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.
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.
Ice cores provide a valuable archive of climate history. for a complete understanding of this archive, it is important to understand air–snow exchange processes through the snow and firn in order to ...fully decode the ice-core record. Transport processes through the snow and firn are dependent upon their physical properties. In this paper, bidirectional permeabilities from selected sections of a 13 mcore from Summit, Greenland, are presented. Differences between lateral and vertical permeabilities are evident throughout the core in permeameter data and in microstructure statistics. Both lateral and vertical permeabilities are consistent with overall patterns of previous polar permeability data with depth. the differences between lateral and vertical permeability measurements for some samples can be attributed to equivalent sphere radius. Further studies examining mean free-path length may be helpful in chemical modeling and in deriving an equation relating permeability to microstructure.
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.
Many extremely low birth weight infants develop pulmonary hypertension late in their clinical course, and over 60% go undetected by early screening echocardiography. At present, no standardised ...screening protocol exists for detecting late pulmonary hypertension in extremely low birth weight infants. We assessed the utility of oxygen supplementation as a predictor of late pulmonary hypertension.
A retrospective single-centre review of extremely low birth weight infants with no evidence of CHD and those surviving for >30 days was performed. The association between oxygen ⩾30% at day of life 30 and diagnosis of late pulmonary hypertension was estimated with an odds ratio and 95% confidence interval using logistic regression. Doppler echocardiography was used to diagnose pulmonary hypertension in the infants.
A total of 230 infants met the study criteria. The incidence of late pulmonary hypertension was 8.3% (19/230). Infants with late pulmonary hypertension were more likely to have a lower mean birth weight (667.1±144 versus 799.3±140 g, p=0.001) and more likely to be small for gestational age (47.4 versus 14.2%, p=0.004). Oxygen requirement ⩾30% at day of life 30 was associated with increased risk of late pulmonary hypertension (odds ratio=3.77, 95% confidence interval=1.42-10.00, p=0.008) in univariate analysis and after adjusting for birth weight (odds ratio=2.47, 95% confidence interval=0.89-6.84, p=0.08).
The need of oxygen supplementation ⩾30% at day of life 30 may be a good screening tool for detecting late pulmonary hypertension in extremely low birth weight infants.
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