Tools for integrating women's health into medical education: clinical cases and concept mapping.

The authors describe two teaching tools, case-based learning and concept mapping, and how they support cross-disciplinary, multidisciplinary, and interdisciplinary learning, use a biopsychosocial model, and promote the integration of sex- and gender-based science into the medical curriculum. The process of case development at MCP Hahnemann University (MCPHU) is outlined in detail for a specific case. That case, which integrates three different components of women's health, is then presented in full. The authors then provide an example of a concept map dealing with women and alcohol use; the map defines current knowledge and serves as a blueprint for developing curricular goals and learning objectives for the topic. Properly constructed concept maps and cases help teach patient-centered approaches to problem solving, address sex- and gender-based differences in disease as well as in pathophysiology and pharmacology, integrate psychosocial issues-such as family dynamics, environmental stressors, access to health care, effective gender-based communication between patient and provider, and cultural variations-along with biomedical ones, and encourage a multidisciplinary approach to patient care. The authors maintain that these tools might be used to transform medical education by making it more integrated and interdisciplinary.

Barriers and solutions to implementing a new curriculum: lessons from the women's health education program at MCP Hahnemann School of Medicine.

The integration of new knowledge into the medical school curriculum is a difficult process. This article proposes effective strategies for overcoming obstacles to curricular integration of women's health and sex and gender topics. Some techniques developed to overcome barriers to the integration of new material into an existing curriculum include faculty development, faculty rewards, development of competencies and assessment tools, interdisciplinary team teaching, standardized patients, and reference resources. An interdisciplinary approach to implementing women's health education, as with most new curricular material, is endorsed for integration of the new field into the medical school curriculum. This proposed model results in general institutional participation and support, especially from senior level leadership. The outlined process enables students and faculty to learn techniques for incorporating emerging information in all disciplines, helping them to become "life-long learners."

The changing face of nephrology.

Projected requirements for nephrology physicians indicate a need for an increase in the number of nephrology trainees. In addition, government regulations are creating the climate to diminish the entry of international medical graduates into all residency programs. To meet the needs of renal patients, especially those with end-stage renal disease, and such areas of growth as nephrology research, more US medical graduates, particularly women and members of minority groups, will have to select nephrology as a career. This article discusses issues that this challenge raises for the specialty, including the impact on patient care, mentoring, and the use of nonphysician clinicians.

A model for integrating women's health issues into a problem-based curriculum.

The process of incorporating new material into an existing medical curriculum frequently produces lengthy debate, political maneuvering, and competition for curricular time. The faculty of the Women's Health Education Program at MCP-Hahnemann School of Medicine, developed a stepwise process, or framework, for including women's health teaching for students in the problem-based curriculum. This process can be applied to the integration of any body of information. The key elements of the process are to define the full scope of what needs to be taught, develop teaching objectives, identify opportunities to introduce the information into the curriculum, develop strategies that capitalize on existing curricula, enlist the collaboration of a broad range of key faculty, develop evaluation tools, and assess whether students have achieved the expected competencies.

Designing evaluations for a women's health education program.

Explicitly incorporating women's health into the medical school curriculum is a relatively new process for educators. Moreover, until recently, no standard definition of women's health had been developed. Because there are no specific evaluation designs for women's health programs, evaluators must adapt existing evaluation concepts to fit the needs of the program. Evaluation is a broad concept that includes assessments of knowledge, skills, and attitudes to reach decisions about program improvements. The purpose of this article is to describe methods of evaluating women's health programs, including how to tailor basic evaluation concepts to the program. Several areas of women's health programming are discussed as background to creating the innovative design for this new program evaluation. An example of an evaluation design for a totally integrated women's health curriculum is presented, including some preliminary data and a discussion of strategies for overcoming obstacles to initiating women's health evaluations.

Multidisciplinary women's health centers--a viable option?

The recognition that women's health encompasses more than reproductive health has led to changes in research and education, and a reexamination of health care delivery to women. Examination of care offered by traditional obstetrical/gynecological practices, besides those of internists and general medicine practitioners, reveals that the care of women is often fragmented. The health care needs of women can be met by an interdisciplinary team approach. The members of the interdisciplinary team include non-physician health care practitioners. Examples of successful models are discussed.

Sex and gender bias in anatomy and physical diagnosis text illustrations.

