Objectives: The aim of this study was to determine the prevalence of bile cast nephropathy (BCN) in autopsied cirrhotic patients and to correlate BCN with clinical and laboratory data to direct attention to this underrecognized renal complication of liver failure.Methods: We assessed 114 autopsy cases of cirrhosis for the presence of renal intratubular bile casts using Hall stain for bile. Presence of bile casts was correlated with etiology of cirrhosis, clinical and laboratory data, and histologic findings.Results: Bile casts were identified in 55% of cases. The most common etiology of cirrhosis was hepatitis C virus (HCV) infection (52%), and serum creatinine (P = .02) and serum urea nitrogen (P = .01) were significantly higher in the Hall-positive group. Conjugated bilirubin was below 20 mg/dL in 90%, and levels below 10 mg/dL were noted in 80% of cases.Conclusions: To our knowledge, this is the largest study of BCN in human subjects and a first report describing the association of BCN with HCV-related cirrhosis. We demonstrated that in the face of protracted chronic hyperbilirubinemia, bile casts are formed at much lower bilirubin levels than previously thought. Furthermore, we proposed an algorithm to assist in better identification of bile casts.

OBJECTIVES:The issue of levamisole-adulterated cocaine is emerging as a rapidly growing public health concern due to an increasing number of reports describing its role in cutaneous vasculitis and agranulocytosis. Of note, levamisole is recognized as a contaminant in 69% of the cocaine used within the United States.METHODS:We describe a patient who was a chronic cocaine user and developed systemic vasculitis characterized by polyarthralgia, bullous skin lesions, agranulocytosis, and antineutrophil cytoplasmic antibody-positive rapidly progressive glomerulonephritis.RESULTS:The skin biopsy specimen demonstrated leukocytoclastic vasculitis. The renal biopsy specimen revealed pauci-immune necrotizing and crescentic glomerulonephritis and unusual deposits with medium electron density composed of granules, microspherules, and rare single fibrils on electron microscopy.CONCLUSIONS:The electron microscopic features of levamisole-adulterated cocaine toxicity are novel findings that are presented for the first time, to our knowledge, in this report.

The Family Home Visit Program (FHV) is part of the year-long 1st year Practice of Medicine course, and involves local multi-generational families and students from the schools of medicine and allied health. The FHV program differs considerably from more traditional community-based clinical practice experience: visits to an ill individual, community-based experiences designed for reminiscence by the "patient," or multiple community-based agency courses/visits. The focus of the cur-rent intergenerational FHV is on interaction between families and students in a non-clinical setting (e.g., relating to patients as "people"), learning about the social and familial context in which health and illness occur and the healthcare priorities of family members. In year 1 of the program, 200 medical students, 40 OT/PT students and 68 families participated; 204 medical students, 70 OT/PT students and 70 families participated in year 2. The development, implementation, evaluation and outcomes of the program across two years are discussed. (C) 2005 by The Haworth Press, Inc. All rights reserved.

Most medical school curricula do not equip students with adequate attitudes, knowledge and skills to care for elderly populations. We describe an effective geriatric curricular infusion model compatible with preserving the overall curricula schema. Course and clerkship directors, staff and faculty from the Office of Educational Development, Center on Aging, curriculum committee and Associate/Assistant Deans of Education, and faculty from the schools of medicine, nursing, and allied health collaborated in the effort. Each of these components and institutional financial commitment were critical to successful basic science and clinical geriatric content infusion addressing the American Geriatric Society (AGS) Core Competencies. Delivery modalities included problem-based learning cases, lectures, standardized patient portrayals for teaching and assessment, and experiential activities with elderly. Assessments were conducted and outcomes tracked in several ways, including: (1) annual course reviews, focus groups, and student evaluations; (2) mandatory geriatrics 4th year graduation competency exam; and, (3) AAMC Graduation Questionnaire responses. Initial data indicate that student knowledge and competencies have increased with increasing exposure in the desired areas, and support infusion as a viable approach to enhancing gerontology and geriatric curricular content.

