Distinct Genomic Expression Signatures after Low-Force Electrically Induced Exercises in Persons with Spinal Cord Injury.

People with a spinal cord injury are at an increased risk of metabolic dysfunction due to skeletal muscle atrophy and the transition of paralyzed muscle to a glycolytic, insulin-resistant phenotype. Providing doses of exercise through electrical muscle stimulation may provide a therapeutic intervention to help restore metabolic function for people with a spinal cord injury, but high-frequency and high-force electrically induced muscle contractions increase fracture risk for the underlying osteoporotic skeletal system. Therefore, we investigated the acute molecular responses after a session of either a 3 Hz or 1 Hz electrically induced exercise program. Ten people with a complete spinal cord injury completed a 1 h (3 Hz) or 3 h (1 Hz) unilateral electrically induced exercise session prior to a skeletal muscle biopsy of the vastus lateralis. The number of pulses was held constant. Tissue samples were analyzed for genomic and epigenomic expression profiles. There was a strong acute response after the 3 Hz exercise leading to the upregulation of early response genes (NR4A3, PGC-1α, ABRA, IRS2, EGR1, ANKRD1, and MYC), which have prominent roles in regulating molecular pathways that control mitochondrial biogenesis, contractile protein synthesis, and metabolism. Additionally, these genes, and others, contributed to the enrichment of pathways associated with signal transduction, cellular response to stimuli, gene expression, and metabolism. While there were similar trends observed after the 1 Hz exercise, the magnitude of gene expression changes did not reach our significance thresholds, despite a constant number of stimuli delivered. There were also no robust acute changes in muscle methylation after either form of exercise. Taken together, this study supports that a dose of low-force electrically induced exercise for 1 h using a 3 Hz stimulation frequency is suitable to trigger an acute genomic response in people with chronic paralysis, consistent with an expression signature thought to improve the metabolic and contractile phenotype of paralyzed muscle, if performed on a regular basis.

Pivoting during a Pandemic: Reimagining Intern Orientation EPA-Based OSCE.

OBJECTIVES: Objective structured clinical examinations (OSCEs) provide reliable and standardized means for assessing the performance of specific clinical skills. Our previous experience with entrustable professional activity-based multidisciplinary OSCEs suggests that this exercise offers just-in-time baseline information regarding critical intern skills. The coronavirus disease 2019 pandemic forced medical education programs to reimagine such educational experiences. For the safety of all of the participants, the Internal Medicine and Family Medicine residency programs pivoted from an in-person OSCE to a hybrid model (combination of in-person and virtual encounters) while maintaining the goals of the OSCEs administered in previous years. Here, we describe an innovative hybrid approach to redesigning and implementing the existing OSCE model while maximizing risk mitigation. METHODS: In total, 41 interns from Internal Medicine and Family Medicine participated in the 2020 hybrid OSCE. Five stations allowed for clinical skills assessment. Faculty completed skills checklists with global assessments and simulated patients completed communication checklists with global assessments. Interns, faculty, and simulated patients completed a post-OSCE survey. RESULTS: Informed consent, handoffs, and oral presentation were the lowest performing stations (29.2%, 53.6%, 53.6%, respectively) as assessed by faculty skill checklists. One hundred percent of interns (41/41) indicated that immediate faculty feedback was the most valuable part of the exercise, and all of the participating faculty believed that the format was efficient, allowing ample time to provide feedback and complete checklists. Eighty-nine percent of simulated patients cited they would be willing to participate again if the same assessment were to be held during the pandemic. The limitations of the study included the lack of demonstration of physical examination maneuvers by interns. CONCLUSIONS: A hybrid OSCE to assess interns' baseline skills during orientation using Zoom technology could be delivered successfully and safely during the pandemic without compromising the program's goals or satisfaction.

Let the Program Evaluation Committee SOAR: Applying the Strengths, Opportunities, Aspirations, and Results (SOAR) Framework for Program Evaluation.

