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Biomedical subjects

W D Mattern

Publications and source records attributed to W D Mattern.

15 recordsLinked to original sources

Computer databases of medical school curricula.

As the pace of curriculum reform in medical education has accelerated during the past decade, so too have demands on curriculum managers to supply increasingly detailed information about the curriculum. In response, a number of schools have joined together to begin work on designs for computer databases of the curriculum. The authors describe three of the most mature curriculum database prototypes, developed by groups at the medical schools of the University of North Carolina at Chapel Hill (UNC), The University of Maryland, and the University of Miami. All three groups have employed relational database management systems to organize information about each "instructional unit" in the preclinical curriculum, including a set of keywords defining the major concepts presented. The keywords are indexed to a controlled vocabulary, either the Medical Subject Headings (MeSH) or a MeSH derivative. The UNC database also employs a textfile management system to provide users with an overview of the entire curriculum. Future work will focus on identifying a suitable controlled vocabulary; capturing content in greater contextual detail; incorporating alternative learning formats, such as problem-based learning; creating links between content items and examination questions; and capturing information generated by student-patient interactions in clinical settings. As a result of recent collaboration with the Association of American Medical Colleges, work to define a prototype national database has begun and a consortium of interested schools is addressing further development activities.

Abstracting and Indexing

A computerized representation of a medical school curriculum: integration of relational and text management software in database design.

We describe the development of a computer-based representation of the medical school curriculum at the University of North Carolina at Chapel Hill (UNC-CH). Over the past seven years the Medical School's Office of Academic Affairs has employed both relational database and text management software to design an integrated curriculum database system. Depending on the function selected--exploring the curriculum, searching through course outlines, retrieving elective descriptions, identifying teaching faculty, or searching for specific topics--either text management or relational database management routines are activated in a manner transparent to the user. Initial evaluation of the system has been positive but highlights the need for a more robust biomedical language for use as a controlled vocabulary to index content. Efforts are now underway, with support from the Association of American Medical Colleges (AAMC), to engage other interested schools in the U.S. and Canada in collaborating on further development of a system.

Abstracting and Indexing

Selection of ESRD treatment: an international study.

Using the method of paired comparisons, we surveyed nephrologists in three different socioeconomic regions, North Carolina, Southern California, and Australia-New Zealand, to determine their preferences among the major end-stage renal disease (ESRD) treatment modalities. For comparison, we also determined how patients were assigned to the treatment modalities, based on registry data in the regions. Preferences were determined in for six standard ESRD treatment modalities--living related donor (LRD), four-antigen match, LRD two-antigen match, and cadaver (CAD) transplantation; and home peritoneal dialysis (HPD), home hemodialysis (HHD), and facility hemodialysis (FHD)--and for three categories of patients--patients with diabetes, patients over age 60, and patients in general. There was overall agreement in the ranking of treatments by the nephrologists from all three regions for each of the three patient categories; however, significant differences were noted between regions in preferences for certain modalities. Comparison within and between regions revealed striking disparities between preferences and practice. Analysis of these findings provides important insights into the process of ESRD treatment selection and identifies issues that merit further consideration.

Attitude of Health Personnel

Integrating and evaluating online bibliographic searching with clinical experiences of third year medical students.

In this paper, we describe the Clinical Health Information Retrieval Project (CHIRP), a trial program which provided online access to MEDLINE for third year students on medicine and pediatrics clerkships at The University of North Carolina School of Medicine. We present the project evaluation plan, report data from student questionnaires and interviews with the chief residents, clerkship directors, and clerkship coordinators, identify problems encountered, and address considerations for extension of the project.

Attitude of Health Personnel

A three-year experience with CCPD in a university-based dialysis and transplantation program.

A three-year experience with CCPD in adults and children in a university-based Dialysis and Transplantation Program is presented. Fifty-one patients began treatment from March of 1984 through February of 1987 (5 infants less than age three years, 11 children ages 3 to 17 years and 35 adults, of whom 8 had diabetes mellitus). The approach to treatment selection and the results of treatment including peritonitis rates and patient outcomes are described in the different groups. CCPD has become the treatment of choice for infants and children with ESRD awaiting kidney transplantation. In adults it is a considered a reasonable alternative, and may be the preferred dialysis, modality, in elderly patients, patients with diabetes mellitus and patients with severe cardiovascular disease who require or prefer assistance, who wish to be at home, and who tolerate hemodialysis poorly. This segment of the dialysis population appears to be increasing steadily.

Academic Medical Centers

Acute renal failure in Rocky Mountain spotted fever.

Review of clinical and pathologic data from ten fatal cases of Rocky Mountain spotted fever (RMSF) revealed the importance of acute renal failure in the clinical course and of multifocal perivascular interstitial nephritis as the principal pathologic lesion. In nine cases, Rickettsia rickettsii were demonstrated by immunofluorescence in the areas of vasculitis. Evidence was lacking for the role of disseminated intravascular coagulation, glomerulonephritis, or myoglobinuria in the pathogenesis of acute renal failure in these cases. Rickettsia-induced vascular injury led to acute renal failure by several mechanisms. Hypovolemia early in the course resulted in reversible, prerenal azotemia. Transient hypotension in midcourse produced acute tubular necrosis. In fulminant cases, preterminal circulatory collapse was associated with coma and oliguria. The interstitial nephritis could not be demonstrated conclusively to contribute to the acute renal failure.