Most medical school curricula do not equip students with adequate attitudes, knowledge and skills to care for elderly populations. We describe an effective geriatric curricular infusion model compatible with preserving the overall curricula schema. Course and clerkship directors, staff and faculty from the Office of Educational Development, Center on Aging, curriculum committee and Associate/Assistant Deans of Education, and faculty from the schools of medicine, nursing, and allied health collaborated in the effort. Each of these components and institutional financial commitment were critical to successful basic science and clinical geriatric content infusion addressing the American Geriatric Society (AGS) Core Competencies. Delivery modalities included problem- based learning cases, lectures, standardized patient portrayals for teaching and assessment, and experiential activities with elderly. Assessments were conducted and outcomes tracked in several ways, including: (1) annual course reviews, focus groups, and student evaluations; (2) mandatory geriatrics 4th year graduation competency exam; and, (3) AAMC Graduation Questionnaire responses. Initial data indicate that student knowledge and competencies have increased with increasing exposure in the desired areas, and support infusion as a viable approach to enhancing gerontology and geriatric curricular content.

Overview of the Geriatrics Curriculum At the University of Texas Medical Branch (UTMB) geriatrics is a content thread woven into the four-year curriculum. Multiple modalities are used to teach and provide experiences that support the identified learning objectives for geriatrics in the curriculum. The geriatrics curriculum is composed of a series of lectures, problem-based learning (PBL) cases, standardized patient encounters, and community experiences that are woven into the overall curriculum. Table 1 shows the general geriatrics content as of September 2003. We are developing a geriatrics week rotation in conjunction with the fourth-year neurology clerkship that will be implemented in June 2004.TABLE 1: Highlights of Geriatrics/Gerontology Curricular Content and Assessment Curriculum Management and Governance Structure The four-year curriculum is under the direction of the dean of the School of Medicine, with the assistance of associate dean for educational affairs, associate dean for regional medical education and director of clinical assessment and professional development, and the assistant dean for educational affairs. Additionally, the Curriculum Committee provides oversight and governance of the curriculum and is assisted by the Curriculum Research Committee, Operations Committee, Course Directors Committee, and Clerkship Directors Committee. Figure 1 shows the governance of the medical school curriculum. The geriatrics medical educator is administratively housed in the School of Medicine, Office of Educational Development. This placement has facilitated the infusion process and the accessibility of educational resources for the project.FIGURE 1. Curriculum GovernanceIn 1998 Years One and Two underwent a curriculum change to an integrative medical curriculum based on problem-based learning. The AAMC/Hartford grant was received in 2000. A geriatrics medical educator was hired in late 2000 to carry out the goals of the grant. At that time, the general “template” for geriatrics content infusion was proposed and adopted in theory, with the specifics to be worked out with the course and clerkship directors. Years Three and Four underwent a review during 2000–01. Recommendations for changes were announced in 2002 that included a balance between ambulatory and inpatient experiences and primary-specialty experiences. In addition, all clerkships were required to implement formal inclusion of basic science principles and significant patient experiences. Elective time was included in the third year and a required basic science selective was incorporated in Year Four. These changes were implemented for Year Four in 2003–04 and changes to Year Four will occur in 2004–05. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The curriculum was undergoing changes for the reasons identified in the previous section. These changes were precipitated by an overall change in the course content and structure in the first two years, and subsequently the third- and fourth-year clinical courses. Additionally, multiple sources identified the need for increased geriatrics and gerontology content. The need to increase geriatrics content in the curriculum was identified by external review and internal self-study. The external reviews were provided in context of a site visit conducted by the Liaison Committee on Medical Education (LCME). Their report identified several content areas, deemed as crucial to the curriculum, for which sufficient evidence of coverage was not apparent. Gerontology and geriatrics was one of these areas. After the LCME visit, a survey was conducted with the Years One and Two course directors to assess whether the specific content areas were covered and the depth of the coverage. Results of the survey showed that gerontology/geriatrics areas were insufficiently addressed in the first two years of the curriculum. These changes and shifts provided a receptive environment for the infusion of geriatrics content. Theme for the Geriatrics Program UTMB has specifically taken an integrative, rather than a stand-alone, approach to including geriatrics in the undergraduate medical school curriculum. It is our belief that geriatrics medicine is interdisciplinary and that care of elderly patients is based on a life-span (integrated) approach, rather than one divorced from the related content. As reflected in Table 1 and List 1 specific themes are included in the course or clerkship content and related to the overall learning objectives.LIST 1. Integrated Curriculum Educational Goals and Learning Objectives for Geriatric and Gerontology Medical CurriculumLearning Outcomes for the Geriatrics Curriculum Following an institutional retreat and task force reports designed to develop educational principles for the integrated medical curriculum, the following objectives for geriatrics and gerontology education were delineated (see List 1). The learning objectives identified during the planning phase served as a guiding force during the development and implementation of the geriatrics content. Additional goals of the geriatrics/gerontology content infusion included an increase in the percentage of geriatric community experiences in the Practice of Medicine course and clinical clerkships, improving the quality and quantity of problem-based cases portraying persons over the age of 65 years, enhancing clinical skills assessments in geriatrics areas, and increasing the interest of students in fields of geriatrics care. Special Programs Seniors/mentor program In 2001, UTMB introduced a Family Home Visit Program as part of the community learning experience in the Practice of Medicine 1 Course. In this program, medicine, occupational therapy and physical therapy students visit multigenerational community families in their homes. At least one family member must be over age 65. Community partnerships There are community partnerships, however at the present time, none are geriatrics-specific. Geriatric standardized patients/simulations Geriatric standardized patients are utilized for teaching and assessment purposes. In the Practice of Medicine (POM) 1 and 2 (first- and second-year courses), students practice history taking and physical exam skills with geriatric standardized patients. In the clinical years, as well as for POM 1 and 2, assessment of student competency occurs with patients of all ages. All students must successfully complete a fourth-year competency exam, which includes a minimum of at least one geriatric patient scenario. Faculty development programs for geriatrics curriculum UTMB's Office of Educational Development sponsors the18-month Scholars in Education program for faculty that focuses on teaching methods and curriculum development. Each session geriatrics faculty participate as scholars. Additionally, three geriatrics faculty have been awarded academic development awards in clinical geriatrics education. Student interest group UTMB started a Geriatrics Student Interest Group on campus in 2001. Activities include movie night (movies with seniors as main characters), learning lunches, dinner lectures, grand rounds, and local and national conferences. In 2002, the Geriatrics Student Interest Group was chartered as an official campus student organization. Palliative care and end-of-life courses UTMB does not have palliative care or end-of-life courses per se. End-of-life issues are a part of the Practice of Medicine 2 course and a part of ethics modules that students are exposed to throughout the curriculum. A series of three end-of-life care Web-based cases has been developed and used in various courses. Resulting Pedagogical Changes Geriatrics serves as a model for a discipline-specific content to be integrated at UTMB. This required recognition of the importance of geriatrics so that content would be readily accepted within courses and/or clerkships. The template and learning objectives are applicable across the curriculum, and as such have been applied by other disciplines. Application of Computer Technology The major use of computer technology for presenting geriatrics content in the curriculum has been through the introduction of geriatrics Web-based interactive cases. Currently there are nine cases completed and four additional cases close to completion. These cases are leveled for the learner and used in both the courses and clerkships. As the geriatrics rotation week is being developed for implementation in the fourth year neurology clerkship, additional cases and Web-based instructional media will be employed. Students’ Clinical Experiences in Geriatrics Students rotate through the Acute Care of the Elderly (ACE) unit, the geriatrics specialty clinics (osteoporosis, falls, incontinence), and county geriatrics clinics with geriatrics faculty. The Program’s Assessment and Evaluation Instruments Students are responsible for more geriatrics-related knowledge and skills on objective standardized clinical examinations and other exams. A requirement for graduation is the successful completion of a geriatrics integrated clinical skills assessment exam. Additionally, data is collected on each of three cohorts, three data points each, on student attitudes and knowledge towards aging. This instrument was developed at Southern Illinois University School of Medicine and was adopted for use at UTMB in the ongoing administration of longitudinal measures within the School of Medicine. Resources Required In order to launch the geriatrics components of the curriculum, it has taken supplemental funding from the Arthur Vining Davis Foundation, and a subcontract from the SWAP-CGEC (i.e., the South, West, and Panhandle Consortium of Geriatrics Education Centers). Additionally, it has taken the time of six to eight faculty members on a regular basis to develop content and check accuracy of materials, and a contributed effort of the technical expertise of the Web-based case template designer to manage the Web-based case implementation. Requirements to Sustain the Program Funding for a full-time geriatrics medical educator is a necessity to maintain and continue growth, provide direction, and oversee to the program. Continued demonstration of the importance of geriatrics in the integrative curriculum and discernment of additional areas for inclusion are important functions of this individual. Unanticipated Outcomes Unanticipated outcomes have come in many forms. Geriatrics is seen on this campus as the “model” for content thread infusion, and the process has been adopted as a standard by the curriculum committee in the School of Medicine. The neurology/geriatrics clerkship combination in the fourth year is a good complement to the other curricular changes. Impact of External Funding Without external funding, the integration of geriatrics content would not be nearly as fully developed as it has become. External funding has made it possible to support a full-time geriatrics medical educator, the geriatrics education efforts of two geriatrics faculty members, and to support initiatives for the interdisciplinary student group. For further information, contact Robert E. Beach, MD, at 〈[email protected]〉.

