Communication and family caregiving for Alzheimer's dementia: linking attributions and problematic integration

This qualitative interpretive study explores emergent themes related to family caregiving issues surrounding Alzheimer's dementia and highlights how caregivers deal with uncertainty. Problematic integration (PI) theory and attribution theory offer useful frameworks for better understanding family caregiving issues. Analysis of the transcribed interviews revealed several emergent themes related to uncertainty and making attributions regarding caregivers' loved ones. These themes included (a) caregiver attributions about pleasure and displeasure, (b) caregiver reactions to attributions, and (c) tools for managing uncertainty. These themes are linked with both PI theory and attribution theory. Limitations and future directions are addressed.     

A brief private group practice rotation changes junior medical students' perception of the surgical lifestyle

BACKGROUND: Surgical practice is often perceived by students as a stressful and demanding lifestyle in which personal and family issues take low priority. For students to receive a more balanced view of surgical practice, we instituted a private practice preceptorship during the last week of our junior surgery clerkship in 2001. We hypothesized that a 4-day preceptorship with surgeons in private practice would improve student perception of surgery as a valid career choice without compromising student educational performance. METHODS: From January to December 2002, 107 junior medical students were assigned to a brief preceptorship with volunteer private practice surgeons during the surgery clerkship (group 1), while 28 students did not participate in the preceptorship (group 2). We assessed student satisfaction via questionnaire and compared student grade performance between groups. RESULTS: One hundred two questionnaires (95%) were returned. Overall, the preceptor experience was rated positively (9.0+/-0.1) based on a 10-point Likert scale. All students commented on the educational or enjoyment value of the preceptorship, with 44% specifically stating that the lifestyle in private surgical practice appeared pleasant. Interestingly, 9% of students volunteered that the experience had swayed them to consider surgery as a career. Twenty-four percent of questionnaires contained negative comments, mainly concerning not enough "hands-on" participation. Grades for the clerkship did not decrease in group 1 when compared with group 2 or with historic controls (n=113). CONCLUSIONS: A 4-day private practice preceptorship at the end of the junior surgery clerkship favorably alters student perceptions of a surgical career without diminishing student grade performance.     

Acute hyperglycemia and the innate immune system: clinical, cellular, and molecular aspects

OBJECTIVE: To extract from the biomedical literature the reported effects of acute hyperglycemia on the major components of the innate immune system and to describe the clinical benefits of strict blood glucose control in certain patients. DATA SOURCE AND SELECTION: A Medline/PubMed search (1966 to July 2004) with manual cross-referencing was conducted, including all relevant articles investigating the effects of acutely elevated glucose levels on innate immunity. All publication types, languages, or subsets were searched. DATA EXTRACTION AND SYNTHESIS: Original and selected review articles, short communications, letters to the editor, and chapters of selected textbooks were extracted. Most recent and relevant clinical trials were reviewed for the introductory section to provide the clinical background to this topic. The selected bench laboratory articles were then divided into three main categories based on the timing of events: a) the early phase of the innate immune reaction; b) the cytokine network; and c) the phagocytic phase. The most obvious findings related to hyperglycemia included reduced neutrophil activity (e.g., chemotaxis, formation of reactive oxygen species, phagocytosis of bacteria), despite accelerated diapedesis of leukocytes into peripheral tissue, as well as specific alterations of cytokine patterns with increased concentrations of the early proinflammatory cytokines tumor necrosis factor-alpha and interleukin-6. Furthermore, a reduction of endothelial nitric oxide formation takes place, thus decreasing microvascular reactivity to dilating agents such as bradykinin, and complement function (e.g., opsonization, chemotaxis) is impaired, despite elevations of certain complement factors. CONCLUSIONS: Acute, short-term hyperglycemia affects all major components of innate immunity and impairs the ability of the host to combat infection, even though certain distinctive proinflammatory alterations of the immune response can be observed under these conditions.     

Peritoneal lavage: a useful diagnostic adjunct for peritonitis

Diagnostic peritoneal lavage (DPL) was used to aid in the rapid diagnosis of peritonitis in 138 patients for whom standard diagnostic criteria were not applicable because the patients had altered sensorium, were elderly, or had multiple medical problems. There were abnormal results in 77 patients, and all but one patient had peritonitis. Sixty-five patients had lesions that could be cured only by operative means; 54% of this group of extremely ill patients survived. Of 61 patients with negative results of DPL, only one had intraperitoneal inflammation (acute cholecystitis), which occurred 4 days after DPL. We believe DPL is a useful procedure for the detection of peritonitis in a critically ill subset of patients for whom the standard diagnostic criteria were not available.     

Addition of "near-miss" cases enhances a quality improvement conference

Medical error is a prominent public issue today. Surgeons, for many decades, have conducted regular and meaningful reviews of most untoward events, which deserve improvement. "Near-miss" is a useful focus for such a conference, in that it avoids a focus on ultimate personal guilt and minimizes exposure to litigation (ie, a nonevent).