Explanatory style and the performance of residents.

PURPOSE: Explanatory (i.e. attributional) style has been shown to be related to performance, especially when attributions are pessimistic. This study tested whether this relationship was present for residents. METHOD: The Attributional Style Questionnaire and the Brief Symptom Inventory were completed by 45 residents. Clinical rotation evaluations and in-training examination scores were used as performance measures. RESULTS: Explanatory style and emotional distress were not related to performance, although explanatory style was correlated with emotional distress. Overall, residents displayed an optimistic explanatory style. CONCLUSION: The absence of a relationship between explanatory style and performance may be due to the tendency for this resident sample to be optimistic. Also, common indicators of residency performance may not accurately measure clinical and academic performance.

Uterine inversion: a life-threatening obstetric emergency.

BACKGROUND: Acute puerperal uterine inversion is a rare but potentially life-threatening complication in which the uterine fundus collapses within the endometrial cavity. Although the cause of uterine inversion is unclear, several predisposing factors have been described. Maternal mortality is extremely high unless the condition is recognized and corrected. METHODS: MEDLINE was searched from 1966 to the present using the key phrase "uterine inversion." Nonpuerperal uterine inversion case reports were excluded from review except when providing information on classification and diagnostic techniques. A summarized case involving uterine inversion and a review of the classification, etiology, diagnosis, and management are reported. RESULTS AND CONCLUSIONS: Although uncommon, if left unrecognized, uterine inversion will result in severe hemorrhage and shock, leading to maternal death. Manual manipulation should be attempted immediately to reverse the inversion. Tocolytics, such as magnesium sulfate and terbutaline, or halogenated anesthetics may be administered to relax the uterus to aid in reversal. Intravenous nitroglycerin provides an alternative to the tocolytics and offers several pharmacodynamic advantages. Treatment with hydrostatic pressure may be attempted while waiting for medications to be administered or for general anesthesia to be induced. In the most resistant of inversions, surgical correction might be required.

A 'stages of change' approach to helping patients change behavior.

Helping patients change behavior is an important role for family physicians. Change interventions are especially useful in addressing lifestyle modification for disease prevention, long-term disease management and addictions. The concepts of "patient noncompliance" and motivation often focus on patient failure. Understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower physician frustration during the change process. In this article, we review the Transtheoretical Model of Change, also known as the Stages of Change model, and discuss its application to the family practice setting. The Readiness to Change Ruler and the Agenda-Setting Chart are two simple tools that can be used in the office to promote discussion.

Contrast sensitivity vision testing: new screening technology for family physicians.

Contrast sensitivity vision testing is the new technology in visual screening. Easy to administer and quick to perform, contrast sensitivity vision testing appears to be cost-effective for use by family physicians. It is a more sensitive indicator of ocular disease than traditional Snellen acuity testing and may detect ocular pathology at an early stage when Snellen acuity is still normal.

Alcohol abuse in the elderly.

Alcoholism is often difficult to recognize in the elderly. Information about alcoholic behavior cannot always be accurately extrapolated to older drinkers. Consequences of alcohol abuse and responses to treatment may be quite different in young and elderly alcoholics. Treatment must focus on such day-to-day problems as loneliness, loss of independence and declining health. Gentle persistence is required in guiding the patient to an awareness of the problem.

Anorexia and weight loss in the elderly. Causes range from loose dentures to debilitating illness.

Differentiating between anorexia (loss of appetite) and weight loss (documented loss of pounds) can be difficult, but the same causes and treatments apply to both. Gastrointestinal and metabolic disorders, cardiopulmonary disease, the presence of a neoplasm or infection, and use of certain drugs are possible medical causes. Inadequate nutritional intake can result from the inability to obtain and prepare foods, dietary restrictions, intolerance to certain foods, and poor oral and dental health. Social factors that can greatly reduce an elderly person's interest in food include loneliness, depression, isolation, and self-consciousness because of hearing and visual impairments. Some problems, such as alcohol abuse or inappropriate use of certain medications, may be revealed only with difficulty, and some of the problems mentioned may overlap. Although the physician may find assessment of anorexia or weight loss in the elderly a challenge, it usually responds well to corrective measures.

A survey of resident perceptions of effective teaching behaviors.

