Notes and emendations (August 31, 1999) by Webmaster Curtis L. Atkin are [bracketed].
"He that sinneth before his maker let him fall into the hand of the physician" - Ecclesiastes 38:15. [For the remainder of this essay, he/him/his is intended to include she/her/hers].
Almost as surely as death and taxes, each of us, sinner or no, will from time to time "fall into the hand of the physician." Nowadays, there is such a profusion of different sorts of doctors that it is often hard to sort out who does what. Doctors seem to use even more confusing words to describe themselves than they do to describe diseases. What follows is a field guide to the medical doctor.
Attending - The doctor who has responsibility for a patient's care while in a hospital. Although there may be many junior doctors (interns, residents, and fellows) as well as doctors consulting from other specialties in a complicated case, the Attending is the doctor who should ultimately made decisions in conjunction with the patient, after discussing with those he has asked to consult. The Attending is the one to whom you need to speak if you are uncertain what is going on ... but you may have to be persistent in getting hold of him!
Doctor - Although most often used to refer to a Medical Doctor (M.D.), the term may also be applied to a Doctor of Osteopathy (D.O.). It is also used to describe a scholar who holds a doctoral degree in any one of a number of non-medical fields, from divinity to dentistry, from music to mathematics, from physics to philosophy. As if this confusion were not enough, the degree of Doctor of Philosophy (Ph.D. or D. Phil. at different universities) is usually gained not in philosophy, but in science, including the medical sciences. Thus the holder of the degrees M.D., Ph.D. had likely done postgraduate research after obtaining his M.D.
Family Physician - A physician who cares for all members of the family. His training has been in all the branches of medicine, including pediatrics as well as obstetrics and gynecology, and he should be board certified as a Family Physician. He undertakes very similar work to a General Practitioner but has had at least three years specific residency training for it. A Family Physician or General Practitioner is usually the best doctor to see you first for any problem unless you are certain that it should be handled by a particular specialist. It has been said that there is no more dangerous place for a patient with a medical condition to be than in a surgical ward, and vice versa!
Fellow - Not a synonym for mate [friend] or boy, but a doctor who has completed his three years of residency and who is undergoing still further training usually in medical research or in preparation for taking sub-specialty board examinations....The word fellow is used also in an entirely separate sense to indicate a doctor who has shown excellence and experience in his field, e.g. a Fellow of the American College of Physicians (FACP).
General Practitioner (Prak tish in uh) - A doctor who has completed his internship, or possibly more training, and who undertakes the general primary care of patients. He performs similar functions to a Family Physician, but likely received his training before the formal training requirements and board examinations for certification as a Family Physician were set up.
Intern (In tern) - A doctor who has just completed his medical student training and who is working for a compulsory year in a hospital before gaining his full certification to practice medicine independently. Interns may have an exaggerated idea of their knowledge of medicine and a cynic has said that it is wise to be treated by one before he finishes his internship and while he still knows it all.
Internist (In tern ist) - A doctor who has specialized in the study of internal medicine and has passed his board examinations in Internal Medicine. Internal Medicine is the branch of medicine dealing primarily with diagnosis, and with treatment without operations. The word physician, as opposed to a surgeon, is often used as a synonym for internist.
Nephrologist (Nef rol o jist) - An internist who specializes in diseases of the kidney. Paradoxically, nephrologist spend much of their time caring for patients whose kidneys don't work, or who don't even have kidneys any more. They then deal with everything except the kidneys. This is not as stupid as is seems, because a doctor who understands well the workings of the kidneys and their impact on other parts of the body is also well placed to understand what happens when the kidneys do not work.
ObGyn (O B G Y N) - combines the functions of Obstetrician (Ob stuh trish un) or specialist in disorders of pregnancy, and the delivery of children, and Gynecologist (Guy nuh col o jist) or specialist of diseases of the female organs.
Resident - A doctor undergoing further training after his internship, to prepare him for sitting the boards (examinations) in a particular specialty. The residency is usually spent largely in hospital practice....
The editor has suggested that our readers might be interested to learn what donations of various sizes will accomplish in the Alport Study. For comparison are included the average annual costs of treatment (dialysis or kidney transplantation) of end stage kidney disease.
