DOCSLIB.ORG

Evaluation and Management of Orthostatic Hypotension JEFFREY B

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Evaluation and Management of Orthostatic Hypotension JEFFREY B Evaluation and Management of Orthostatic Hypotension JEFFREY B. LANIER, MD; MATTHEW B. MOTE, DO; and EMILY C. CLAY, MD Martin Army Community Hospital Family Medicine Residency, Fort Benning, Georgia Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. Common symptoms include dizzi- ness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Less common symp- toms include syncope, dyspnea, chest pain, and neck and shoulder pain. Causes include dehydration or blood loss; disorders of the neurologic, cardiovascular, or endocrine systems; and several classes of medications. Evaluation of suspected orthostatic hypotension begins by identifying reversible causes and underlying associated medical condi- tions. Head-up tilt-table testing can aid in confirming a diagnosis of suspected orthostatic hypotension when standard orthostatic vital signs are nondiagnostic; it also can aid in assessing treatment response in patients with an autonomic disorder. Goals of treatment involve improving hypotension without excessive supine hypertension, relieving ortho- static symptoms, and improving standing time. Treatment includes correcting reversible causes and discontinuing responsible medications, when possible. Nonpharmacologic treatment should be offered to all patients. For patients who do not respond adequately to nonpharmacologic treatment, fludrocortisone, midodrine, and pyridostigmine are pharmacologic therapies proven to be beneficial. Am( Fam Physician. 2011;84(5):527-536. Copyright © 2011 Ameri- can Academy of Family Physicians.) ▲ Patient information: rthostatic hypotension is defined Pathophysiology A handout on orthostatic as a decrease in systolic blood A normal hemodynamic response to hypotension, written by the authors of this article, pressure of 20 mm Hg or a changes in posture requires normal func- is provided on page 537. decrease in diastolic blood pres- tion of the cardiovascular and autonomic O sure of 10 mm Hg within three minutes of nervous systems. Standing results in blood standing compared with blood pressure from pooling of approximately 500 to 1,000 mL the sitting or supine position. Alternatively, in the lower extremities and splanchnic cir- the diagnosis can be made by head-up tilt- culation. This initiates an increase in sym- table testing at an angle of at least 60 degrees.1 pathetic outflow, which increases peripheral Orthostatic hypotension is often found in vascular resistance, venous return, and car- older patients and in those who are frail.2 It diac output, thereby limiting the decrease is present in up to 20 percent of patients older in blood pressure. than 65 years.3 In one study, the prevalence These compensatory mechanisms result of orthostatic hypotension was 18 percent in in a decrease in systolic blood pressure (5 to patients older than 65 years, but only 2 per- 10 mm Hg), an increase in diastolic blood cent of these patients were symptomatic.3 pressure (5 to 10 mm Hg), and an increase in In the absence of volume depletion, pulse rate (10 to 25 beats per minute). How- younger patients with orthostatic hypoten- ever, orthostatic hypotension may result if sion usually have chronic autonomic failure. there is inadequate intravascular volume, A related problem, postprandial hypoten- autonomic nervous system dysfunction, sion, is common in older patients and those decreased venous return, or inability to with autonomic dysfunction. In postpran- increase cardiac output in response to pos- dial hypotension, there is a decrease in sys- tural changes.5 Decreased cerebral perfu- tolic blood pressure of at least 20 mm Hg sion produces the neurologic symptoms of within 75 minutes of a meal.4 orthostatic hypotension.5 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2011 American Academy of Family Physicians. For the private, noncommercial September use1, 2011 of one ◆ individual Volume user 84, of Number the Web site.5 All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or permission Family Physicianrequests. 