Successful use of problem-based learning in a third-year pediatric clerkship.

OBJECTIVE: To determine the effect of changing from lectures to a problem-based learning (PBL) curriculum on student knowledge accrual and satisfaction with the didactic portion of a clerkship. DESIGN: Study of cohorts before and after PBL introduction and in comparison with unchanged medicine clerkship. SETTING: Third-year pediatric clerkship at 5 clinical sites. PARTICIPANTS: The PBL curriculum was introduced in the 1996 academic year. The 2 classes before the intervention served as historic controls (n = 319), whereas the 2 classes after PBL served as the intervention group (n = 320). INTERVENTION: Small groups of students worked through 6 PBL cases representing common pediatric illnesses. MAIN OUTCOME MEASURES: Knowledge was assessed with the pediatric and internal medicine subject examination of the National Board of Medical Examiners (NBME); student satisfaction was assessed by an anonymous end-of-rotation questionnaire. RESULTS: Scores on the pediatric subject examination improved significantly from means of 69.2 and 70.0 in the historic control group to 73.6 and 74.2 in the PBL cohort (P <.01). Scores on the internal medicine subject exam during the same time periods remained unchanged until the second year after the change (69.1 and 70.2, respectively, before the change; 70.1 and 72.4, respectively, after the change). Analysis of variance results indicated a significant increase in pediatric subject examination scores associated with the introduction of PBL (P <.01). Overall student satisfaction with the pre-PBL lecture series was 3.3, whereas PBL sessions received a score of 4.3. CONCLUSION: Use of PBL in a clinical clerkship was associated with higher scores on the NBME subject examination and increased student satisfaction. These results should encourage the use of PBL during the clinical years.

CaseLog: semantic network interface to a student computer-based patient record system.

We have developed a computer program called CaseLog, which serves as an exemplary, computer-based patient record (CPR) system. The program allows for the introduction of the students to issues unique to patient record systems. These include record security, unique patient identifiers, and the use of controlled vocabularies. A particularly challenging aspect of the development of this program was allowing for student entry of controlled vocabulary terms. There were four goals we wished to achieve: students should be able to find the terms they are looking for; once a term has been found, it should be easy to find contextually related terms; it should be easy to determine that a sought-for term is not in the vocabulary; and the structure of the vocabulary should be dynamically altered by contextual information to allow its use for a variety of purposes. We chose a semantic network for our vocabulary structure. Within the processing power of the equipment we were working with, we achieved our goals. This paper will describe the development of the vocabulary, the design of the CaseLog program, and the feedback from student users of the program.

Bibliographic control of audiovisuals: analysis of a cataloging project using OCLC.

The staff of the Quillen-Dishner College of Medicine Library cataloged 702 audiovisual titles between July 1, 1982, and June 30, 1983, using the OCLC database. This paper discusses the library's audiovisual collection and describes the method and scope of a study conducted during this project, the cataloging standards and conventions adopted, the assignment and use of NLM classification, the provision of summaries for programs, and the amount of staff time expended in cataloging typical items. An analysis of the use of OCLC for this project resulted in the following findings: the rate of successful searches for audiovisual copy was 82.4%; the error rate for records used was 41.9%; modifications were required in every record used; the Library of Congress and seven member institutions provided 62.8% of the records used. It was concluded that the effort to establish bibliographic control of audiovisuals is not widespread and that expanded and improved audiovisual cataloging by the Library of Congress and the National Library of Medicine would substantially contribute to that goal.

Selective hypoaldosteronism in infancy. Report of a case.

A 10-week-old female infant had anorexia, failure to thrive, and dehydration. Hyponatremia and hyperkalemia were found, along with urinary salt loss and increased plasma renin activity. Plasma deoxycorticosterone, corticosterone, and urinary 18-hydroxycorticosterone levels were increased. The plasma aldosterone levels were inappropriately reduced given the degree of sodium depletion present, while urinary aldosterone concentrations were persistently low. These are characteristic findings of an enzymatic defect in the synthesis of aldosterone involving 18-dehydrogenase, also known as methyl oxidase defect type 2. The infant responded to therapy with fludrocortisone acetate, including catch-up growth in both length and weight. The disease is transmitted by an autosomal recessive gene.

Endocrine complications of topical and intralesional corticosteroid therapy.

Four previously healthy children acquired skin problems that were treated with topical or intralesional fluorinated corticosteroids. Three developed signs that suggested Cushing's syndrome 1-4 months after initial treatment. Investigation showed low plasma cortisol levels and inadequate response to corticotrophin stimulation. After 7 months of treatment with topical steroids the fourth child presented with failure to thrive; during a febrile illness he had a convulsion followed by acute hypotension which responded to parenteral corticosteroid administration. Adrenal function was not studied in this patient. Although fluorinated corticosteroids seldom lead to overt adrenal suppression in children, they may impair pituitary-adrenal responses in some. Such patients should be given oral or parenteral steroid cover in the event of illness or trauma.

CT-determined canine kidney and urine iodine concentration following intravenous administration of sodium diatrizoate, metrizamide, iopamidol, and sodium ioxaglate.

Following 24-hour fasting and fluid deprivation, sequential changes in CT numbers of the canine kidney were determined in 4 dogs, each of whom received, at intervals, IV sodium diatrizoate, metrizamide, iopamidol, and sodium ioxaglate at a dose of 500 mgI/kg body weight. The urinary bladder was catheterized for baseline determination of urine osmolality and, subsequently, urine volume and CT number, CT number of the bladder urine from 0 to 10 minutes and from 10 to 20 minutes post-injection was obtained by scanning known dilutions of urine in vitro. Peak renal cortical enhancement occurred within 2 minutes of bolus injection and was not dependent on the chemical make-up of the contrast agent. Peak medullary enhancement occurred within 3 minutes of bolus injection. Peak medulla CT number following sodium diatrizoate was significantly less than that following metrizamide (P less than 0.025) or iopamidol (P less than 0.01). Peak medulla CT number was significantly less following sodium diatrizoate (P less than 0.01), metrizamide (P less than 0.01) and iopamidol (P less than 0.05) than following sodium ioxaglate. Urine iodine concentrations followed a similar pattern, with significant differences as follows: sodium diatrizoate less than metrizamide = iopamidol less than sodium ioxaglate. It was concluded that the investigational agents metrizamide, iopamidol, and sodium ioxaglate have theoretical advantage for excretory urography. Differences in renal handling of these agents are detectable, with CT scanning as differences in renal medullary enhancement and urine iodine concentration.

Cholesteatoma of the upper urinary tract.

Cholesteatoma of the urinary tract is a rare condition which can be diagnosed radiographically. The radiographic findings of stringy intraluminal defects or nodules that may lightly calcify or coalesce to form a discrete mass in association with calculi and/or obstruction are characteristic. A history of chronic urinary tract infection, renal colic, and desquamated epithelial cells in the urine further support the diagnosis.