Acute Kidney Injury

Vascular access in a University transplant and dialysis program. Results, costs, and manpower implications.

Vascular access has become the most common operation performed at North Carolina Memorial Hospital, Chapel Hill. Three hundred vascular access procedures performed between 1971 and 1975 were reviewed as to results, costs, and manpower commitment. Subcutaneous radial arterial venous fistula was the procedure of choice, with a 67% two-year patency and the lowest incidence of complications. An average of 1.7 operations per patient was necessary to maintain access. Patients used an average of 19 hospital days per year of dialysis for vascular access and an average of 35 hospital days per year of dialysis for all medical problems. Cost of hospitalization averaged $6,818 per patient per year of dialysis, and for vascular access alone averaged $3,452 per patient per year of dialysis. To create and maintain vascular access, 1,000 hours of operating room time were required, at an expense of $200,000. Vascular access in support of patients undergoing chronic hemodialysis requires a massive commitment of dollars, time, and personnel.

Animals

Failure of successful renal transplantation to reverse the dialysis-associated encephalopathy syndrome.

A patient is described who had been on home dialysis for two years before receiving a cadaver kidney transplant. In retrospect, minor speech difficulties were noted two weeks before the transplant. A week after the transplant the characteristic speech, movement and electroencephalographic (EEG) abnormalities of the dialysis encephalopathy syndrome abruptly presented. Relentless neurological deterioration ensued ending in death three months later despite excellent function in the transplant. The significance of this observation is related to current theories of pathogenesis.

Adult

Formaldehyde-induced hemolysis during chronic hemodialysis.

We investigated an outbreak of hemolytic anemia among patients on hemodialysis shortly after the installation of a new water-filtration system. Using in vitro technics, we demonstrated that a water-soluble inhibitor of red-cell metabolism could easily be extracted from the intact filters. Subsequent experiments showed this toxic substance to be formaldehyde, a potent reducing agent whose mechanism of action involves conversion of NAD to NADH. This alteration of the redox state of the erythrocyte leads to inhibition of glycolysis at the level of glyceraldehyde 3-phosphate dehydrogenase and rapid decline in cellular energy (ATP) stores. Because formaldehyde is widely used as a preservative for dialysis equipment, the toxicity of this agent for red blood cells is of clinical importance.

Adenosine Triphosphate

Venous embolus to a transplanted kidney. Diagnosis and treatment.

We are reporting the first case, to our knowledge, of a venous embolus to a transplanted kidney. The embolus occurred five days after transplantation of a cadaver kidney in a 31-year-old woman who was receiving estrogen-progesterone therapy for menorrhagia. Five hours after acute onset of left flank pain and anuria, the embolus was identified at the anastomosis of the donor renal vein to the external iliac vein. The embolus was manipulated distally in the external iliac vein and excluded by proximal division of the vein. Recovery was eventually complete, despite two major postoperative complications, acute tubular necrosis and a perirenal hematoma secondary to heparin sodium therapy. Radionuclide scanning was critically important in establishing the diagnosis and in assessing the potential for the kidney to recover from acute tubular necrosis. On the basis of this experience, we believe that prompt surgical intervention is indicated for acute venous occlusion.

Adult

Use of radionuclide imaging in the early diagnosis and treatment of renal allograft rejection.

Data are presented on the clinical application of radionuclide imaging to evaluate changes in cadaver transplant function in the immediate postoperative period. The method uses orthoiodohippuric acid (hippuran) administered IV, with scintillation imaging, and curve analysis by a digital computer. An initial study is always obtained 24 hours after transplantation. Serial studies are then obtained, as needed, to interpret the clinical course. Selected cases are presented which illustrate the use of this protocol in various clinical settings. In the oliguric patient serial studies have been of particular value. They have identified ATN so that over-enthusiastic treatment for rejection could be avoided. They have also identified acute rejection complicating ATN so that high dose steroid therapy could be administered appropriately. In the non-oliguric patient they have frequently contributed to the early diagnosis of acute rejection, and they have been useful in monitoring the effect and duration of treatment for severe rejection crisis. It is concluded that radionuclide imaging studies, when carefully applied and interpreted, are a valuable adjunct to the management of patients in this complex clinical setting.

Acute Disease

Treatment of peritonitis due to Curvularia and Trichosporon with amphotericin B.

Fungal infection is a rare cause of peritonitis among patients receiving continuous ambulatory peritoneal dialysis. Most cases of fungal peritonitis are secondary to candida infection. Two uncommon agents of fungal peritonitis are Curvularia species and Trichosporon beigelii. We report on two patients receiving peritoneal dialysis who presented for medical evaluation within a 1-week period. Fungal culture of the dialysis catheter was positive for Curvularia species in one case and for T. beigelii in the other. Both patients probably had acquired their infections through environmental contamination. Successful treatment of these infections includes removal of the peritoneal dialysis catheter and administration of intravenous amphotericin B.

Adult