A 58-year-old man presented to the emergency department with acute urinary retention and abdominal pain. Laboratory tests revealed a serum creatinine level of 20 mg/dL and blood urea nitrogen of 263 mg/dL. A urinary catheter was placed and drained 2 L of urine. On examination, his skin was covered diffusely with a fine white powder known as "uremic frost" (Figure). These skin findings rapidly resolved over the next 48 hours with improvement of his severe uremia.Uremic frost is a manifestation of severe azotemia where tiny, yellow-white urea crystals deposit on the skin, resulting in a frosted appearance as sweat evaporates. 1 It is most frequently observed on areas of skin with eccrine glands and hair such as the scalp, neck, face, forearms, and chest and can be easily wiped away. 2 Uremic frost was first described by Hirschsprung in 1865 3 but is now a rarely observed physical examination finding in settings in which hemodialysis is readily available. Among 9 cases of uremic frost published in the literature, the mean blood urea nitrogen was 199 mg/dL and the mean serum creatinine level was 17.5 mg/dL. 2 Although a rare finding, uremic frost remains an important sign of severe renal failure, particularly in clinical settings with limited resources.
Lifelong learning is central to the identity of a physician. Yet rarely in medical education do we emphasize how to learn. Instead, we generally work under the assumption that physicians, who were proficient enough to succeed in their premedical years, are optimally skilled at learning during medical school, postgraduate training, and throughout their careers. This assumption goes untested, but when the desired outcome of education initiatives is enacting evidence-based practices, it is crucial that health systems use methods of learning that are the most effective, efficient, and durable.McEvoy et al 1 report the results of a single-center randomized cluster crossover trial using spaced education and retrieval practice with feedback to disseminate knowledge to clinicians at scale and measure the effect on prescribing patterns. After completing an app-based educational module with daily multiple-choice quiz questions over 4 weeks, clinicians were more likely to follow the evidence-based practice of prescribing balanced crystalloids rather than normal saline. This approach exemplifies how learning health systems can use evidence-based learning to improve clinical practice.
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