OBJECTIVE: Annual program evaluations are important activities of all graduate medical education programs. Although the Accreditation Council for Graduate Medical Education provides general guidelines, there is substantial scope for educational innovation. Strengths, opportunities, aspirations, and results (SOAR) is a strengths-based framework for strategic planning. Because SOAR emphasizes positivity and engagement, it is an appealing framework for evaluating graduate medical education programs. Our objective was to demonstrate the feasibility and acceptability of SOAR in a program evaluation committee of a fellowship program to generate strategic initiatives. METHODS: The authors used the four steps of SOAR within the program evaluation committee in 2022. Interviewers collected positive stories to understand program strengths. Then, rapid ideation was used to translate strengths into opportunities. These opportunities were condensed and refined for fellows to assess how well they align with aspirations. The ones that aligned best with aspirations were prioritized for implementation. Results were monitored through a scorecard based on specific, measurable, achievable, relevant, and time-bound (SMART) goals every month. RESULTS: Of 15 divisional members, 11 participated (73.3%). Five major strengths were identified: supportive environment, variety of cases, scheduling flexibility, integration with larger networks, and multidisciplinary collaboration. These 5 yielded 15 opportunities, which were refined and condensed to 9. Four were selected for implementation: scholarly works accountability group, hybrid-flex curriculum, fellowship weekly huddles, and structured electives. Scorecards have shown successful implementation during a 4-month period. CONCLUSIONS: SOAR is an innovative and feasible approach to program evaluation that uses trainee engagement to translate and synergize existing program strengths into actionable program improvement.

Healthcare educational debt in the united states: unequal economic impact within interprofessional team members.

BACKGROUND: Advancing healthcare access and quality for underserved populations requires a diverse, culturally competent interprofessional workforce. However, high educational debt may influence career choice of healthcare professionals. In the United States, health professions lack insight into the maximum educational debt that can be supported by current entry-level salaries. The purpose of this interprofessional economic analysis was to examine whether average educational debt for US healthcare graduates is supportable by entry-level salaries. Additionally, the study explored whether trainees from minoritized backgrounds graduate with more educational debt than their peers in physical therapy. METHODS: The study modeled maximum educational debt service ratios for 12 healthcare professions and 6 physician specialties, incorporating profession-specific estimates of entry-level salary, salary growth, national average debt, and 4 loan repayment scenarios offered by the US Department of Education Office of Student Financial Aid. Net present value (NPV) provided an estimate for lifetime "economic power" for the modeled careers. The study used a unique data source available from a single profession (physical therapy, N = 4,954) to examine whether educational debt thresholds based on the repayment model varied between minoritized groups and non-minoritized peers. RESULTS: High salary physician specialties (e.g. obstetrics/gynecology, surgery) and professions without graduate debt (e.g. registered nurse) met debt ratio targets under any repayment plan. Professions with strong salary growth and moderate debt (e.g. physician assistant) required extended repayment plans but had high career NPV. Careers with low salary growth and high debt relative to salary (e.g. physical therapy) had career NPV at the lowest range of modeled professions. 29% of physical therapy students graduated with more debt than could be supported by entry-level salaries. Physical therapy students from minoritized groups graduated with 10-30% more debt than their non-minoritized peers. CONCLUSIONS: Graduates from most healthcare professions required extended repayment plans (higher interest) to meet debt ratio benchmarks. For several healthcare professions, low debt relative to salary protected career NPV. Students from minoritized groups incurred higher debt than their peers in physical therapy.

Empathy levels among health professional students at a large midwestern public university - a cross-sectional study.

BACKGROUND: Empathic care is considered extremely important by patients and providers alike but there is still an ample need for assessing empathy among healthcare students and professionals and identifying appropriate educational interventions to improve it. This study aims to assess empathy levels and associated factors among students at different healthcare colleges at the University of Iowa. METHODS: An online survey was delivered to healthcare students, including nursing, pharmacy, dental, and medical colleges (IRB ID #202,003,636). The cross-sectional survey included background questions, probing questions, college-specific questions, and the Jefferson Scale of Empathy-Health Professionals Student version (JSPE-HPS). To examine bivariate associations, Kruskal Wallis and Wilcoxon rank sum tests were used. A linear model with no transformation was used in the multivariable analysis. RESULTS: Three hundred students responded to the survey. Overall JSPE-HPS score was 116 (± 11.7), consistent with other healthcare professional samples. There was no significant difference in JSPE-HPS score among the different colleges (P = 0.532). CONCLUSION: Controlling for other variables in the linear model, healthcare students' view of their faculty's empathy toward patients and students' self-reported empathy levels were significantly associated with students' JSPE-HPS scores.

