Pregnancies were included if a baseline serum creatinine (measured between one year prior to conception through 6 weeks gestation), and another serum creatinine value prior to 20 weeks of gestation were measured. Decrease in serum creatinine was defined as any decrease (at least 0.01 mg/dL) from baseline. The primary outcome was diagnosis of preeclampsia. Exclusion criteria included fetal anomalies, fetal demise, multiple gestation, or delivery prior to 20 weeks. Bivariable analyses were performed using Chi-square, ANOVA, and Student's t test. Logistic regression was used to determine odds of developing preeclampsia controlling for confounders. RESULTS: We identified 392 pregnancies that met inclusion criteria. Preeclampsia was diagnosed in 56 (14.3%) pregnancies. Patients diagnosed with preeclampsia were more likely to have a history of preeclampsia in a prior pregnancy, chronic hypertension (HTN), and diabetes. They were also more likely to have aspirin prescribed in the current pregnancy. Prevalence of advanced maternal age, multiparity, obesity, smoking, history of autoimmune disease, history of CKD, gestational HTN, or multiple pregnancy were not significantly different between patients with and without a diagnosis of preeclampsia. After controlling for confounders, a decrease in serum creatinine from baseline was not significantly associated with a diagnosis of preeclampsia (OR 0.76, CI 0.32-1.78). CONCLUSION: After controlling for risk factors associated with preeclampsia, a decrease in serum creatinine from baseline was not significantly associated with a diagnosis of preeclampsia in this high-risk cohort.

Hispanics with primary biliary cirrhosis are more likely to have features of autoimmune hepatitis and reduced response to ursodeoxycholic acid than non-Hispanics.

BACKGROUND & AIMS: Primary biliary cirrhosis (PBC) is a cholestatic disease that predominantly affects middle-aged Caucasian women. Studies have suggested that PBC has a more aggressive course in individuals of Hispanic ancestry. We investigated the clinical presentation and progression of PBC in an ethnically diverse population. METHODS: We performed a cross-sectional study, analyzing data from Hispanic (n = 70) and non-Hispanic patients (n = 134) with PBC seen at the University of Miami/Jackson Memorial Hospital from January 1, 2000, through December 31, 2011. We compared demographics, clinical presentation, response to therapy, and outcomes between the groups. RESULTS: Age at diagnosis, antimitochondrial antibody positivity, frequency of advanced histologic stage, use and dose of ursodeoxycholic acid (UDCA), and the presence of pruritus or fatigue were similar between groups. Hypothyroidism was less frequent among Hispanics (16% vs 29% in non-Hispanics; P = .04). Hispanic subjects were more likely to have overlap syndrome of PBC and autoimmune hepatitis than non-Hispanics (31% vs 13%; P = .002). After a median follow-up period of 3.65 years, a greater percentage of Hispanics had ascites (24% vs 12%; P = .03) and variceal bleeding (20% vs 7%; P = .01), although there were no differences in the number of deaths or liver transplants. Of 204 total patients, 180 received UDCA for at least 1 year. A lower proportion of Hispanic patients had a biochemical response to treatment (60% vs 88%; P < .0001). Independent predictors of poor biochemical response were younger age at diagnosis and Hispanic ethnicity. CONCLUSIONS: In a cross-sectional study, patients of Hispanic ethnicity with PBC had an increased prevalence of overlap syndrome, reduced response to UDCA treatment, and more frequent complications of portal hypertension than non-Hispanic patients.

A Predictive Model for USMLE Step 1 Scores.

PURPOSE: The United States Medical Licensing Examination (USMLE) Step 1 plays a pivotal role in one's residency application. While prior literature has investigated which factors influence performance on the examination, the authors sought to include factors such as performance on a well-used question bank and financial need to develop a predictive model. METHOD: After obtaining institutional review board approval, the authors surveyed two consecutive second-year medical school classes and correlated the data to the students' Step 1 and National Board of Medical Examiners (NBME) Comprehensive Basic Science Examination (CBSE) scores. The survey included questions such as how many days they studied per week, how many days they studied in total, which resources they used, how they performed on question banks, group studying habits, and whether they were receiving financial aid. The authors also assessed whether the students received only A letter grades during the first year of medical school. The authors used SPSS® Statistics V22.0 (IBM® Corporation, NY, USA ) and included one-way analysis of covariance (ANOVA) and multiple linear regression for statistical analysis. RESULTS: Eighty-one students completed the survey with an average Step 1 score of 240.5 and with an average study time of 39.5 days. The Step 1 Scores significantly correlated with the CBSE taken immediately preceding the dedicated study period (r=0.711, P=<0.001), UWorld Question Bank (UWorld) percentage correct (r = 0.622, P<0.001), straight As during first-year (r=0.356, P=0.001), and financial need (r=0.318, P=0.01). The scores were not correlated with age, gender, Medical College Admissions Test (MCAT), prior medical training, number of days studied, or the students' perception of appropriate time studied. The authors developed a predictive model accounting for 62.3% of the variability. 140.625+(0.319xCBSE)-(3.817xA)+(5.845xN)+(0.452xU), where A=1 if straight As, N=1 if receiving need-based scholarship, U=UWorld percent-correct, and CBSE=the three-digit score of the CBSE taken prior to the dedicated study period. CONCLUSIONS: Academic performance and financial need may predict Step 1 scores. Interestingly, the number of days studied did not have a correlation with scores, suggesting that increased length of study may not ameliorate poor grades.