527 Orthostatic Hypotension SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Consider head-up tilt-table testing in patients with symptoms of C 6, 14 orthostatic hypotension despite normal vital signs, or in patients who are unable to stand for orthostatic vital sign measurements. Patients with chronic orthostatic hypotension should be counseled C 6, 22 to avoid large carbohydrate-rich meals, limit alcohol intake, and ensure adequate hydration. Fludrocortisone, midodrine, and pyridostigmine (Mestinon) are B 26, 28, 29 effective therapies for chronic orthostatic hypotension. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml. Clinical Presentation and Evaluation may present with neck and shoulder pain, Orthostatic hypotension may be acute or orthostatic dyspnea, and chest pain.7 Table 1 chronic. Patients may present with light- outlines the differential diagnosis of ortho- headedness, blurred vision, dizziness, weak- static hypotension, which may be caused by ness, and fatigue, or with syncope (in the a number of things, including dehydration, acute care setting).6 Less commonly, they blood loss, medication, or a disorder of the neurologic, cardiovascular, or endocrine sys- tem.8-10 Evaluation of suspected orthostatic Table 1. Differential Diagnosis of Orthostatic Hypotension hypotension begins by identifying reversible causes and underlying associated medical Cardiovascular 8-10 Endocrine10 conditions. Table 2 lists historical features Anemia Adrenal insufficiency that suggest a specific diagnosis in the Cardiac arrhythmia Diabetes insipidus patient with orthostatic hypotension.7,8 In Congestive heart failure Hyperglycemia, acute addition to assessing for symptoms of ortho- Myocardial infarction Hypoaldosteronism stasis, the physician should elicit symptoms Myocarditis Hypokalemia of autonomic dysfunction involving the gas- Pericarditis Hypothyroidism trointestinal and genitourinary systems.7 Valvular heart disease Pheochromocytoma Key physical examination findings in the Venous insufficiency 8-10 Intravascular volume depletion evaluation of suspected orthostatic hypoten- Drugs10 Blood loss sion are listed in Table 3.11,12 A detailed assess- Alcohol Dehydration ment of the motor nervous system should be Antiadrenergics Pregnancy/postpartum performed to evaluate for signs of Parkinson Antianginals Shock disease, as well as cerebellar ataxia.7 Blood Antiarrhythmics Miscellaneous8-10 pressure and pulse rate should be measured Anticholinergics AIDS in the supine position and repeated after the Antidepressants Anxiety or panic disorder patient has been standing for three min- Antihypertensives Eating disorders utes. As many as two-thirds of patients with Antiparkinsonian agents Prolonged bed rest Diuretics orthostatic hypotension may go undetected Narcotics if blood pressure is not measured while 13 Neuroleptics supine. However, a retrospective review Sedatives of 730 patients found that orthostatic vital signs had poor test characteristics (positive Information from references 8 through 10. predictive value = 61.7 percent; negative pre- dictive value = 50.2 percent) when compared 528 American Family Physician www.aafp.org/afp Volume 84, Number 5 ◆ September 1, 2011 Orthostatic Hypotension Table 2. Historical Clues to Diagnosis of Orthostatic Hypotension Historical features Possible etiology Abnormal uterine bleeding, fatigue, rectal bleeding Anemia Amaurosis fugax, aphasia, dysarthria, unilateral Stroke sensory and motor symptoms Bradykinesia, pill-rolling tremor, shuffling gait Parkinson disease Burns Intravascular volume depletion Chest pain, palpitations, shortness of breath Congestive heart failure, myocardial infarction, myocarditis, pericarditis Chills, fever, lethargy, nausea, vomiting Gastroenteritis, sepsis Extremity swelling Congestive heart failure, venous insufficiency High-risk sexual behavior AIDS, neurosyphilis Progressive motor weakness Guillain-Barré syndrome, multiple system atrophy Relapsing neurologic symptoms in various anatomic Multiple sclerosis locations Symptoms after a meal Postprandial hypotension Witnessed collapse Cardiac arrhythmia, seizure Information from references 7 and 8. Table 3. Physical Examination Clues to Diagnosis of Orthostatic Hypotension Examination findings Possible diagnosis Comments Aphasia, dysarthria, facial droop, hemiparesis Stroke — Cardiac murmur or gallop Congestive heart failure, — myocardial infarction Cogwheel rigidity, festinating gait, lack of Parkinson disease — truncal rotation while turning, masked facies Confusion, dry mucous membranes, dry Dehydration (in older Study of 55 patients 61 to tongue, longitudinal tongue furrows, speech patients) 98 years of age in emergency difficulty, sunken eyes, upper body weakness care setting found these findings highly reliable12
