Department of Surgery: University of Maryland School of Medicine.
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Baltimore↗
Biomedical subjects
Bruce Jarrell
Publications and source records attributed to Bruce Jarrell.
A basis for electronic cognitive simulation: the heuristic patient.
Although medical trainees are expected to become expert quickly and safely, limited electronic methods are available to rehearse medical cognition for common outpatient and non-emergent inpatient problems. We conducted a series of formal observational sessions designed to determine what interaction requirements are desirable for student rehearsal of medical management by using an electronic patient. The studies utilized both manual and electronic methods for a student to evaluate and manage patients with medical and surgical problems. We observed the following major requirements for an effective simulation experience: the user must have a trial-and-error experience with the patient; the user must have unconstrained access to query and treat the patient; anatomic and physiologic values in the patient must change appropriately in response to user actions; and the user must be able to control certain time-related aspects of the simulation. When these requirements are implemented within a simulation, user-directed management of an electronic patient, by itself, becomes a strong aid to learning by trial- and-error techniques. We conclude that the heuristic patient is a practical and useful concept. Once fully developed, it would allow rehearsal of patient care decision making, intrinsically demonstrating trainee knowledge deficits, and resulting in self-directed learning.
Clinical Clerkship↗
A decade of experience with renal transplantation in African-Americans.
OBJECTIVE To evaluate the strategies instituted by the authors' center to decrease the time to transplantation and increase the rate of transplantation for African-Americans, consisting of a formal education program concerning the benefits of living organ donation that is oriented to minorities; a laparoscopic living donation program; use of hepatitis C-positive donors in documented positive recipients; and encouraging vaccination for hepatitis B, allowing the use of hepatitis B core Ab-positive donors. SUMMARY BACKGROUND DATA The national shortage of suitable kidney donor organs has disproportional and adverse effects on African-Americans for several reasons. Type II diabetes mellitus and hypertension, major etiologic factors for end-stage renal disease, are more prevalent in African-Americans than in the general population. Once kidney failure has developed, African-Americans are disadvantaged for the following reasons: this patient cohort has longer median waiting times on the renal transplant list; African-Americans have higher rates of acute rejection, which affects long-term allograft survival; and once they are transplanted, the long-term graft survival rates are lower in this population than in other groups. METHODS From March 1990 to November 2001 the authors' center performed 2,167 renal transplants; 944 were in African-Americans (663 primary cadaver renal transplants and 253 primary Living donor renal transplants). The retransplants consisted of 83 cadaver transplants and 17 living donor transplants. Outcome measures of this retrospective analysis included median waiting time, graft and patient survival rates, and the rate of living donation in African-Americans and comparable non-African-Americans. Where applicable, data are compared to United Network for Organ Sharing national statistics. Statistical analysis employed appropriate SPSS applications. RESULTS One- and 5-year patient survival rates for living donor kidneys were 97.1% and 91.3% for non-African-Americans and 96.8% and 90.4% for African-Americans. One- and 5-year graft survival rates were 95.1% and 89.1% for non-African-Americans and 93.1% and 82.9% for African-Americans. One- and 4-year patient survival rates for cadaver donor kidneys were 91.4% and 78.7% for non-African-Americans and 92.4% and 80.2% for African-Americans. One- and 5-year graft survival rates for cadaver kidneys were 84.6% and 73.7% for non-African-Americans and 84.6% and 68.9% for African-Americans. One- and 5-year graft and patient survival rates were identical for recipients of hepatitis C virus-positive and anti-HBc positive donors, with the exception of a trend to late graft loss in the African-American hepatitis C virus group due to higher rates of noncompliance, an effect that disappears with censoring of graft loss from that cause. The cadaveric renal transplant median waiting time for non-African-Americans was 391 days compared to 734 days nationally; the waiting time for African-Americans was 647 days compared to 1,335 days nationally. When looking at all patients, living and cadaver donor, the median waiting times are 220 days for non-African-Americans and 462 days for African-Americans. CONCLUSIONS Programs specifically oriented to improve volunteerism in African-Americans have led to a marked improvement in overall waiting time and in rates of living donation in this patient group. The median waiting times to cadaveric renal transplantation were also significantly shorter in the authors' center, especially for African-American patients, by taking advantage of the higher rates of hepatitis C infection and encouraging hepatitis B vaccination. These policies can markedly improve end-stage renal disease care for African-Americans by halving the overall waiting time while still achieving comparable graft and patient survival rates.
Adolescent↗