Postprandial Hypotension Luciano, Gina L., MD; Brennan, Maura J., MD; Rothberg, Michael B., MD
The American journal of medicine,
03/2010, Letnik:
123, Številka:
3
Journal Article
Recenzirano
Abstract Postprandial hypotension is both common in geriatric patients and an important but under-recognized cause of syncope. Other populations at risk include those with Parkinson disease and ...autonomic failure. The mechanism is not clearly understood, but appears to be secondary to a blunted sympathetic response to a meal. This review discusses the epidemiology, risk factors, and pathophysiology of postprandial hypotension in the elderly, as well as diagnosis and treatment strategies. Diagnosis can be made based on ambulatory blood pressure monitoring and patient symptoms. Lifestyle modifications such as increased water intake before eating or substituting 6 smaller meals daily for 3 larger meals may be effective treatment options. However, data from randomized, controlled trials are limited. Increased awareness of this disease may lead to improved quality of life, decreased falls and injuries, and the avoidance of unnecessary testing.
Evidence-based medicine (EBM) skills are important to daily practice, but residents generally feel unskilled incorporating EBM into practice. The Kolb experiential learning theory, as applied to ...curricular planning, offers a unique methodology to help learners build an EBM skill set based on clinical experiences. We sought to blend the learner-centered, case-based merits of the morning report with an experientially based EBM curriculum. We describe and evaluate a patient-centered ambulatory morning report combining the User's Guides to the Medical Literature approach to EBM and experiential learning theory in the internal medicine department at Baystate Medical Center.
The Kolb experiential learning theory postulates that experience transforms knowledge; within that premise we designed a curriculum to build EBM skills incorporating residents' patient encounters. By developing structured clinical questions based on recent clinical problems, residents activate prior knowledge. Residents acquire new knowledge through selection and evaluation of an article that addresses the structured clinical questions. Residents then apply and use new knowledge in future patient encounters.
To assess the curriculum, we designed an 18-question EBM test, which addressed applied knowledge and EBM skills based on the User's Guides approach. Of the 66 residents who could participate in the curriculum, 61 (92%) completed the test. There was a modest improvement in EBM knowledge, primarily during the first year of training.
Our experiential curriculum teaches EBM skills essential to clinical practice. The curriculum differs from traditional EBM curricula in that ours blends experiential learning with an EBM skill set; learners use new knowledge in real time.
Residents are required by the Accreditation Council for Graduate Medical Education to complete a scholarly project during residency, but they may not have dedicated time or instruction to be able to ...successfully achieve this goal.
In 2013 at Baystate Medical Center, we developed the Case Report Curriculum to guide internal medicine interns through the process of writing and presenting a case report. Core faculty and chief residents facilitate six sessions, which are scheduled throughout the year. Sessions combine large- and small-group discussion with facilitated independent work as well as postsession assignments and timely feedback from course facilitators. Topics include selecting a case report, crafting learning objectives, writing a discussion, authorship and creating a title, generating a poster, and presenting a poster. At the culmination of the conference series, interns present their completed case reports at an institutional academic day where judges critique and score their posters.
Over the past 4 years, 95%-100% of our interns have participated in the required curriculum and presented their posters. We found that the majority of interns go on to present additional scholarly works at regional and national meetings during their second and third postgraduate years. Due to the success of the curriculum, interns from additional programs within the institution now attend the conference series.
The Case Report Curriculum is a successful conference series that guides interns through the process of writing a case and can inspire additional scholarship during residency.
Abstract Introduction Increased knowledge and confidence in caring for patients during their end-of-life stages is vital to resident training. As the elderly population continues to grow, it is ...crucial that physicians meet the rising demand for competent end-of-life care and appropriately refer them to palliative and hospice care. This teaching tool is a case-based discussion module that was created to educate internal medicine residents about the differences between palliative care and hospice care so that they may apply their understanding to day-to-day practice and refer patients appropriately. Methods The module is divided into two parts: the goal of the first part is to engage learners at their current knowledge level through a “buzz word” activity. Learners are split into small groups and asked to offer descriptive words for hospice or palliative care. Through group discussion facilitated by the instructor's inquiry of these “buzz words,” the group actively compares and contrasts the defining features of palliative care and hospice care. The second part of the module introduces an unfolding case that allows learners to apply their understanding of the defining features of the two services. Through facilitated case discussion, groups discuss next steps in management and explore how these next steps may help in determining when to appropriately refer patients to palliative and/or hospice care. The entire module is completed in one hour. Results Approximately 20 residents participated in this case-based discussion. Nine residents (who were present at the beginning of the conference) were able to take a pretest. Six of the nine residents (who were able to remain until the end of the hour) took a posttest. Mean score of the pretest was 68%. Mean score of the posttest was 78%. Discussion This case-based discussion module helped residents to gain greater knowledge and confidence in their management of patients at the end of life. Although limited by attendance, we were able to see an objective improvement between pre- and posttest mean scores. Residents specifically expressed greater confidence in understanding the indications for referring patients to the palliative care and hospice services at the conclusion of the module. Additionally, the palliative care and hospice care services at our institution noticed greater awareness, utilization, and understanding amongst the group that had participated in the teaching module.