Neuromuscular and gene signaling responses to passive whole-body heat stress in young adults.

This study aimed to investigate whether acute passive heat stress 1) decreases muscle Maximal Voluntary Contraction (MVC); 2) increases peripheral muscle fatigue; 3) increases spinal cord excitability, and 4) increases key skeletal muscle gene signaling pathways in skeletal muscle. Examining the biological and physiological markers underlying passive heat stress will assist us in understanding the potential therapeutic benefits. MVCs, muscle fatigue, spinal cord excitability, and gene signaling were examined after control or whole body heat stress in an environmental chamber (heat; 82 °C, 10% humidity for 30 min). Heart Rate (HR), an indicator of stress response, was correlated to muscle fatigue in the heat group (R = 0.59; p < 0.05) but was not correlated to MVC, twitch potentiation, and H reflex suppression. Sixty-one genes were differentially expressed after heat (41 genes >1.5-fold induced; 20 < 0.667 fold repressed). A strong correlation emerged between the session type (control or heat) and principal components (PC1) (R = 0.82; p < 0.005). Cell Signal Transduction, Metabolism, Gene Expression and Transcription, Immune System, DNA Repair, and Metabolism of Proteins were pathway domains with the largest number of genes regulated after acute whole body heat stress. Acute whole-body heat stress may offer a physiological stimulus for people with a limited capacity to exercise.

The Doctors in the House: Examining Physician Legislators in the US Congress from 2011 to 2020.

OBJECTIVES: Legislation dictating federal healthcare policy is drafted largely by members of the US Senate and House of Representatives. As such, their personal and professional backgrounds play important roles in setting the national healthcare agenda. We examine the professional and legislative records of the 28 federal physician legislators with voting privileges between 2011 and 2020. METHODS: Two researchers compiled the names of every federal legislator in both the US Senate and the US House of Representatives who served at any time between 2011 and 2020. The researchers used publicly available records to abstract information regarding their professional and legislative records. Data were then analyzed using descriptive statistics. RESULTS: The majority of the 28 federal physician legislators are Doctor of Medicine graduates (96%), Republican (86%), represent southern states (71%), were in private practice before serving as legislators (78.5%), and have not previously held elected positions as legislators (57%). Approximately 15% of the bills that they sponsor are related to health policy. Obstetrics/Gynecology, Surgery, and Family Medicine are the most common specialties. On average, it takes 25 years from medical school graduation to election to their federal legislative position. Approximately half represent states, or districts within states, in which they attended medical school or completed residency. CONCLUSIONS: To engage in meaningful healthcare policy advocacy, professional organizations must support and encourage leadership training for physicians, increase the geographic and professional diversity of physician legislators, prioritize the election of physicians from both political parties, and inculcate deep and lasting professional relationships to physicians in Congress.

Warmer Weather and the Risk of Urinary Tract Infections in Women.