Amount would approximately cover the cost of
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How does dialysis correct the imbalances which occur in a patient with failing kidneys? You recall that kidneys which have lost most of their function can no longer regulate the excretion of salt and water, can no longer excrete waste products from the protein we eat, and fail to produce hormones which stimulate red blood cell production and regulate the integrity of bones. Regular treatment with dialysis corrects, at least partially, each of these abnormalities and reduces the symptoms of renal failure.
The ordinary types of treatment, hemodialysis and peritoneal dialysis, work on the principle of hemodiffusion . Imagine a bottle containing two different fluids, for instance blood and dialysis solution, separated from each other by porous membrane. In the artificial kidney machine the membrane is a complex chemical polymer, made very thin, which allows small molecules such as salt, water, urea, creatinine, acids, potassium and the like to pass from one fluid compartment to the other. In the case of the peritoneal dialysis, the membrane is the thin layer of cells which line the abdominal cavity. The peritoneal membrane is less uniform than an artificial membrane, and allows some larger molecules, up to 20 times the size of urea, to pass from blood to dialysate. This may be an advantage, because there is evidence that these unidentified "middle-sized molecules" may cause some of the symptoms of uremia.
With both types of membranes, small chemical molecules diffuse easily from the fluid where they are in high concentration (blood) to the fluid of low concentration (dialysate) and are discarded with the dialysate. This works well for urea, creatinine, potassium and acid. Relatively large amounts of these substances are removed during a dialysis procedure, to the patient's benefit. However, simple diffusion does not remove very much salt and water. The dialysis solution has about the same concentration of salt (sodium chloride) as does the blood, and there is no driving force for salt to move across the membrane from blood to dialysate. Some other trick is needed to remove accumulated salt and water from dialysis patients.
The arrangement used during treatment with the artificial kidney is called hemofiltration . A pump is used to apply pressure on the blood side of the dialysis membrane, or a vacuum is created on the dialysate side. This results in a head of hydraulic pressure forcing water from the blood to dialysate, and dragging salt along with the water. Depending on the degree of pressure and the porosity of the membrane, large quantities of both water and salt, can be removed. When the patient is being treated by peritoneal dialysis, the force for water and salt removal is osmosis . Do you recall from junior high school science how this force works? When the concentration of particles on one side of a permeable membrane is higher than on the other, an osmotic force exists. Water moves to the side of the higher concentration of particles, to dilute it down and equalize the solutions. In practice, a high concentration of the simple sugar, glucose, is added to peritoneal dialysis solution. While in the abdominal cavity, the dialysate increases in volume because water and salt are drawn from blood into the peritoneal cavity. The volume of peritoneal dialysis solution drained and discarded is greater than the volume originally placed in the peritoneal cavity, resulting in net salt and water removal from the patient.
The efficiency of artificial membranes used in dialysis machines is continually improving. Newer dialysis ("high flux" membranes) permit the removal of fantastic quantities of water and salt, permit the diffusion of the larger "middle molecules" and can shorten a hemodialysis treatment by one-half. More sophisticated machines and closer nursing supervision are required, increasing the cost. However, patients on high flux dialysis prefer the shortened dialysis time, tolerate the treatment better and feel stronger between treatments.
Unfortunately, dialysis machines don't produce hormones . Dialysis patients are anemic, can develop bone disease, and have abnormal renin regulation. Next time we'll discuss how these problems can be managed.
For those of you who keep track of when our newsletters are distributed, you will notice that it has been almost ten months since our last newsletter. The day after I had the last newsletter typed and ready for print I gave birth to a beautiful baby girl. In addition, our family moved to Mead, Washington earlier this year. It seems no matter how hard I try, there's just always something that gets me behind in my duties!
There is much attention in the media these days about the great strides being made in tracking defective genes in major diseases such as muscular dystrophy. These major organizations have national fund raisers, big name celebrities and millions of dollars to fund the research. The Hereditary Nephritis Foundation is funding research to accomplish the same as these major organizations with occasional local fund raisers, big hearted people (without national fame) who contribute their time, talents and efforts and hard earned money donated by you and I. The road is long and sometimes it seems that what we are trying to achieve is impossible, but it isn't. The research that Dr. Atkin and his colleagues are doing will lead us to answers about Hereditary Nephritis.
There is a lot we can each do to help reach our goal. Talk to your friends and neighbors about Hereditary Nephritis and our organization. They may be able to give us the assistance we need to find the answers.
