Search

Medical Education 2012: 46: 974-982 Objectives This study was intended to examine whether a marketing research approach improves understanding of medical specialty selection by medical students. This approach likens students to consumers who are deciding whether or not to purchase a product (specialty). This approach proposes that when consumers' criteria match their perceptions of a product's features, the likelihood that they will purchase it (select the specialty) increases. This study examines whether exploring students' selection criteria and perceptions of various specialties provides additional insights into the selection process. Methods Using a consumer behaviour model as a framework, a questionnaire was designed and administered to Year 6 (final-year) students in 2008 and 2009 to elicit information on their knowledge about and interests in various specialties, the criteria they used in specialty selection, and their perceptions of six specialties. Results A total of 132 (67%) questionnaires were returned. In many instances, consistency between selection criteria and perceptions of a specialty was accompanied by interest in pursuing the specialty. Exceptions were noted and pointed to areas requiring additional research. For example, although > 70% of female students replied that the affordance of a controllable lifestyle was an important selection criterion, many were interested in obstetrics and gynaecology despite the fact that it was not perceived as providing a controllable lifestyle. Minimal overlap among students reporting interest in primary specialties that possess similar characteristics (e.g. paediatrics and family medicine) demonstrated the need to target marketing (recruitment) efforts for each specialty individually. Conclusions Using marketing research concepts to examine medical specialty selection may precipitate a conceptual shift among health care leaders which acknowledges that, to attract students, specialties must meet students' selection criteria. Moreover, if consumers (students) deem a product (specialty) unattractive, it may need to be examined further to improve its appeal. [ABSTRACT FROM AUTHOR]

Sepsis and septic shock remain major causes of mortality and morbidity worldwide. Previously, high dose corticosteroids were used to dampen the inflammatory response but studies and meta-analyses showed this to be of no benefit and possibly detrimental. Subsequently, low dose corticosteroids were used in the treatment of sepsis and septic shock with the hypothesis that these conditions are associated with relative adrenal insufficiency. Although some studies showed promising results larger studies and meta-analyses have failed to reproduce these effects and the use of corticosteroids in the treatment of sepsis and septic shock remains controversial. We review the current literature and guidelines regarding low dose corticosteroid use in the management of sepsis and septic shock. [Copyright &y& Elsevier]

Abstract: Background: Patients receiving intensive care frequently need pharmacologic support of their blood pressure because of shock. In some patients, shock is so severe that extremely high doses of vasopressors are needed to elevate their blood pressure. Objective: We sought to ascertain the maximal dose of vasopressors administered to patients, and to describe the population of patients receiving vasopressors in one intensive care unit. Methods: All adult patients admitted in 2001 to a 10-bed surgical unit in a university hospital, and receiving a vasopressor agent for 1 hour or more, underwent recordings of their demographic data, diagnoses upon admission, Acute Physiological and Chronic Health Evaluation (APACHE) II scores, vasopressors (including type, initial dose, dose increases, and maximal dose), number of days administered, complications, and mortality. Results: Of 689 patients whose charts were reviewed, 72 received vasopressors. The mean age was 65 ± 21.4 years, and 66% were male. The mean APACHE II scores were 24 ± 6.2. The administration of .5 μg/kg/minute of norepinephrine or epinephrine resulted in 96% sensitivity and a specificity of 76% for the likelihood of mortality. Using Kaplan-Meyer curves, those patients receiving less than .5 μg/kg/minute demonstrated an 80% 6-year survival. All 17 patients receiving more than 3.8 μg/kg/minute of norepinephrine, and all 5 patients receiving more than 9.6 μg/kg/minute of epinephrine, died. The length of time during which patients received less than their maximal dose of vasopressors had no influence on survival (P = .4). The elderly (aged ≥75 years) and the young (aged <75 years) had the same intensive care unit survival rates when receiving vasopressors. Conclusion: In this study, little likelihood of intensive care unit survival was evident when patients received more than .5 μg/kg/minute of norepinephrine or epinephrine. [Copyright &y& Elsevier]