PURPOSE: The incidence of urinary tract infections is seasonal, peaking in summer months. One possible mechanism for the observed seasonality of urinary tract infections is warmer weather. MATERIALS AND METHODS: We identified all urinary tract infection cases located in approximately 400 metropolitan statistical areas in the contiguous United States between 2001 and 2015 using the Truven Health MarketScan® databases. A total of 167,078,882 person-years were included in this data set and a total of 15,876,030 urinary tract infection events were identified by ICD-9 code 599.0. Weather data for each metropolitan statistical area and date were obtained from the National Centers for Environmental Information. We computed the mean temperature during the period 0 to 7 days prior to the urinary tract infection diagnosis. We used a quasi-Poisson generalized linear model. The primary outcome was the number of urinary tract infections each day in a metropolitan statistical area in each age group. Covariates considered included age group, day of week, year and the temperature during the previous 7 days. RESULTS: Warmer weather increases the risk of urinary tract infections among women treated in outpatient settings in a dose-response fashion. On days when the prior week's average temperature was between 25 and 30C, the incidence of urinary tract infections was increased by 20% to 30% relative to when the prior week's temperature was 5 to 7.5C. CONCLUSIONS: The incidence of urinary tract infections increases with the prior week's temperature. Our results indicate that warmer weather is a risk factor for urinary tract infections. Furthermore, as temperatures rise, the morbidity attributable to urinary tract infections may increase.

Successful implementation of a longitudinal skill-based teaching curriculum for residents.

BACKGROUND: Despite significant teaching responsibilities and national accreditation standards, most residents do not receive adequate instruction in teaching methods. Published reports of residents-as-teachers programs vary from brief one-time exposures to curricula delivered over several months. A majority of interventions described are one or two-day workshops with no clear follow-up or reinforcement of skills. A three-year longitudinal teaching skills curriculum was implemented with these goals: 1) deliver an experiential skill-based teaching curriculum allowing all residents to acquire, practice and implement specific skills; 2) provide spaced skills instruction promoting deliberate practice/reflection; and 3) help residents gain confidence in their teaching skills. METHODS: One hundred percent of internal medicine residents (82/82) participated in the curriculum. Every 10 weeks residents attended a topic-specific experiential skills-based workshop. Each workshop followed the same pedagogy starting with debriefing/reflection on residents' deliberate practice of the previously taught skill and introduction of a new skill followed by skill practice with feedback. Every year, participants completed: 1) assessment of overall confidence in each skill and 2) retrospective pre-post self-assessment. A post-curriculum survey was completed at the end of 3 years. RESULTS: Residents reported improved confidence and self-assessed competence in their teaching skills after the first year of the curriculum which was sustained through the three-year curriculum. The curriculum was well received and valued by residents. CONCLUSIONS: A formal longitudinal, experiential skills-based teaching skills curriculum is feasible and can be delivered to all residents. For meaningful skill acquisition to occur, recurrent continuous skill-based practice with feedback and reflection is important.

Well-Being, Burnout, and Resiliency Among Early-Career Rheumatologists: A Qualitative Study.

BACKGROUND/OBJECTIVE: Physician well-being is being increasingly recognized for its important role in high-quality patient care, integrity of the healthcare system, and vitality of the workforce. However, little is known about well-being, resiliency, and burnout among rheumatologists, particularly early-career rheumatologists. In this qualitative study, the investigators explore these concepts among early-career rheumatologists. METHODS: We performed a qualitative study using semistructured phone interviews of rheumatologists who completed fellowship in 2017. Participants were recruited through purposive sampling. Twenty questions were devised by the investigators, covering sample demographics, exploring definitions of well-being, resiliency, and burnout, and probing potential solutions.Interviews were recorded and transcribed independently and verified for consistency. The investigators used grounded theory to code the transcripts and iteratively derive categories, subthemes, and themes until reaching theoretical sufficiency. RESULTS: Sixty-four rheumatologists were interviewed, accounting for 30.6 hours of material. Seven major themes were identified: (1) well-being as a holistic state where an individual is able to translate one's potential to maximal performance, (2) work-family balance as a dynamic equilibrium changing over time, (3) inadequacy of training in addressing self-doubt over autonomy, (4) uncertainty over career development and progression, (5) excessive administrative burdens, (6) protective nature of longitudinal relationships, and (7) addressing burnout requires a multifaceted approach at multiple levels. CONCLUSIONS: New rheumatologists face a series of challenges as they enter the workforce. Investments into well-being can help reduce the risk of burnout and enlarge our community. Our results highlight drivers and potential solutions, as identified by recent fellowship graduates.

Impact of short- and long-term electrically induced muscle exercise on gene signaling pathways, gene expression, and PGC1a methylation in men with spinal cord injury.