OBJECTIVE: To examine the sex and gender distribution of illustrations in two atlases, five anatomy texts, and five physical diagnosis texts. DESIGN: Of 4060 illustrations that were identifiable by sex and gender in 12 commonly used anatomy and physical diagnosis textbooks, 3827 were categorized by two reviewers as female, male, or neutral. RESULTS: Females were represented, on average, in 21.2% of the anatomy text illustrations; males were represented, on average, in 44.3%; 34.4% of the illustrations were neutral. Of the nonreproductive anatomy illustrations, a mean of 11.1% (range, 4.6% to 23.8%) depicted women and 43.1% (range, 35.4% to 56.2%) depicted men. Of nonreproductive anatomy illustrations, a mean of 45.8% (range, 27.2% to 59.9%) were neutral. Overall, the physical diagnosis text illustrations demonstrated a more equal sex and gender distribution (21.5% female and 24.8% male). However, in the reproductive chapters of the physical diagnosis texts, females were depicted in a mean of 71.1% (range, 63.2% to 79.0%) of the illustrations, while in the nonreproductive chapters, females were depicted in 8.8% of total illustrations. CONCLUSIONS: In anatomy and physical diagnosis texts, women are underrepresented in illustrations of nonreproductive anatomy. The finding that males are depicted in a majority of nonreproductive anatomy illustrations may perpetuate the image of the male body as the normal or standard model for medical education.

Renal disease in the elderly: the role of the renal biopsy.

The causes of renal disease in the young and the elderly vary in their frequency. There are many indications for renal biopsy in older patients, with the nephrotic syndrome (NS) being the most common, followed by acute renal failure. Biopsy does not carry a greater risk for older patients, but there is a greater risk of complications when there is coexistent renal insufficiency. Interpretation of the renal biopsy in elderly patients may be more complex because of changes associated with aging or intercurrent disease--arteriolar sclerosis and global sclerosis. A prospective study is needed to determine the exact prevalence of renal insufficiency, NS, and other renal diseases in noninstitutionalized elderly individuals and to determine the role of renal biopsy in making these determinations.

Treating hypertension in the elderly.

This article discusses various topics related to treating hypertension in the elderly, including pseudohypertension, systolic hypertension, characteristics of young and elderly hypertensive patients, diagnostic considerations in evaluating elderly hypertensive patients, and general therapeutic considerations.

Blood pressure of infants of hypertensive mothers: a two-year follow-up.

This study was designed to determine if the blood pressure (BP) of infants in the first two years of life relates to the presence of maternal hypertension during pregnancy. The BP of infants was measured at birth, and at 9, 18, and 24 months after delivery. Women with elevated BP in pregnancy or labor (n = 190) were enrolled as cases. Two-hundred-and-one normotensive women served as controls. The cases were divided according to the time BP became elevated, i.e., before or after 24 weeks of pregnancy, and intrapartum only. The largest of the case groups was hypertensive intrapartum only. A minority of the case mothers had proteinuria in association with elevated BP. There were no differences in BP between case and control infants at bith or at 9 and 18 months of age. However, by 24 months of age, the systolic BP of the infants of case mothers was higher (p less than .05) than that of the infants of control mothers. No differences in systolic BP could be attributed to the time of onset of maternal hypertension.

Free water reabsorption during saline diuresis in experimental enterococcal pyelonephritis in rats.

Inability to attain Umax after overnight dehydration is the earliest functional abnormality in human and experimental pyelonephritis caused by diverse microorganisms. In order to characterize the defect in Umax in experimental enterococcal pyelonephritis, another index of renal concentrating ability. TcH2O, was determined during saline loading. Normal TcH2O depends on adequate sodium chloride delivery and reabsorption in the ascending limb of Henle's loop and water reabsorption from the collecting duct. Rats with early pyelonephritis, 3 days after intravenous injection of enterococci, were compared with normal rats in studies of Umax during hydropenia and TcH2O during 1.2% saline infusion. Mean Umax in infected rats was significantly lower than in uninfected rats (1120 vs. 2767 mOsm/kg H2O) (p less than 0.01), but CIn in infected rats was not significantly different from that in uninfected rats (0.96 vs. 0.89 ml/min per 100 gm) (p less than 0.05). During saline diuresis, maximal Cosm/CIn was more than 35% in both the normal and infected rats. The relationship between TcH2O/CIn and Cosm/CIn was linear in both groups, and the r, slope, any y intercept of the regression equation of TcH2O/CIn vs. Cosm/CIn in infected rats were not significantly different from those in normal rats. During saline diuresis the regression of sodium excretion UNaV/CIn) vs. Cosm in infected rats was not significantly different from that in control rats. The finding of normal TcH2O during saline loading suggests that reabsorption of increasing amounts of sodium chloride from the ascending limb of Henle's loop and reabsorption of water in the collecting duct are normal in early pyelonephritis.