My mother and brother have nephritis. I have uncles who died of nephritis years before I was born. I have two beautiful children. I want to do all I can to make their lives better and to keep them from feeling the pain and ravages of this awful disease. I hope you will join me to do the same for your children and your loved ones who could also be affected by Hereditary Nephritis.
Thank you to everyone who contributed to this newsletter. We hope you find this publication informative and interesting. We encourage you to support HNF with your input, any related articles and other information of interest as well as your donations.
[Reprinted from The Daily Spectrum newspaper, St. George, Utah, Sunday, June 4, 1989, page 6.]
NYU Medical Center: The growing success of transplant surgery has dramatically increased the demand for donor organs, according to a surgeon at New York University Medical Center.
"On any given day in the United States, about 15,000 people are waiting for an urgently needed kidney, heart, liver or pancreas," said Dr. Richard Weil, professor of surgery. "With the success rate for transplant surgery steadily improving, the main limiting factor is the shortage of people willing to provide organs."
An article in an upcoming issue of the center's Health Letter states that in 1988, some 10,000 kidney transplants were performed in the U.S. along with about 2,000 heart transplants, 1,500 liver transplants and 200 pancreas transplants.
"The success rate for cadaver kidney transplants after one year has increased from 50 percent in the mid-1970 to more than 75 percent today," Weil said. "Liver transplants have a 65 percent success rate, compared to 25 percent 10 years ago, and 80 percent of heart transplants are currently successful."
In addition, pancreas transplants are becoming more frequent, and small intestine transplants may move within a few years from the experimental stage to a viable treatment option, he said.
"For people with end-stage heart and liver diseases, survival is not possible without transplantation," Weil asserted. "Since it appears unlikely that artificial organs can be greatly improved in the near future, enlarging the supply of donor organs is essential."
"The two sources of transplantable organs are living persons and human cadavers. The pool of potential living kidney donors can be expanded from close relatives to include distant relatives or such genetically unrelated individuals as spouses and friends."
There is a very small risk [about one-tenth of 1 percent] of mortality for living kidney donation.
The increase in donor organs must come mainly from people who designate organs for transplant after they are dead.
"These organs come from patients who have sustained brain death in a hospital and whose hearts are still functioning," Weil observed. "Donating an organ is the ultimate act of charity. It is a difficult decision to make under such extremely stressful circumstances as a close relative's brain death. It is far better to decide on organ donation before such situation arise."
In many states, organ donor cards are attached to driver's licenses. Other verifiers of organ-donation commitment are close relatives, one's personal physician, or one's attorney.
CHICAGO (AP): Failure to take medication is the leading cause of organ rejection among kidney transplant patients three months beyond surgery, a study shows, and that's a particularly bitter pill for doctors.
"It's obviously very important in transplanting because the consequences can be fatal, and it's wasted money and effort," said Dr. Robert Schweizer, professor of surgery at the University of Connecticut.
Non-compliance appears to be highest among patients younger than 20, blacks, Hispanics, and low-income individuals regardless of race, said Schweizer, who conducted the study.
"Any transplant surgeon with 20 years' experience has cases that break your heart," said Dr. Paul Peters, chairman of surgery at the University of Texas Southwestern Medical Center at Dallas.
Schweizer said in a report presented before the American Society of Transplant Surgeons that failure to take medication was noted among 47 to 260 patients, or 18 percent, who received kidneys at Hartford Hospital from 1971 to 1984.
Patients who suffered organ rejection or died within three months of surgery were excluded from the study.
An average of four years passed before the errant patients stopped taking their medication and exhibited organ rejection, Schweizer said. Transplant patients must take drugs every day of their lives to keep their bodies' natural immune system from rejecting the organ.
A subsequent study conducted from 1984 to 1987 found 30 of 196 kidney recipients, or 15 percent, failed to take their medication, Schweizer said. An average of two years passed before organ rejection was noted.
Eighty-two kidney recipients were evaluated from 1987 to 1988, following staff efforts to boost compliance. Only two refused to take their medication, or 2.4 percent, Schweizer said.
Liver and heart recipients were included in the third study.
Three of the 13 liver patients were repeatedly noncompliant, two of whom died. Three of the 50 heart recipients did not take their medication, one of whom died.