Exercise attenuates the development of chronic noncommunicable diseases (NCDs). Gene signaling pathway analysis offers an opportunity to discover if electrically induced muscle exercise regulates key pathways among people living with spinal cord injury (SCI). We examined short-term and long-term durations of electrically induced skeletal muscle exercise on complex gene signaling pathways, specific gene regulation, and epigenetic tagging of PGC1a, a major transcription factor in skeletal muscle of men with SCI. After short- or long-term electrically induced exercise training, participants underwent biopsies of the trained and untrained muscles. RNA was hybridized to an exon microarray and analyzed by a gene set enrichment analysis. We discovered that long-term exercise training regulated the Reactome gene sets for metabolism (38 gene sets), cell cycle (36 gene sets), disease (27 gene sets), gene expression and transcription (22 gene sets), organelle biogenesis (4 gene sets), cellular response to stimuli (8 gene sets), immune system (8 gene sets), vesicle-mediated transport (4 gene sets), and transport of small molecules (3 gene sets). Specific gene expression included: oxidative catabolism of glucose including PDHB (P < 0.001), PDHX (P < 0.001), MPC1 (P < 0.009), and MPC2 (P < 0.007); Oxidative phosphorylation genes including SDHA (P < 0.006), SDHB (P < 0.001), NDUFB1 (P < 0.002), NDUFA2 (P < 0.001); transcription genes including PGC1α (P < 0.030) and PRKAB2 (P < 0.011); hypertrophy gene MSTN (P < 0.001); and the myokine generating FNDC5 gene (P < 0.008). Long-term electrically induced exercise demethylated the major transcription factor PGC1a. Taken together, these findings support that long-term electrically induced muscle activity regulates key pathways associated with muscle health and systemic metabolism.

Leadership training programs in graduate medical education: a systematic review.

BACKGROUND: With the increasing recognition that leadership skills can be acquired, there is a heightened focus on incorporating leadership training as a part of graduate medical education. However, there is considerable lack of agreement regarding how to facilitate acquisition of these skills to resident, chief resident, and fellow physicians. METHODS: Articles were identified through a search of Ovid MEDLINE, EMBASE, CINAHL, ERIC, PsycNet, Cochrane Systemic Reviews, and Cochrane Central Register of Controlled Trials from 1948 to 2019. Additional sources were identified through contacting authors and scanning references. We included articles that described and evaluated leadership training programs in the United States and Canada. Methodological quality was assessed via the MERSQI (Medical Education Research Study Quality Instrument). RESULTS: Fifteen studies, which collectively included 639 residents, chief residents, and fellows, met the eligibility criteria. The format, content, and duration of these programs varied considerably. The majority focused on conflict management, interpersonal skills, and stress management. Twelve were prospective case series and three were retrospective. Seven used pre- and post-test surveys, while seven used course evaluations. Only three had follow-up evaluations after 6 months to 1 year. MERSQI scores ranged from 6 to 9. CONCLUSIONS: Despite interest in incorporating structured leadership training into graduate medical education curricula, there is a lack of methodologically rigorous studies evaluating its effectiveness. High-quality well-designed studies, focusing particularly on the validity of content, internal structure, and relationship to other variables, are required in order to determine if these programs have a lasting effect on the acquisition of leadership skills.

The ecology of program director leadership: power relationships and characteristics of effective program directors.

BACKGROUND: Program directors are often perceived as strong and independent leaders within the academic medical environment. However, they are not as omnipotent as they initially appear. Indeed, PDs are beholden to a variety of different agents, including trainees (current residents, residency applicants, residency alumni), internal influencers (departmental faculty, hospital administration, institutional graduate medical education), and external influencers (the Accreditation Council for Graduate Medical Education (ACGME), medical education community, and society-at-large). Altogether, these agents form a complex ecosystem whose dynamics and relationships shape the effectiveness of program directors. MAIN BODY: This perspective uses management theory to examine the characteristics of effective PD leadership. We underline the importance of authority, accessibility, adaptability, authenticity, accountability, and autonomy as core features of successful program directors. Additionally, we review how program directors can use the six power bases (legitimacy, referent, informational, expert, reward, and coercive) to achieve positive and constructive change within the complexity of the academic medical ecosystem. Lastly, we describe how local and national institutions can better structure power relationships within the ecosystem so that PD leadership can be most effective. CONCLUSION: Keen leadership skills are required by program directors to face a variety of challenges within their educational environments. Understanding power structures and relationships may aid program directors to exercise leadership judiciously towards fulfilling the educational missions of their departments.