Experimental Candida albicans, Staphylococcus aureus, and Streptococcus faecalis pyelonephritis in diabetic rats.

Pyelonephritis was studied after an intravenous injection of Candida albicans, Staphylococcus aureus, or enterococcus in alloxan-diabetic rats and in water-diuresing or non-diuresing nondiabetic rats. The renal microbial populations of C. albicans or S. aureus were found to be greater than 10(5) colony-forming units per g for up to 42 days in diabetic rats, whereas the kidneys tended to become sterile in nondiabetic rats. No significant difference was found in the course of enterococcal pyelonephritis in diabetic versus control rats. The difference in the 50% infective dose for each microorganism between diabetic and control rats was less than or equal to log10. Neither duration of diabetes nor weight loss contributed to the greater and more sustained renal populations of C. albicans and S. aureus in diabetic rats. The inflammatory reaction in kidneys infected with S. aureus or C. albicans was greater in diabetic rats. Fungus balls associated with ureteral obstruction and gross multiple renal abscesses occurred in diabetic, but not in nondiabetic, rats infected with Candida. Growth of C. albicans and S. aureus in vitro in urine from diabetic rats was significantly greater than it was in urine from control rats. Addition of water or glucose to the urine of non-diuresing, nondiabetic rats significantly increased in vitro growth of S. aureus and C. albicans. These studies demonstrate greater severity of infection in the diabetic kidney due to S. aureus and C. albicans, which can be partially explained by decreased inhibitory activity of urine for these organisms in diabetic rats.

Sickle cell trait and hematuria associated with von Willebrand syndromes.

A von Willebrand syndrome was present in four patients with sickle cell trait and hematuria. The first two patients had severe anemia and active bleeding and received cryoprecipitate, with prompt cessation of hemorrhage. All of the patients had repetitive laboratory and clinical features; that is, reduced, but detectable, factor VIII-related antigen, heterogeneity of, and incongruities within, the coagulation studies performed by consistently defective platelet aggregation to ristocetin correctable only with normal plasma. Bleeding outside the genitourinary tract never was observed. Because of the focal nature of the hemorrhage, the hematuria may not have been perceived as part of a general hemorrhagic disorder and the diagnosis not pursued. These observations suggest that when sickle cell trait and hematuria occur together, a von Willebrand syndrome should be a major diagnostic consideration that ultimately may point toward a rational, effective, easily administered, and clinicially acceptable form of treatment with cryoprecipitate.

Effect of indomethacin and sodium meclofenamate on the renal concentrating defect in experimental enterococcal pyelonephritis in rats.

The present studies have confirmed a severe urinary concentrating defect early in the course of experimental enterococcal pyelonephritis. This defect in maximum concentrating ability was almost completely reversed immediately following indomethacin or sodium meclofenamate intravenously. This effect of indomethacin and sodium meclofenamate was transient and was not associated with a fall in numbers of enterococci per gram of kidney. Injection of indomethacin or sodium meclofenamate in noninfected rats had no effect on maximum renal concentrating ability. The potential mechanisms by which indomethacin and sodium meclofenamate, inhibitors of renal prostaglandin synthesis, could reverse a defect in maximum urinary concentration are discussed.

Content and distribution of water and electrolytes in maitenance hemodialysis.

A group of patients whose dietary potassium was unrestricted and who received 12-18 h of Kiil dialysis twice weekly against a bath containing no potassium, had body potassium concentrations (total body potassium/intracellular volume) of 7.6% lower than normal. Despite marked hypokalemia at the end of dialysis, suprisingly few electrocardiographic changes were seen. Another group of subjects, dialyzed fro 5-6 h thrice weekly against a bath containing 1 mEq/liter of potassium in a Dow dialyzer, showed more marked electrocardiographic abnormalities despite smaller alterations in transmembrane potassium gradients. Rapidity of establishment of potassium gradients is important as well as magnitude. The following changes occur in a single dialysis: 100 mEq of cell potassium and 20 mEq of extracellular potassium leave the body; 100 mEq of extracellular sodium enter the cells and 415 mEq of extracellular sodium leave the body; 3.5 liters of water leave the extracellular fluid, 2.5 liters into the bath and 1 liter into the cells.