Load more

Recommended publications
  • Control Study of Pregnancy Complications and Birth Outcomes
    Hypertension Research (2011) 34, 55–61 & 2011 The Japanese Society of Hypertension All rights reserved 0916-9636/11 $32.00 www.nature.com/hr ORIGINAL ARTICLE Hypotension in pregnant women: a population-based case–control study of pregnancy complications and birth outcomes Ferenc Ba´nhidy1,Na´ndor A´ cs1, Erzse´bet H Puho´ 2 and Andrew E Czeizel2 Hypotension is frequent in pregnant women; nevertheless, its association with pregnancy complications and birth outcomes has not been investigated. Thus, the aim of this study was to analyze the possible association of hypotension in pregnant women with pregnancy complications and with the risk for preterm birth, low birthweight and different congenital abnormalities (CAs) in the children of these mothers in the population-based data set of the Hungarian Case–Control Surveillance of CAs, 1980–1996. Prospectively and medically recorded hypotension was evaluated in 537 pregnant women who later had offspring with CAs (case group) and 1268 pregnant women with hypotension who later delivered newborn infants without CAs (control group); controls were matched to sex and birth week of cases (in the year when cases were born), in addition to residence of mothers. Over half of the pregnant women who had chronic hypotension were treated with pholedrine or ephedrine. Maternal hypotension is protective against preeclampsia; however, hypotensive pregnant women were at higher risk for severe nausea or vomiting, threatened abortion (hemorrhage in early pregnancy) and for anemia. There was no clinically important difference in the rate of preterm births and low birthweight newborns in pregnant women with or without hypotension. The comparison of the rate of maternal hypotension in cases with 23 different CAs and their matched controls did not show a higher risk for CAs (adjusted OR with 95% confidence intervals: 0.66, 0.49–0.84).
    [Show full text]
  • Advanced Interpretation of Adult Vital Signs in Trauma William D
    Advanced Interpretation of Adult Vital Signs in Trauma William D. Hampton, DO Emergency Physician 26 March 2015 Learning Objectives 1. Better understand vital signs for what they can tell you (and what they can’t) in the assessment of a trauma patient. 2. Appreciate best practices in obtaining accurate vital signs in trauma patients. 3. Learn what teaching about vital signs is evidence-based and what is not. 4. Explain the importance of vital signs to more accurately triage, diagnose, and confidently disposition our trauma patients. 5. Apply the monitoring (and manipulation of) vital signs to better resuscitate trauma patients. Disclosure Statement • Faculty/Presenters/Authors/Content Reviewers/Planners disclose no conflict of interest relative to this educational activity. Successful Completion • To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. • Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Vital Signs Vital Signs Philosophy: “View vital signs as compensatory to the illness/complaint as opposed to primary.” Crowe, Donald MD. “Vital Sign Rant.” EMRAP: Emergency Medicine Reviews and Perspectives. February, 2010. Vital Signs Truth over Accuracy: • Document the true status of the patient: sick or not? • Complete vital signs on every patient, every time, regardless of the chief complaint. • If vital signs seem misleading or inaccurate, repeat them! • Beware sending a patient home with abnormal vitals (especially tachycardia)! •Treat vital signs the same as any other diagnostics— review them carefully prior to disposition. The Mother’s Vital Sign: Temperature Case #1 - 76-y/o homeless ♂ CC: 76-y/o homeless ♂ brought to the ED by police for eval.