Learning to drive: resident physicians' perceptions of how attending physicians promote and undermine autonomy.

BACKGROUND: Providing appropriate levels of autonomy to resident physicians is an important facet of graduate medical education, allowing learners to progress toward the ultimate goal of independent practice. While studies have identified the importance of autonomy to the development of resident physicians, less is known about resident perspectives on their "lived experiences" with autonomy and ways in which clinical educators either promote or undermine it. The current study aims to provide an empirically based practical framework based on resident perspectives through which supervising physicians can attempt to more adequately foster resident physician autonomy. METHODS: Residents completed open ended surveys followed by facilitated group discussions of their perspectives on autonomy. Qualitative thematic analysis identified key themes in resident definitions of autonomy and how clinical educators either promote or undermine resident autonomy during supervision. Fifty-nine resident physicians representing six different specialties from two institutions participated. RESULTS: Learners felt that autonomy was critical to their development as independent physicians. Leading the approach to care, a sense of ownership for patients, and receiving appropriate levels of supervision were identified as key components of autonomy. Attending physicians who promoted this active involvement with patient care were felt to have a strong positive influence on resident autonomy. Autonomy was undermined when decisions were micromanaged and resident input in decision-making process was minimized. CONCLUSIONS: Fostering autonomy is a critical aspect of medical education. Allowing residents to take the lead in the delivery of patient care while supporting them as important members of the health care team can help to promote resident autonomy in the clinical setting.

Resident perceptions of the impact of duty hour restrictions on resident-attending interactions: an exploratory study.

BACKGROUND: The institution of duty hour reforms by the Accreditation Council for Graduate Medical Education in 2003 has created a learning environment where residents are consistently looking for input from attending physicians with regards to balancing duty hour regulations and providing quality patient care. There is a paucity of literature regarding resident perceptions of attending physician actions or attitudes towards work hour restrictions. The purpose of this study was to identify attending physician behaviors that residents perceived as supportive or unsupportive of their compliance with duty hour regulations. METHODS: Focus group interviews were conducted with residents exploring their perceptions of how duty hour regulations impact their interactions with attending physicians. Qualitative analysis identified key themes in residents' experiences interacting with faculty in regard to duty hour regulations. Forty residents from five departments in two hospital systems participated. RESULTS: Discussion of these interactions highlighted that attending physicians demonstrate behaviors that explicitly or implicitly either lend their support and understanding of residents' need to comply with these regulations or imply a lack of support and understanding. Three major themes that contributed to the ease or difficulty in addressing duty hour regulations included attending physicians' explicit communication of expectations, implicit non-verbal and verbal cues and the program's organizational culture. CONCLUSIONS: Resident physicians' perception of attending physicians' explicit and implicit communication and residency programs organization culture has an impact on residents' experience with duty hour restrictions. Residency faculty and programs could benefit from explicitly addressing and supporting the challenges that residents perceive in complying with duty hour restrictions.

Impact of adding additional providers to resident workload and the resident experience on a medical consultation rotation.