Since the initial report by De Wind and Payne in 1976 on intestinal bypass surgery for the treatment of obesity, several cases of d-lactic acidosis have been described. This syndrome is characterized by episodic increases in levels of plasma d-lactate (an isomer of l-lactate) produced from bacterial carbohydrate metabolism. d-Lactate is the anion responsible for the associated metabolic acidosis as described by Oh and colleagues. Surgical procedures that cause anatomic or functional short bowel facilitate the overgrowth of d-lactate-producing gram-positive organisms (such as Lactobacillus species, Streptococcus bovis, Bifidobacterium species, and Eubacterium species) at the expense of the gramnegative flora. Treatment of d-lactic acidosis has been successful with carbohydrate restriction and oral antibiotics, such as vancomycin, metronidazole, clindamycin, tetracycline, neomycin, and kanamycin. In patients who are taking metformin to control their diabetes, the development of metabolic acidosis is an alarming sign, because mortality is high if the acidosis is metformin induced. It is thus important to differentiate between the two conditions, give appropriate treatment, and prevent further recurrences of either condition.

Adenosine is released from renal cells, and extracellular adenosine may influence the effects of ischemia on medullary tubule segments by altering ion transport or renal hemodynamics. While adenosine release and excretion are enhanced during renal ischemia, the specific sites of renal adenosine production have not been completely elucidated. In the present study, extracellular adenosine concentrations in suspensions of renal outer medulla and thick ascending limb segments were quantitated by reversed-phase high performance liquid chromatography. Media from other medullary (OM) suspensions incubated for 8 and 15 minutes at 0% oxygen contained significantly greater amounts of adenosine (1.404 +/- 0.21 and 2.034 +/- 0.27 ng/micrograms protein, respectively), when compared to values obtained from media of suspensions incubated for equivalent periods under non-hypoxic conditions (8, 20, and 95% oxygen), 0.78 +/- 0.05 (8 min) and 1.37 +/- 0.21 ng/micrograms protein (15 min). Similarly, adenosine release was greater in medullary thick ascending limb (mTAL) suspensions incubated for 8 minutes at 0% versus 8% oxygen (0.81 +/- 0.17 vs. 0.20 +/- 0.12 ng/micrograms protein, respectively). Moreover, the observed increase in adenosine release by thick ascending limbs at 0% oxygen could be inhibited completely by either furosemide or ouabain. These studies demonstrate that: 1) the renal medulla and medullary thick ascending limb are sites of adenosine release; 2) adenosine release by the mTAL is enhanced significantly during hypoxic conditions; and 3) the increased release of adenosine during hypoxia appears to be related to ion transport and oxidative metabolism, as the increased release was prevented by two disparate inhibitors of transport in this segment.