Background: Morning report was initially created to meet service needs. Purpose: The objective was to improve morning report through a toolkit combining principles of learning theory with resident ...teaching. Methods: The toolkit consists of three parts: a guideline describing expectations, a worksheet outlining teaching plans, and a feedback form facilitating post-presentation feedback. In 2009-2010, internal medicine residents met with a chief resident before their presentations to refine teaching plans. The chief resident then supported the presenter in achieving their objectives and provided post-presentation feedback. Residents were surveyed before and 6 months after the intervention. Mean scores were compared using an unpaired t test. Results: Residents' ratings improved in the following domains: understanding expectations (3.10 vs. 4.02, p = .0003), presentation organization (3.50 vs. 4.25, p = .005), and creating and accomplishing learning objectives (3.31 vs. 4.00, p = .002). Residents commented positively on the improved presentations. Conclusions: This toolkit, based on educational principles, improved morning report presentations.
Since 2011, aviation has revolutionized their approach to safety. The aviation industry has adopted a multi-faceted approach to improve safety through decreasing duty hour limits and implementing ...processes to mitigate fatigue-related errors as well as creating cultural shifts in responsibility for safety. These changes have been guided by data generated by quality-improvement methodology. In contrast, duty hour limits in graduate medical education have not yet seen dramatic data-driven reform. Key advancements in aviation fatigue mitigation and implications for residency education are explored in this article. Scientifically based processes to optimize duty hours, quality-improvement strategies to iteratively monitor and reform duty limits, systematic change focusing on a just culture, and financial disincentives and incentives as a catalyst for change are discussed.
Interestingly, modified barium swallow revealed no significant pharyngeal residue, laryngeal penetration, or tracheal aspiration, possibly because of compensatory swallowing strategies. Because the ...patient was not deemed an aspiration risk, she was discharged and scheduled with an otolaryngology consult and outpatient speech therapy to treat both dysphagia and dysphonia. On the contrary, another study showed increased RLN diameter in the time between initial visualization and complete thyroid removal, presumed to be from edema (Fig. 2 B). ...it is possible that stretch may cause vasa nervorum ischemia, in turn causing edema exacerbating neural dysfunction. Some meta-analyses examining randomized control trials and cohorts have shown that IONM may prevent transient RLN palsy, but not permanent RLN palsy,2 whereas another meta-analysis stated that there is no significant difference unless the surgery was high risk from repeat operation or malignancy.3 Issues of IONM technology and technique standardization, and the selective use of postoperative laryngoscopy for assessing the true prevalence of RLN injury have been some of the most significant limitations in present studies.3 Furthermore, high-volume surgeons ($45 operated thyroid sites/year) had significantly lower rates of RLN injury overall than low-volume surgeons (<45 operated thyroid sites/year).4 This was independent of the type of RLN identification, but the difference was only significant when the nerve was visually identified.
Background
Medical educators need valid, reliable, and efficient tools to assess evidence-based medicine (EBM) knowledge and skills. Available EBM assessment tools either do not assess skills or are ...laborious to grade.
Objective
To validate a multiple-choice–based EBM test—the Resident EBM Skills Evaluation Tool (RESET).
Design
Cross-sectional study.
Participants
A total of 304 medicine residents from five training programs and 33 EBM experts comprised the validation cohort.
Main Measures
Internal reliability, item difficulty, and item discrimination were assessed. Construct validity was assessed by comparing mean total scores of trainees to experts. Experts were also asked to rate importance of each test item to assess content validity.
Key Results
Experts had higher total scores than trainees (35.6 vs. 29.4,
P
< 0.001) and also scored significantly higher than residents on 11/18 items. Cronbach’s alpha was 0.6 (acceptable), and no items had a low item-total correlation. Item difficulty ranged from 7 to 86%. All items were deemed “important” by > 50% of experts.
Conclusions
The proposed EBM assessment tool is a reliable and valid instrument to assess competence in EBM. It is easy to administer and grade and could be used to guide and assess interventions in EBM education.
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