To compare inter-laboratory and inter-assay measurements of total cortisol in patients with septic shock and to evaluate current recommendations for diagnosis of corticosteroid insufficiency in septic shock. In the multinational CORTICUS study duplicate serum samples were taken before and after corticotropin stimulation tests in patients with septic shock. Serum cortisol was measured in paired samples, one being measured by the chemical laboratory of each participating site and the other by a central laboratory using an electrochemiluminescence immunoassay. Cortisol levels measured by tandem mass spectrometry were used as a ‘gold standard’ reference method in a subset of samples. A total of 425 corticotropin tests (850 cortisol samples) were available for comparison of local and central laboratory measurements. The concordance correlation coefficient between central laboratoty immunoassay and local hospital assays was 0.98 (CI 0.97–0.99) when the immunoassay of one manufacturer was used and 0.60 (CI 0.54–0.65) when immunoassays of different manufacturers were used. The comparison with the reference method of mass spectrometry showed concordance correlation coefficients ranging from 0.43 to 0.97 depending on the assay under study. Diagnosis of corticosteroid insufficiency was diverging due to inter-assay variations in up to 27% of cases. In samples taken from patients in septic shock, there was a high inter-assay variation of total serum cortisol. Comparisons with a reference method revealed both over- and underestimations of true cortisol levels. These inter-assay variations in samples of patients with septic shock complicate the diagnosis of corticosteroid insufficiency. [ABSTRACT FROM AUTHOR]

We present a model in which investment in schooling generates two kinds of returns: the labor-market return, resulting from higher wages, and a marriage-market return, defined as the impact of schooling on the marital surplus share one can extract. Men and women may have different incentives to invest in schooling because of different market wages or household roles. This asymmetry can yield a mixed equilibrium with some educated individuals marrying uneducated spouses. When the labor-market return to schooling rises, home production demands less time, and the traditional spousal labor division norms weaken, more women may invest in schooling than men. (JEL I21, J12, J24, J31) [ABSTRACT FROM AUTHOR]

Use of etomidate in the critically ill is controversial due to its links with an inadequate response to corticotropin and potential for excess mortality. In a septic shock population, we tested the hypotheses that etomidate administration induces more non-responders to corticotropin and increases mortality and that hydrocortisone treatment decreases mortality in patients receiving etomidate. An a-priori sub-study of the CORTICUS multi-centre, randomised, double-blind, placebo-controlled trial of hydrocortisone in septic shock. Use and timing of etomidate administration were collected. Endpoints were corticotropin response and all-cause 28-day mortality in patients receiving etomidate. Five hundred patients were recruited, of whom 499 were analysable; 96 (19.2%) were administered etomidate within the 72 h prior to inclusion. The proportion of non-responders to corticotropin was significantly higher in patients who were given etomidate in the 72 h before trial inclusion than in other patients (61.0 vs. 44.6%, P = 0.004). Etomidate therapy was associated with a higher 28-day mortality in univariate analysis ( P = 0.02) and after correction for severity of illness (42.7 vs. 30.5%; P = 0.06 and P = 0.03) in our two multi-variant models. Hydrocortisone administration did not change the mortality of patients receiving etomidate (45 vs. 40%). The use of bolus dose etomidate in the 72 h before study inclusion is associated with an increased incidence of inadequate response to corticotropin, but is also likely to be associated with an increase in mortality. We recommend clinicians demonstrate extreme caution in the use of etomidate in critically ill patients with septic shock. [ABSTRACT FROM AUTHOR]

Land plants are prone to strong thermal variations and must therefore sense early moderate temperature increments to induce appropriate cellular defenses, such as molecular chaperones, in anticipation of upcoming noxious temperatures. To investigate how plants perceive mild changes in ambient temperature, we monitored in recombinant lines of the moss Physcomitrella patens the activation of a heat-inducible promoter, the integrity of a thermolabile enzyme, and the fluctuations of cytoplasmic calcium. Mild temperature increments, or isothermal treatments with membrane fluidizers or Hsp90 inhibitors, induced a heat shock response (HSR) that critically depended on a preceding Ca2+ transient through the plasma membrane. Electrophysiological experiments revealed the presence of a Ca2+-permeable channel in the plasma membrane that is transiently activated by mild temperature increments or chemical perturbations of membrane fluidity. The amplitude of the Ca2+ influx during the first minutes of a temperature stress modulated the intensity of the HSR, and Ca2+ channel blockers prevented HSR and the onset of thermotolerance. Our data suggest that early sensing of mild temperature increments occurs at the plasma membrane of plant cells independently from cytosolic protein unfolding. The heat signal is translated into an effective HSR by way of a specific membrane-regulated Ca2+ influx, leading to thermotolerance. [ABSTRACT FROM AUTHOR]