Background and Purpose— The aim of this study was to explore the possible contribution of alterations in cerebral hemodynamics to the evolution of cognitive impairment in patients with Alzheimer disease (AD). Method— Fifty-three patients with AD were investigated. The evolution of cognitive decline over 12 months was evaluated by means of changes in Mini Mental State Examination (MMSE) and AD Assessment Scale for Cognition (ADAS-Cog) scores. Demographic characteristics, vascular risk profile, pharmacological treatment, and presence of white matter lesions were assessed at entry. Further, a basal evaluation of cerebrovascular reactivity to hypercapnia was measured with transcranial Doppler ultrasonography using the breath-holding index (BHI). Results— Of all the variables considered, both MMSE and ADAS-Cog changes had the highest correlation with BHI, followed by age and diabetes. After subdividing both cognitive measures reductions into bigger and smaller-than-average decline (2 points for MMSE; 5 points ...

Cerebrovascular Reactivity and Cognitive Decline in Patients With Alzheimer Disease

Background: An impairment of cerebral microvessels is reported both in normal ageing and in senescence-associated processes, as well as in Alzheimer’s disease (AD) and vascular deme

Cerebrovascular Reactivity in Degenerative and Vascular Dementia: A Transcranial Doppler Study

Medical Education 2011: 45: 995–1005

Context  A particularly onerous aspect of the transition from medical student to practising doctor concerns the necessity to be able to rapidly identify acutely unwell patients and initiate appropriate resuscitation. These are skills in which many graduates feel poorly prepared and are considered by some to be best learned on the job. This constructivist study investigated the factors that influence the behaviour of junior doctors in this context and initiated the development of a framework that promotes understanding of this important area.

Methods  Focus groups involving 36 clinicians with a variety of clinical experience were conducted and analysed using a qualitative, grounded theory approach. The complex relationships between emergent themes guided the development of a framework that was refined and validated by further interviews with participants.

Results  Six main themes, grouped under three broad headings, emerged from the data: ‘transferring knowledge into practice’ and ‘decision making and uncertainty’ (cognitive challenges); ‘acts and omissions’ and ‘identity and expectations’ (roles and responsibilities), and, finally, ‘the medical hierarchy’ and ‘performing under stress’ (environmental factors). The framework presented within this paper illustrates the complex relationships between these factors.

Conclusions  Although the potential of metacognitive strategies to reduce medical error is acknowledged, the framework promotes looking beyond the individual to consider the contributions to patient safety of identity issues, role uncertainty and the hierarchical clinical environment. A more distributed approach to situation awareness may help junior doctors to better tolerate complexity and uncertainty. The efficacy of simulation as an educational strategy may be improved by finding ways to recreate the hierarchical and stressful environment in which junior doctors practise. Junior doctors should be aware of the impact of affect and emotion on behaviour, and clinical supervisors should strive to ensure that roles and responsibilities are explicitly discussed.

Understanding the behaviour of newly qualified doctors in acute care contexts.

Educators in medical schools around the world are presently experimenting with innovative ways of using web-based learning to supplement the existing teaching and learning process. We have recently used a popular open-source course management system (CMS) called the modular object-oriented dynamic learning environment (Moodle) to construct an online site (DPhysiol) to facilitate our face-to-face teaching of physiology to a group of first-year students in the Bachelor of Medicine and Bachelor of Surgery program. The integration of the Moodle site into our teaching was assessed using online log activity, student examination marks, and feedback from students. The freely available Moodle platform was simple to use, helped to effectively deliver course materials, and has features that allowed cooperative learning. Students who used the CMS throughout their academic year and commented favorably regarding its use as a complement to the face-to-face classroom sessions. The group of students used the CMS obtained significantly higher scores in the final examination compared with the previous class that did not use the CMS. In addition, there was a significant correlation between student participation and performance in online quizzes and their final examination marks. However, students' overall online usage of the CMS did not correlate with their examination marks. We recommend Moodle as a useful tool for physiology educators who are interested in integrating web-based learning into their existing teaching curriculum.

