Insights from outstanding rural internal medicine residency rotations at the University of Washington.

PURPOSE: Despite being well suited to provide the breadth of care needed in rural areas, few general internists become rural physicians. Little formal rural residency training is available and no formal curricula exist. For over 25 years the University of Washington School of Medicine has provided elective WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) rural residency rotations to expose residents to the rewards and challenges of rural practice. This study identified the characteristics of outstanding rural residency rotations. METHOD: The key preceptors at three outstanding rural residency sites were interviewed about their experiences, teaching strategies, and opinions about curriculum. Their responses were categorized. Seven university-based residents and eight training at WWAMI sites recorded and rated the value of over 1,500 learning encounters. RESULTS: The preceptors agreed that outstanding rotations were led by enthusiastic preceptors who served as role models for excellence. These preceptors provided residents with meaningful responsibilities and emphasized independent decision making based on the history and physical examination. They stressed supervised independence and self-directed learning with frequent structured feedback for residents. The residents rated the learning value of patient encounters in rural locations significantly higher than that of those in university clinics. CONCLUSIONS: Exceptional rural residency experiences involve excellent role models who provide meaningful responsibility and emphasize core skills using a learner-centered approach. Rural training experiences should be supported, and the suggestions of outstanding preceptors should be used to develop and disseminate a curriculum that will better prepare residents for rural practice.

Potentiation of warfarin anticoagulation associated with topical methyl salicylate.

OBJECTIVE: To report a case of international normalized ratio (INR) elevation resulting from the administration of topical methyl salicylate in a patient whose INR was previously stable while she received warfarin anticoagulation. CASE SUMMARY: A 22-year-old white woman presented with an INR of 12.2 after applying a topical pain-relieving gel to her knees daily for eight days. The potentiation of the warfarin anticoagulation was attributed to the low-dose methyl salicylate contained in the product. DISCUSSION: Methyl salicylate is systemically absorbed through the skin in measurable amounts, and may increase warfarin action by affecting vitamin K metabolism or by displacing warfarin from protein-binding sites. While several investigators have reported this interaction with use of high-dose methyl salicylate, this case indicates that a significant interaction can occur with the use of lower topical doses of methyl salicylate as well. CONCLUSIONS: Healthcare providers and patients taking warfarin must be aware of the potential hazard of using topical methyl salicylate in combination with warfarin.

False-positive captopril renography in patients taking calcium antagonists.

UNLABELLED: Captopril-enhanced renography is the noninvasive test of choice for the diagnosis of renovascular hypertension. Previous studies have shown that bilateral symmetrical changes are associated with many renal conditions. However, patients with normal renal angiography occurred in our institutions despite this scintigraphic pattern, and no known conditions could explain these results. The purpose of this study was to evaluate the diagnostic implications of bilateral symmetrical renal function deterioration on captopril renography. METHODS: Eighty-six captopril renal scintigraphies performed at two centers to exclude renovascular hypertension (50 consecutive patients after the observation of a bilateral symmetrical renal function deterioration despite a normal angiogram at one institution and 36 patients with both captopril renography and renal angiography at the other institution) were retrospectively reviewed. Baseline and captopril-enhanced renograms were obtained with 99mTc-mercaptoacetyltriglycine and a 1-day protocol in 50 patients; 36 patients were studied using 99mTc-diethylenetriamine pentaacetic acid and a 2-day protocol. Bilateral symmetrical renal function deterioration was detected. RESULTS: Ten patients presented with bilateral symmetrical renal function deterioration on their captopril renograms; 9 of them were taking calcium antagonists (p=0.015). Control studies performed in 5 patients without these medications demonstrated normal captopril renograms in 4 and persistent renal dysfunction in 1. No explanation was found for the patient who was not taking any medication. Angiograms performed in 5 patients showed normal renal arteries. An 11th patient who was taking a calcium antagonist showed dysfunction of his one kidney on the captopril renogram but no artery stenosis on the renal angiogram. CONCLUSION: Calcium antagonists can cause false-positive captopril renograms. These medications should be stopped before captopril renography, and physicians should be aware of this possible drug interaction if bilateral symmetrical renal function deterioration is seen on a patient's captopril renogram.

Urinary tract dilatation in utero: classification and clinical applications.

A morphologic classification of in utero urinary tract dilatation is presented. Ninety-two hydronephrotic fetal kidneys diagnosed with ultrasound were graded according to the proposed classification. The findings suggest that grade I dilatation (anteroposterior diameter of the renal pelvis less than 10 mm) should be considered normal. Grades II and III constitute an intermediate hydronephrosis, requiring postnatal urologic surgery in nearly half the cases. Grade IV (moderate dilatation of the calyces, with easily identified residual renal cortex) and grade V (severe dilatation of the calyces with atrophic cortex) are clearly pathologic and require neonatal corrective surgery. It is hoped that use of this simple and practical classification will facilitate communication and comparison of results in the literature.

Ureteropelvic junction stenosis: antenatal ultrasonographic diagnosis, postnatal investigation, and follow-up.

Between January 1981 and October 1984, the diagnosis of ureteropelvic junction (UPJ) stenosis was suspected in 39 fetuses after routine obstetrical ultrasound (US) examination. Postnatal investigation revealed that the initial diagnosis had been accurate in 30 cases (77%). There were 35 UPJ stenoses in 30 patients. The degree of dilatation of the renal pelvis (grades III, IV, or V) observed postnatally with sonography as well as the obstructive excretory pattern noted by renal isotope scanning were used as criteria to determine the need for early postnatal pyeloplasty (performed in 25 patients), which relieved the obstruction and, in the majority of patients, improved renal structure and function.

Cystic hypernephroma mimicking an hepatic mass.

A renal mass was correctly identified with Tc-99m sulfur colloid liver-spleen scan and Tc-99m glucoheptonate scintigraphy while CT scan was misinterpreted as showing a hepatic lesion.