    [Show full text]
  • Have Already Been Described to Occur with Some
    804 Letters, Correspondence, Book reviews have already been described to occur with Correspondence to: Dr D Michel, Service de Neu- some mutations. rologie, Hôpital de Bellevue, 42055 Saint-Etienne, There are only two previous reports Cedex 2, France. relating to three pairs of identical twins with CMT and known genetic defects. In the two 1 Goldsmith P, Rowe D, Jäger R, et al. Focal ver- pairs with the 17p11.2 duplication there was tebral artery dissection causing Brown- remarkable clinical variability.6 We have also Séquard’s syndrome. J Neurol Neurosurg Psy- seen a pair of identical twins with a P0 muta- chiatry 1998;64:415–16. 2 Gutowski NJ, Murphy RP, Beale DJ. Unilateral tion in whom there was marked variability in upper cervical posterior spinal artery syndrome early ages (unpublished data). Apart from the following sneezing. J Neurol Neurosurg Psychia- asymmetry of toe responses in one of the try 1992;55:841–3. probands, the genetically identical twins 3 Bergqvist CAG, Goldberg HI, Thorarensen O, et al. Posterior cervical spinal cord infarction described here are phenotypically very simi- following vertebral artery dissection. Neurology lar, suggesting that the expression of this 1997;48:1112–5. mutation was not influenced by other non- 4 Hundsberger T, Thömke F, Hopf HC, et al. genetic factors. Symmetrical infarction of the cervical spinal cord due to spontaneous bilateral vertebral Codon 39 seems to be of particular Sagittal T2 weighted MRI of the cervicodorsal artery dissection. Stroke 1998;29:1742. importance to Cx32 protein function as cord : high linear signal extending from C4 to 5 Masson C.
    [Show full text]
  • Definitions • Septic Shock
    BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Ann Rheum Dis Definitions • Septic shock: Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain mean artery pressure (MAP) ≥65 mmHg and serum lactate level >2 mmol/L (1). • Renal failure: Doubling of basal Creatinine value or urine output <0.5 ml/kg/h for ≥12h (2) • Heart failure: Gradual or rapid change in heart failure signs and symptoms resulting in a need for urgent therapy (3). • Myocarditis: Myocarditis was diagnosed if serum levels of high-sensitivity cardiac troponin I were above the 99th percentile upper reference limit and compatible abnormalities were shown in electrocardiography and echocardiography. • Encephalopathy: Impaired consciousness as change of consciousness level (somnolence, stupor, and coma) or consciousness content (confusion and delirium) (4). • Thrombosis: Clinically or by imaging diagnosed acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism (5). References 1. World Health Organization. Clinical management of severe acute respiratory infection when Novel coronavirus (nCoV) infection is suspected: interim guidance. 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection- when-novel-coronavirus-(ncov)-infection-is-suspected. 2. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 2012;120:c179-84. 10.1159/000339789. 3. Gheorghiade M, Zannad F, Sopko G, et al. Acute heart failure syndromes: current state and framework for future research. Circulation. 2005;112(25):3958-3968. 4. Mao L, Jin H, Wang M, et al.
    [Show full text]
  • Spinal Cord Injury Manual
    Spinal Cord Injury Manual A publication of the Regional Spinal Cord Injury Center of the Delaware Valley The Regional Spinal Cord Injury Center of the Delaware Valley provides a comprehensive program of patient care, community education, and research. It is a federally designated program of Thomas Jefferson University and its affiliated institutions of Thomas Jefferson University Hospital and Magee Rehabilitation Hospital. JG 10-1325 Spinal Cord Injury Patient-Family Teaching Manual A Publication of the Regional Spinal Cord Injury Center of the Delaware Valley Researched and prepared by the clinical personnel of Thomas Jefferson University Hospital and Magee Rehabilitation Hospital Available online at: www.spinalcordcenter.org © 1993, 2001, 2009 Thomas Jefferson University. This publication is the property of Thomas Jefferson University. All rights reserved. This Manual is intended for use in a total system of care that meets all applicable CARF standards for SCI Centers. Neither Thomas Jefferson University Hospital, nor Magee Rehabilitation Hospital is responsible for any liability, claims, demands or damages asserted to be the result, either directly or indirectly, of the information contained herein. The use or reprinting of any part of this manual requires the express permission of Thomas Jefferson University. 3.11.10 3.11.10 Dedication The Handbook Committee of the RSCICDV gratefully acknowledges the assistance and dedication of all who contributed to this manual, and all the others who worked so hard to make this Handbook a reality.