BACKGROUND: Excellence in Graduate Medical Education requires the right clinical environment with an appropriate workload where residents have enough patients to gain proficiency in medicine with optimal time for reflection. The Accreditation Council for Graduate Medical Education (ACGME) has focused more on work hours rather than workload; however, high resident workload has been associated with lower resident participation in education and fatigue-related errors. Recognizing the potential risks associated with high resident workload and being mindful of the costs of reducing resident workload, we sought to reduce residents' workload by adding an advanced practice provider (APP) to the surgical comanagement service (SCM) and study its effect on resident satisfaction and perceived educational value of the rotation. METHODS: In Fiscal Year (FY) 2014 and 2015, an additional faculty member was added to the SCM rotation. In FY 2014, the faculty member was a staff physician, and in FY 2015, the faculty member was an APP.. Resident workload was assessed using billing data. We measured residents' perceptions of the rotation using an anonymous electronic survey tool. We compared FY2014-2015 data to the baseline FY2013. RESULTS: The number of patients seen per resident per day decreased from 8.0(SD 3.3) in FY2013 to 5.0(SD 1.9) in FY2014 (p < 0.001) and 5.7(SD 2.0) in FY2015 (p < 0.001). A higher proportion of residents reported "just right" patient volume (64.4%, 91.7%, 96.7% in FY2013, 2014, 2015 respectively p < 0.001), meeting curricular goals (79.9%, 95.0%, 97.2%, in FY2013, 2014 and 2015 respectively p < 0.001), and overall educational value of the rotation (40.0%, 72.2%, 72.6% in FY2013, 2014, 2015 respectively, p < 0.001). CONCLUSIONS: Decreasing resident workload through adding clinical faculty (both staff physician and APPs) was associated with improvements on resident perceived educational value and clinical experience of a medical consultation rotation.

Obesity and post-cardiopulmonary bypass-associated acute kidney injury: a single-center retrospective analysis.

OBJECTIVE: The authors specifically explored the association of obesity (based on body mass index [BMI]) and the risk of developing acute kidney injury after cardiopulmonary bypass (AKICPB). DESIGN: Single-center retrospective study. SETTING: Academic medical center. PARTICIPANTS AND INTERVENTIONS: After IRB approval, 376 eligible adults who underwent cardiac surgery with cardiopulmonary bypass between 2006-2010 were included in the final retrospective analysis. Patients undergoing "off-pump" procedures, cardiac transplants, repair of congenital heart disease, and patients with preoperative circulatory assist devices were excluded. RESULTS: The overall incidence of developing AKICPB in this population based on the Acute Kidney Injury Network serum creatinine criteria was 39% (147 of 376). Among the BMI classes, the morbidly obese cohort (ie, BMI>40 kg/m(2)) had a significantly greater risk of developing AKICPB than those in lower BMI classes. BMI>40 kg/m(2) was significantly associated with development of AKICPB even after accounting for covariates (ie, diabetes mellitus, hypertension, age, severity of illness, and CPB time) (overall p = 0.018). The odds ratio of AKICPB in the BMI>40 kg/m(2) cohort relative to BMI<25 kg/m(2) was 2.39 (95% CI: 0.98, 5.82; p = 0.055), with no significant difference in risk of developing AKICPB among the 4 lower BMI classes. CONCLUSION: BMI>40 kg/m(2) is associated with a significantly higher risk of developing of AKICPB.

Hydralazine associated pauci-immune glomerulonephritis.

Hydralazine is a medication that has been used to manage hypertension and heart failure. In this case series, we report 4 patients who presented to a large, Midwestern academic medical center on chronic hydralazine therapy with acute kidney injury, nephritic urine sediment on urine microscopy, and the simultaneous presence of autoantibodies suggesting both drug-induced lupus and drug-induced vasculitis. All of them had evidence of pauci-immune glomerulonephritis on kidney biopsy. All the patients reported in our series are white women older than 60 years who were receiving hydralazine for more than 12 months at a dose of 150 mg or more. On initial presentation, all had evidence of acute kidney injury with nephritic sediment. These patients also had high titers of serum anti-neutrophil cytoplasmic antibodies of the antimyeloperoxidase subtype and simultaneous presence of multiple autoantibodies. All of them subsequently underwent a kidney biopsy, which revealed pauci-immune glomerulonephritis. This case series draws rheumatologists' attention to the possibility of pauci-immune glomerulonephritis in patients taking hydralazine, highlights the presence of multiple antibodies in these cases, and questions the long-term use of hydralazine especially in an elderly female population.