Medical Students' Attitudes Toward Non-Adherent Patients Before and After a Simulated Patient-Role Activity and Small-Group Discussion: Revisited.

Introduction This study seeks to explore whether the documented decline in medical student empathy can be prevented or slowed using simulated patient-role activities and small-group discussions about the patient experience of living with a chronic illness. Methods First-year students (M1, n = 118) at the University of Central Florida College of Medicine (UCFCOM) participated in a simulated patient-role activity resembling the experience of a patient with Type 2 diabetes mellitus. The activity included taking daily "medication," participating in moderate exercise, and maintaining a low carbohydrate diet. At the end of the simulated patient-role activity, students took part in a small-group discussion about their experiences. Students completed the Jefferson Scale of Physician Empathy: Student Version (JSPE:S) before and after the activity. Additionally, fourth-year students (M4) at UCFCOM completed the JSPE:S to serve as the control, as this class completed the curriculum without any simulated patient-role activities. Results A total of 86 responses out of 118 possible M1 participants (73% response rate) were received. Of these, 62 surveys were completed and were therefore used for statistical analysis. A dependent sample t-test revealed no statistically significant increase on pre-activity (M = 111.15, SD = 8.56) and post-activity (M = 111.38, SD = 9.12) empathy scores (p = .78). A positive correlation was revealed to exist between pre- and post-activity empathy scores (r = 0.72, p < 0.001). Empathy comparisons for the full sample M1 post-activity results (n = 62) and the M4 results (n = 16, M = 106.56, SD = 10.61) revealed no statistically significant difference (p = .11). Discussion Although previous authors have shown that patient role-playing activities, such as those performed in this study, should maintain and/or increase empathy in medical students, our findings suggest that on a short-term scale, empathy levels were not affected by the activity.

Uric Acid as a Marker of Kidney Disease: Review of the Current Literature.

Uric acid has been implicated in the pathophysiology of renal disease; however renal clearance makes a causal relationship difficult to prove. We examine the current literature to support a potential role of uric acid in the development of kidney disease and to determine the potential to use uric acid as a marker for future renal decline. After review, we conclude that uric acid is definitively linked to the development of chronic kidney disease and can be a poor prognostic factor for the development of acute renal failure, as well. However, further human research is needed before predictive models utilizing uric acid can be developed and used in the clinical setting.

An Update on Treatment of Drug-Induced Liver Injury.

Drug-induced liver injury (DILI) has been linked to more than 1,000 medications and remains the most common cause of acute liver failure in the United States. Here, we review the most current literature regarding treatment and make recommendations for the management of this relatively common disease. Since treatment of DILI remains largely elusive, recent studies have attempted to define new management strategies for these difficult patients. Early diagnosis and withdrawal of the suspected medication is the mainstay of treatment of DILI. For acetaminophen and Amanita mushroom poisoning, there are specific therapies in use. Finally, there are other possible management modalities for DILI, including corticosteroids and ursodeoxycholic acid.

Clinical manifestations and treatment of drug-induced hepatotoxicity.

With an increase of prescription medication and herbal supplement use, drug-induced liver injury (DILI) has become an increasingly important entity. Because DILI is a usually readily treatable condition, it is essential for providers to reach a diagnosis in a timely fashion. Unfortunately, varied clinical presentations, difficulties in establishing causality, and lack of a gold standard diagnostic criterion may make early diagnosis difficult. This article seeks to define commonly used terminology, describe common clinical presentations of DILI, provide an overview of current diagnostic criteria, and provide management guidelines.