    [Show full text]
  • Orthostatic Hypotension in a Cohort of Hypertensive Patients Referring to a Hypertension Clinic
    Journal of Human Hypertension (2015) 29, 599–603 © 2015 Macmillan Publishers Limited All rights reserved 0950-9240/15 www.nature.com/jhh ORIGINAL ARTICLE Orthostatic hypotension in a cohort of hypertensive patients referring to a hypertension clinic C Di Stefano, V Milazzo, S Totaro, G Sobrero, A Ravera, A Milan, S Maule and F Veglio The prevalence of orthostatic hypotension (OH) in hypertensive patients ranges from 3 to 26%. Drugs are a common cause of non-neurogenic OH. In the present study, we retrospectively evaluated the medical records of 9242 patients with essential hypertension referred to our Hypertension Unit. We analysed data on supine and standing blood pressure values, age, sex, severity of hypertension and therapeutic associations of drugs, commonly used in the treatment of hypertension. OH was present in 957 patients (10.4%). Drug combinations including α-blockers, centrally acting drugs, non-dihydropyridine calcium-channel blockers and diuretics were associated with OH. These pharmacological associations must be administered with caution, especially in hypertensive patients at high risk of OH (elderly or with severe and uncontrolled hypertension). Angiotensin-receptor blocker (ARB) seems to be not related with OH and may have a potential protective effect on the development of OH. Journal of Human Hypertension (2015) 29, 599–603; doi:10.1038/jhh.2014.130; published online 29 January 2015 INTRODUCTION stabilization, and then at 1 and 3 min after standing. The average of the Orthostatic hypotension (OH) is defined as the reduction in blood last two SBP and DBP values measured in the supine position and the pressure (BP) of at least 20 mmHg systolic and/or 10 mm Hg lowest value during standing were considered.
    [Show full text]
  • Blood Pressure Management
    Blood Pressure Management By Karen J. McConnell, Pharm.D., FCCP, BCPS-AQ Cardiology; and William L. Baker, Pharm.D., FCCP, FACC, BCPS, AQ-Cardiology Reviewed by Tyan F. Thomas, Pharm.D., BCPS; and Stacy L. Elder, Pharm.D., BCPS LEARNING OBJECTIVES 1. Distinguish key differences between various national and international hypertension (HTN) guidelines. 2. Demonstrate appropriate drug selection and blood pressure goals for the treatment of HTN according to the presence of concomitant conditions. 3. Devise an evidence-based treatment strategy for resistant HTN to achieve blood pressure goals. 4. Justify the use of ambulatory blood pressure monitoring. 5. Develop treatment strategies for hypertensive urgency and emergency. 6. Construct appropriate drug therapy plans for the treatment of hypotension. 7. Assess the potential effect of pharmacogenomics on blood pressure. EPIDEMIOLOGY ABBREVIATIONS IN THIS CHAPTER Hypertension (HTN) is a persistent, nonphysiologic elevation in blood ABPM Ambulatory blood pressure monitoring pressure; it is defined as (1) having a systolic blood pressure (SBP) ACE Angiotensin-converting enzyme of 140 mm Hg or greater; (2) having a diastolic blood pressure (DBP) AGT Angiotensinogen of 90 mm Hg or greater; (3) taking antihypertensive medication; or ARB Angiotensin receptor blocker (4) having been told at least twice by a physician or other health ASCVD Atherosclerotic cardiovascular professional that one has HTN. According to WHO, almost 1 billion disease people had uncontrolled HTN worldwide in 2008. The American Heart CAD Coronary artery disease Association (AHA) estimates that 41% of the U.S. population will have CCB Calcium channel blocker a diagnosis of HTN by 2030, an increase of 8.4% from 2012 estimates.
