Tolvaptan for Volume Management in Heart Failure

Volume management in acute decompensated and chronic heart failure (HF) remains a significant challenge. Although progress has been made in the development of mortality-reducing neurohormonal regimens in the reduced ejection fraction population, no clinical trial has yet demonstrated anything more than symptomatic relief or biomarker reduction with pharmacotherapeutic volume-based interventions made in the acutely decompensated individual or those with evolving outpatient congestion. As the number of patients with HF continues to grow, in addition to HF-related hospitalizations, identifying therapies that have the potential to aid in diuresis more safely and efficaciously is paramount to decreasing inpatient length of stay and preventing unnecessary admissions. More recently, a significant amount of research has been dedicated to the use of vasopressin antagonists, specifically tolvaptan, as adjunctive therapy to loop and thiazide diuretics. Although these agents do not seem to have a pervasive role in fluid management in the acute decompensated and chronic HF populations, they are effective tools to have available for specific clinical situations. This review summarizes the literature surrounding the use of tolvaptan for volume management in congestive HF, as well as offering practical guidance for use of this agent.     

Internal Medicine Residents’ Perceptions of Virtual Morning Report: a Multicenter Survey

ImportanceThe COVID-19 pandemic disrupted graduate medical education, compelling training programs to abruptly transition to virtual educational formats despite minimal experience or proficiency. We surveyed residents from a national sample of internal medicine (IM) residency programs to describe their experiences with the transition to virtual morning report (MR), a highly valued core educational conference.ObjectiveAssess resident views about virtual MR content and teaching strategies during the COVID-19 pandemic.DesignAnonymous, web-based survey.ParticipantsResidents from 14 academically affiliated IM residency programs.Main MeasuresThe 25-item survey on virtual MR included questions on demographics; frequency and reason for attending; opinions on who should attend and teach; how the virtual format affects the learning environment; how virtual MR compares to in-person MR with regard to participation, engagement, and overall education; and whether virtual MR should continue after in-person conferences can safely resume. The survey included a combination of Likert-style, multiple option, and open-ended questions.ResultsSix hundred fifteen residents (35%) completed the survey, with a balanced sample of interns (39%), second-year (31%), and third-year (30%) residents. When comparing their overall assessment of in-person and virtual MR formats, 42% of residents preferred in-person, 18% preferred virtual, and 40% felt they were equivalent. Most respondents endorsed better peer-engagement, camaraderie, and group participation with in-person MR. Chat boxes, video participation, audience response systems, and smart boards/tablets enhanced respondents’ educational experience during virtual MR. Most respondents (72%) felt that the option of virtual MR should continue when it is safe to resume in-person conferences.ConclusionsVirtual MR was a valued alternative to traditional in-person MR during the COVID-19 pandemic. Residents feel that the virtual platform offers unique educational benefits independent of and in conjunction with in-person conferences. Residents support the integration of a virtual platform into the delivery of MR in the future.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06963-7.KEY WORDS: graduate medical education, internal medicine residency, morning report, virtual     

The half-hitch knot: a rational alternative to the square knot

The half-hitch knot, an alternative to the square knot for tying a suture, has been presented. A square knot is satisfactory, but because of its configuration it is difficult to tie, and in actual practice it is seldom used. Instead, a series of half hitches is tied. A half-hitch knot is as secure as a square knot and much easier to tie. However, it too must be tied in proper configuration to be reliable. The technique for tying a half-hitch knot and some of its characteristics are described.     

Female teachers’ math anxiety affects girls’ math achievement

People’s fear and anxiety about doing math—over and above actual math ability—can be an impediment to their math achievement. We show that when the math-anxious individuals are female elementary school teachers, their math anxiety carries negative consequences for the math achievement of their female students. Early elementary school teachers in the United States are almost exclusively female (>90%), and we provide evidence that these female teachers’ anxieties relate to girls’ math achievement via girls’ beliefs about who is good at math. First- and second-grade female teachers completed measures of math anxiety. The math achievement of the students in these teachers’ classrooms was also assessed. There was no relation between a teacher’s math anxiety and her students’ math achievement at the beginning of the school year. By the school year’s end, however, the more anxious teachers were about math, the more likely girls (but not boys) were to endorse the commonly held stereotype that “boys are good at math, and girls are good at reading” and the lower these girls’ math achievement. Indeed, by the end of the school year, girls who endorsed this stereotype had significantly worse math achievement than girls who did not and than boys overall. In early elementary school, where the teachers are almost all female, teachers’ math anxiety carries consequences for girls’ math achievement by influencing girls’ beliefs about who is good at math.     

Long-term effects of nutrient intervention on markers of bone remodeling and calciotropic hormones in late-postmenopausal women

BACKGROUND: Adequate intakes of calcium and vitamin D reduce bone loss and fracture risk in the elderly. Other nutrients also affect bone health, and adequate intakes may influence bone turnover and balance. OBJECTIVE: We compared the long-term effects on bone turnover markers and calciotropic hormones of a multinutrient supplement, a calcium and vitamin D supplement, and dietary instruction aimed at increasing calcium intake through foods. DESIGN: Ninety-nine healthy postmenopausal women participated in a 3-y, randomized trial, receiving either 1) supplemental calcium (1450 mg/d) and vitamin D [10 microg (400 IU)/d], 2) calcium, vitamin D, and other nutrients (multinutrient supplement), or 3) dietary instruction (dietary control group). Data are from 83 subjects who completed the trial. RESULTS: Increases over baseline in calcium intakes and serum 25-hydroxyvitamin D concentrations were sustained over 3 y in all treatment groups. Circulating parathyroid hormone concentrations were reduced at year 1 in all treatment groups but trended toward baseline thereafter. Bone turnover markers followed a similar pattern, and none of the changes in biochemical concentrations differed significantly between groups. CONCLUSIONS: All 3 interventions offer long-term feasibility for increasing calcium intake and serum 25-hydroxyvitamin D concentrations. The dietary addition of micronutrients implicated in skeletal physiology confers no obvious bone-sparing effect in healthy postmenopausal women beyond that of calcium and vitamin D alone. The attenuation over time in suppression of parathyroid hormone and bone turnover might help explain why nutrient intervention tends to have less of a bone-sparing effect than do skeletally active medications such as estrogen or bisphosphonates.