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.

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.

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.

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.

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.

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.

Preferences of nephrologists among end-stage renal disease treatment options.

We surveyed 49 practicing nephrologists in North Carolina and determined their preferences among eight currently available end-stage renal disease treatment modalities using the method of paired comparisons. We also obtained background information about the nephrologists and their practices and data from the North Carolina Network about actual assignment of patients to treatment during the year prior to the survey. There was a striking congruence (p less than 0.001) of treatment preferences among the nephrologists. Although transplantation modalities were clearly preferred over both home and facility dialysis, and home hemodialysis was the preferred dialysis modality, relatively few patients received transplants or were trained for home hemodialysis. The elements contributing to treatment selection other than physician preference are discussed.

Toward consensus. Training in procedural skills for internal medicine residents.

The faculty, residents, and fellows of the Department of Medicine, University of North Carolina (UNC) School of Medicine, Chapel Hill, were surveyed about procedures that graduates of general internal medicine programs should be able to perform independently. More than 95% of the 177 respondents agreed that, of 71 procedures, all program graduates should be able to perform 13 without supervision. Our results are similar to those of studies at two other universities with geographically distant and philosophically different departments of medicine. The UNC faculty, fellows, and residents had significant differences of opinion on the need for training in 18 procedures. Residents tended to endorse training in the largest number of procedures, faculty the fewest, with fellows in between. The respondents' subspecialty affiliations did not influence their opinions on any of the procedural skills.

Infections associated with subclavian Uldall catheters.

During a 12-month period, the use of a subclavian vein Uldall catheter (UC) for hemodialysis or plasmapheresis in 27 patients was studied prospectively. Ten patients had ten UC site infections. Organisms associated with these infections included Staphylococcus epidermidis (five), Staphylococcus aureus (four), Proteus mirabilis (two), and Enterococcus (one). The four S aureus infections occurred 1, 2, 4, and 9 days after UC insertion, whereas the five S epidermidis infections occurred 6, 17, 17, 26, and 97 days after insertion. Five patients had associated bacteremias; in one of these patients, the bacteremia was the major cause of death. The incidence of UC site infection and bacteremia based was higher than the incidence of infection reported with any other type of vascular access for hemodialysis. Further studies are necessary to define whether the UC should be routinely employed for temporary vascular access.

Reversal of skin test anergy during maintenance hemodialysis by protein and calorie supplementation.

The effect of protein and calorie supplementation on the immune function of two maintenance hemodialysis patients was assessed. Before nutritional supplementation, both patients were anergic to four skin test antigens and had low relative percentages and absolute number of T lymphocytes. After 3 months of nutritional supplements both patients responded to in vivo skin testing to at least two antigens and in both patients, the relative percentage and absolute number of T lymphocytes increased. These two cases illustrate that the defect in cell-mediated immunity and impaired delayed cutaneous hypersensitivity which is known to occur in hemodialysis patients may be a reversible manifestation of protein-calorie malnutrition.