    [Show full text]
  • Preventing and Treating Orthostatic Hypotension: As Easy As A, B, C
    REE VI W CME EDUCATIONAL OBJECTIVE: Readers will teach their patients to avoid episodes of orthostatic hypotension CREDIT JUAN J. FIGUEROA, MD JEF F REY R. BASFORD, MD, PhD PHILLI P A. LOW, MD Department of Neurology, Mayo Department of Physical Medicine and Rehabili- Department of Neurology, Mayo Clinic, Clinic, Rochester, MN tation, Mayo Clinic, Rochester, MN Rochester, MN Preventing and treating orthostatic hypotension: As easy as A, B, C ■ ABSTRT AC rthostatic hypotension is a chronic, O debilitating illness associated with com- Orthostatic hypotension is a chronic, debilitating illness mon neurologic conditions (eg, diabetic neu- that is difficult to treat. The therapeutic goal is to im- ropathy, Parkinson disease). It is common in prove postural symptoms, standing time, and function the elderly, especially in those who are institu- rather than to achieve upright normotension, which can tionalized and are using multiple medications. lead to supine hypertension. Drug therapy alone is never Treatment can be challenging, especially if the problem is neurogenic. This condition adequate. Because orthostatic stress varies with circum- has no cure, symptoms vary in different cir- stances during the day, a patient-oriented approach that cumstances, treatment is nonspecific, and ag- emphasizes education and nonpharmacologic strategies gressive treatment can lead to marked supine is critical. We provide easy-to-remember management hypertension. recommendations, using a combination of drug and non- This review focuses on the prevention and drug treatments that have proven efficacious. treatment of neurogenic causes of orthostatic hypotension. We emphasize a simple but ef- ■ KEY POINTS fective patient-oriented approach to manage- ment, using a combination of nonpharmaco- Treatment is directed at increasing blood volume, de- logic strategies and drugs clinically proven creasing venous pooling, and increasing vasoconstriction to be efficacious.
    [Show full text]
  • Orthostatic Hypotension in Older People: Considerations, Diagnosis and Management
    Clinical Medicine 2021 Vol 21, No 3: e275–82 REVIEW Orthostatic hypotension in older people: considerations, diagnosis and management Authors: Melanie Dani,A Andreas Dirksen,B Patricia Taraborrelli,B Dimitrios Panagopolous,C Miriam Torocastro,D Richard SuttonE and Phang Boon LimF Orthostatic hypotension (OH) is very common in older admissions resulting from OH have risen dramatically over the last people and is encountered daily in emergency departments decade.4 and medical admissions units. It is associated with a higher OH is neither incidental nor benign. It is associated with a higher risk of falls, fractures, dementia and death, so prompt risk of coronary artery disease, myocardial infarction, stroke, falls, recognition and treatment are essential. In this review fracture, road accidents and death.5–8 A sustained reduction in ABSTRACT article, we describe the physiology of standing (orthostasis) systolic BP on standing is an independent risk factor for death and the pathophysiology of orthostatic hypotension. We with a 45% 5-year mortality.9 Furthermore, the diagnosis can be focus particularly on aspects pertinent to older people. overlooked when patients with delayed OH are unaware of their We review the evidence and consensus management reduced cerebral perfusion, reporting falls rather than dizziness or guidelines for all aspects of management. We also tackle syncope. the challenge of concomitant orthostatic hypotension and It is thus essential that it is identified, and that the consequences supine hypertension, providing a treatment overview as are anticipated and managed. In this review article, we outline well as practical suggestions for management. In summary, the pathophysiology of OH, along with specific associations orthostatic hypotension (and associated supine hypertension) to consider in older people.