Integrating an open-source course management system (Moodle) into the teaching of a first-year medical physiology course: a case study.

Practical examinations in anatomy are usually conducted on specimens in the anatomy laboratory (referred to here as the "traditional" method). Recently, we have started to administer similar examinations online using the quiz facility in Moodle™. In this study, we compare student scores between two assessment environments viz. online and traditional environments. We hypothesized that regardless of the examination medium (traditional or online) overall student performance would not be significantly different. For the online medium, radiological images, prosected specimens, and short video clips demonstrating muscle action were first acquired from resources used for teaching during anatomy practical classes. These were optimized for online viewing and then uploaded onto Moodle learning management software. With regards to the traditional format, actual specimens were usually laid out in a circular stream. Identification tags were then attached to specific spots on the specimens and questions asked regarding those identified spots. A cohort of students taking practical examinations in six courses was studied. The courses were divided into three pairs with each pair credit-weight matched. Each pair consisted of a course where the practical examination was conducted online and the other in the traditional format. There was no significant difference in the mean scores within each course pair. In addition, a significant positive correlation between score in traditional and online formats was found. We conclude that mean grades in anatomy practical examination conducted either online or in the traditional format were comparable. These findings should reassure teachers intending to use either format for their practical examinations.

Anatomy practical examinations: how does student performance on computerized evaluation compare with the traditional format?

Background: Acute medical management is an important component of the Modernising Medical Careers (MMC) project which has recently been implemented in the UK. A web-based interactive course in acute medicine has been developed which complements the clinical teaching provided to senior medical students at the University of Glasgow. A study was undertaken to evaluate the teaching and assess the knowledge of acute medicine among final year medical students using an online questionnaire. Methods: The undergraduate medical school Virtual Learning Environment (VLE) was constructed using the Moodle learning management system. The online questionnaire was constructed as part of the interactive acute medicine course hosted on the VLE. Final year students using this course were asked to complete the questionnaire anonymously. A 5-point Likert scale was used to assess different aspects of acute medical management and evaluate the teaching. Results: From 210 students using the website, 99 (47.1%) completed the online questionnaire. Nephrology and neurology were identified as the most challenging specialties in acute medicine. The areas of acute management in which students felt they lacked most knowledge were drug overdose and acute renal failure. Drug prescribing was also identified as an area of the curriculum requiring further development. Conclusions: This approach to blended learning is popular with our medical students. Online evaluation has helped with curriculum development and, by identifying important areas of acute medicine teaching that can be improved, is feeding into our curriculum revision.

Acute medicine teaching in an undergraduate medical curriculum: a blended learning approach.

Interactive acute medicine

Background and Purpose— There is growing evidence that pharmacologic interference with the renin-angiotensin system may reduce risk of stroke, although the mechanism is unclear. Impaired reactivity of cerebral vessels has recently been recognized as a risk factor for stroke. We examined the effect of the angiotensin-converting enzyme (ACE) inhibitor perindopril on cerebral vasomotor reactivity to acetazolamide in patients with lacunar cerebral infarction. Methods— We studied a cohort of male patients between 3 and 12 months after lacunar infarction confirmed on computed tomography. Each patient received perindopril 4 mg daily or matching placebo for 2 weeks in a randomized, double-blind, placebo-controlled crossover fashion. A 1-week washout period was observed between dosing periods. Cerebral vasomotor reactivity (increase in middle cerebral artery mean flow velocity in response to intravenous injection of 15 mg/kg acetazolamide) was measured before and after each dosing period using standard Doppler ult...

Effect of Perindopril on Cerebral Vasomotor Reactivity in Patients With Lacunar Infarction

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Acute medicine teaching in an undergraduate medical curriculum: a blended learning approach.

Interactive acute medicine

Effect of Perindopril on Cerebral Vasomotor Reactivity in Patients With Lacunar Infarction