Family practice has shown increasing interest in clarifying what constitutes effective teaching skills. This investigation enlists the support of family practice residents to further clarify which teaching behaviors and skills most significantly contribute to their medical education. Family practice residents in all 24 programs in Ohio were surveyed to determine their perceptions of the effectiveness of 38 separate clinical teaching behaviors. A rank order listing of these behaviors is presented to aid in organized faculty development programs, as well as to provide guidelines individual faculty can follow to improve family practice resident education. Factor analysis of the residents' responses indicate that clinical competence, providing constructive feedback to residents, and demonstrating a positive attitude toward teaching residents are perceived as necessary attributes of the most effective clinical teachers.

Usefulness of liposomes carrying losefamate for CT opacification of liver and spleen.

Losefamate, a hepatobiliary contrast agent, was encapsulated into liposomes to increase its ability to opacify the liver and spleen on computed tomographic (CT) images. Multilamellar lipid vesicles (lecithin, cholesterol, and stearylamine, in 4:1:1 molar ratio) containing iosefamate in their aqueous phase were prepared. Seven dogs received intravenous injections of 100-300 mg I/kg in one of three forms: encapsulated, unencapsulated, or a mixture of the two in equal parts. Animals that received the opaque vesicles had marked opacification of their livers, bile ducts, gallbladders, spleens (maximum 106 H enhancement), and gastrointestinal tracts. Spleen CT values (an indicator of encapsulated material uptake) were always higher in these dogs than in the animals receiving equivalent amounts of unencapsulated iosefamate alone. At the high-dose level, liver uptake of the encapsulated materials was also greater. Liposome-encapsulated hepatobiliary contrast agents are effective liver and spleen opacifiers for CT imaging in the dog.

Liposome dialysis for improved size distributions.

A technique is described which allows reproducible preparation of liposomes with improved size-frequency distributions. The recent procedure of extrusion of crude liposome dispersions through controlled-pore polycarbonate membranes is used to control the upper limit of liposome diameter. Subsequent dialysis, using the same type of membrane, can remove the majority of liposomes smaller than a predetermined size. The pattern of dialysis of a liposome preparation is a function of the size-frequency distribution (as well as the membrane pore size) and can be used to approximate the distribution and/or used to monitor the reproducibility of liposome preparations.

Liposome disposition in vivo II: Dose dependency.

The dose-dependent disposition of extruded multilamellar (diameter approximately 1 micrometer) negatively charged liposomes containing entrapped [14C]inulin was studied in mice. Mice received 1500, 300, or 15 mumoles of liposomal lipid/kg iv. Carbon 14 levels were measured in the blood, liver, spleen, and carcass for 72 hr. A pronounced saturation effect, consistent with the known dose behavior of other colloids, was seen at early times; it was manifested by higher dose values in the blood and spleen but by lower liver values as the dose increased. This dose effect was attenuated in the liver but was maintained in the spleen at later times, and percent dose values approached plateau values in all tissues for all doses at later times. [14C]Inulin was used at the liposomal marker because of its inability to enter cells (or, presumably, leave them if delivered there by liposomes) in its free form. An early decline in carbon 14 levels (over the first 48 hr) was seen in the liver for the low and medium doses. Because of the known ability of blood factors to cause liposomes to leak their contents, this decline was interpreted as being a loss of [14C]inulin from extracellularly bound liposomes during this period. Moreover, the plateau carbon 14 levels at later times were interpreted as approximating the true level of intracellular inulin delivery by the liposomes.

Liposome disposition in vivo: effects of pre-dosing with lipsomes.

The effect of a high, intravenous dose of extruded multilamellar liposomes (1.1 g lipid/kg body weight) upon the subsequent ability of mouse tissues to take-up or bind a second intravenous dose of similar liposomes encapsulating 14C-inulin has been studied in vivo. The first and second doses were separated by either 1,5 or 24 hours. All tissue levels were measured one hour after the second dose. Controls received only the second dose. When the two doses were separated by one hours, 14C-levels in liver were depressed 6-fold and blood levels rose 29-fold relative to controls. However spleen uptake of lipsomes increased to three times control levels. When the two doses were separated by 24 hrs, the first dose had only a minimal effect on the disposition of the second dose. The results are consistent with a reversible blockade of hepatic, but not spleenic uptake and/or binding sites, by the first dose and indicate that adjusting a liposome dose (i.e. number of lipsomes) or use of a drug-free liposome pre-dose may be a useful technique for reducing hepatic uptake, increasing the circulation life time and/or modifying the tissue disposition properteries of therapeutic liposomes without changing liposome composition or size.