    [Show full text]
  • Venous Thromboembolism: Lifetime Risk and Novel Risk Factors A
    Venous Thromboembolism: Lifetime risk and novel risk factors A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF THE UNIVERSITY OF MINNESOTA BY Elizabeth Jean Bell, M.P.H. IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY Adviser: Aaron R. Folsom, M.D., M.P.H. March 2015 © Elizabeth Jean Bell 2015 ACKNOWLEDGEMENTS This research was supported by a training grant in cardiovascular disease epidemiology and prevention, funded by the National Institutes of Health. This fellowship has significantly enhanced my doctoral training experience. I could not have completed this research without the support of a great many people. I would first like to thank my advisor, Aaron Folsom. Thank you for taking me on as a mentee, not only at the doctorate level, but also at the master’s level. Undoubtedly you were an influence in my choice to continue my education with a doctorate in the first place. I recognize and appreciate the countless hours you have spent teaching and guiding; thank you for your thorough comments, quick turnaround times, and for always challenging me to achieve. I have learned much from you, including a passion for research. A huge thank you to Pam Lutsey, who has served as an informal mentor to me throughout my master’s and doctorate programs. Thank you for a countless number of things, including guiding my data analyses back before I knew how to do data analyses, sharing your expertise on every paper I have led, and being a role model to aspire to. Thank you to Alvaro Alonso and Saonli Basu, who have each offered their expertise through serving on my doctoral committee.
    [Show full text]
  • Medicine in the Elderly Postural Hypotension and Falls Postgrad Med J: First Published As 10.1136/Pgmj.71.835.278 on 1 May 1995
    Postgrad MedJ3 1995; 71: 278-283 C) The Fellowship of Postgraduate Medicine, 1995 Medicine in the elderly Postural hypotension and falls Postgrad Med J: first published as 10.1136/pgmj.71.835.278 on 1 May 1995. Downloaded from T Kwok, J Liddle, IR Hastie Falls Falls are the most common cause ofaccidents in older people.' Accidents at home account for 3700 of fatal accidents and of these 57%O occur in people of 75 years and above.2 In the Health of the Nation, the Government propose a target reduction of 330o for fatal accidents in the elderly by the year 2005. The medical workload from accidents and the numbers of unreported accidents in older people are much higher than previously recognised.' Although the proportion of falls which result in a serious injury is low, the absolute number of older people who suffer fractures is high, and places a heavy demand on both the health and social services. Even falls which result in only minimal physical injury can have significant psychological and social consequences. Older people fall for many reasons and often with disastrous consequences; a Falls and older people serious injury may signal the end of that older person's independent lifestyle. Illnesses, impairment of the special senses, adverse reactions to drugs and * falling is a symptom and should be environmental hazards may all contribute. These causes require thorough and taken seriously * a full diagnosis needs to be reached skilled detection and assessment followed by proper treatment and preventive * general advice on diet, fall measures.
    [Show full text]
  • Pulmonary Embolism Caused by Ovarian Vein Thrombosis During Cesarean Section: a Case Report
    Oda et al. JA Clinical Reports (2018) 4:3 DOI 10.1186/s40981-017-0142-1 CASEREPORT Open Access Pulmonary embolism caused by ovarian vein thrombosis during cesarean section: a case report Yutaka Oda1* , Michie Fujita2, Chika Motohisa3, Shinichi Nakata3, Motoko Shimada1 and Ryushi Komatsu4 Abstract Background: Ovarian vein thrombosis is a rare complication of pregnancy. The representative complaints of patients with ovarian vein thrombosis are abdominal pain and fever. In some cases, however, fatal pulmonary embolism may develop. We report a case of pulmonary embolism presenting with severe hypotension and loss of consciousness during cesarean section possibly caused by ovarian vein thrombosis. Case presentation: A 25-year-old woman at 38 weeks 4 days of gestation was scheduled for repeat cesarean section. Her past history was unremarkable, and the progress of her pregnancy was uneventful. She did not experience any symptoms indicative of deep vein thrombosis. Cesarean section was performed under spinal anesthesia, and a healthy newborn was delivered. After removal of the placenta, she suddenly developed dyspnea, hypotension, and loss of consciousness with decreased peripheral oxygen saturation. Blood pressure, heart rate, and oxygen saturation recovered after tracheal intubation and mechanical ventilation with oxygen. Postoperative computed tomography revealed no abnormality in the brain or in the pulmonary artery, but a dilated right ovarian vein with thrombi, extending up to the inferior vena cava, was found. A diagnosis of pulmonary embolism caused by ovarian vein thrombosis was made, and heparin was administered. The tracheal tube was removed on the first postoperative day. Her postoperative course was uneventful, and she was discharged with no complications.
    [Show full text]