Teaching fearlessness: a manifesto.

CONTEXT: Negative role modeling is a plague medical educators fight once students enter the clinical arena. The literature is replete on the fact that students routinely encounter faculty who display attitudes and behaviors inconsistent with the values taught throughout the medical curriculum, particularly in the preclinical years. APPROACH: Using a back and forth between the text of a third-year student's reflective essay and two of her faculty's observations on her negative encounters with several clinical faculty, the authors propose 'teaching for fearlessness.' DISCUSSION: Using Papadimos and Murray's use of 'fearless speech' derived from Foucault's thinking on parrhesia, the authors build a case that students should be encouraged to expose and challenge inequities on behalf of their patients, themselves and the profession at large. CONCLUSIONS: Medical educators should model and provide students with opportunities to develop and use 'fearless speech' as a way to reshape the culture of medical education and patient care.

Decline in creatinine clearance in a patient with glomerulomegaly associated with a congenital cyanotic heart disease.

Glomerulomegaly is associated with congenital cyanotic heart disease and has heretofore been considered a benign condition. We describe a patient with congenital cyanotic heart disease and glomerulomegaly. Deterioration of renal function was demonstrated by comparison of creatinine clearances measured at the time of kidney biopsy and 4 years later. No alteration in kidney histology other than glomerulomegaly and focal glomerulosclerosis at autopsy could account for this deterioration. This is the first description of deterioration of renal function in a patient with glomerulomegaly and congenital cyanotic heart disease. This observation may influence the management of patients with glomerulomegaly and congenital cyanotic heart disease who are potential recipients of heart or heart-lung allografts.

Influence of low-dose cyclosporine on the outcome of treatment with OKT3 for acute renal allograft rejection.

The outcomes of 51 consecutive patients who received OKT3 for acute renal allograft rejection were analyzed. Thirty patients (group 1), previously maintained on cyclosporine, continued to receive 50% of their maintenance dose of CsA during OKT3; 21 patients (group 2) either never received CsA or temporarily discontinued CsA during OKT3. All patients received low doses of azathioprine and prednisone during OKT3. Rejection was reversed by OKT3 in 90% of patients in group 1 and in 62% of patients in group 2. Continuation of CsA during OKT3 did not increase the incidence of serious infections following OKT3. Serum creatinine concentrations in groups 1 and 2 were comparable before, during, and after therapy with OKT3 suggesting that low doses of CsA do not induce graft dysfunction during therapy with the monoclonal antibody. In a subset of 22 prospectively studied patients, anti-OKT3 antibodies developed in 2 of 13 patients (15%) who continued low-dose CsA during OKT3 and in 6 of 9 patients (67%) in whom CsA was temporarily discontinued during OKT3. We conclude that administration of low doses of CsA during therapy with OKT3 may reduce the formation of anti-OKT3 antibodies without compromising reversal of rejection by the monoclonal antibody and without increasing the short-term risk of infection or graft dysfunction.

Bullous skin lesions associated with Yersinia enterocolitica septicemia.

An 86-year-old woman developed large bullae on both legs during the course of septicemia due to Yersinia enterocolitica. Although erysipelas-like lesions and erythema nodosum have been known to be associated with Yersinia infections, this is the first reported case with multiple bullae.

Primary hyperparathyroidism: hyperparathyroid crisis.

Hyperparathyroid crisis is a rare disease but should be suspected in acutely ill patients complaining of weakness, lethargy, nausea, vomiting, confusion and abdominal pain. Despite the variety of clinical manifestations, the syndrome forms a distinctive pattern which, in the presence of a serum calcium level greater than 16 mg/100 ml, should be recognized. The most difficult problem in diagnosis is the differentiation of hyperparathyroid crisis from ectopic parathyroid hormone-producing tumors. The disease is an endocrine emergency which requires prompt surgery after rapid correction of dehydration and hypercalcemia. The best results are achieved by removing offending parathyroid tissue within 72 hours after the onset of symptoms.