Three Weeks of Team-Based Leaning Do Not Overload Undergraduate Students.

CONTEXT: Team-based learning (TBL) is a flipped-classroom approach requiring students to study before class. Fully flipped curricula usually have fewer in-class hours. However, for practical reasons, several programs implement a few weeks of TBL without adjusting the semester timetable. Students fear that they will be overloaded by the individual and collaborative study hours needed to prepare for TBL. METHODS: We implemented three consecutive weeks of TBL in a 15-week lecture-based course on the renal system. In-class time and assessments were unchanged for all courses. Four hundred fifty-nine first-year undergraduate medical students (229 in 2018; 230 in 2019) were invited to complete weekly logs of their individual and collaborative study hours during lectures and TBL, along with questionnaires on cognitive load and perception of the course. Our program changed from A to E grading in 2018 to pass-fail grading in 2019. RESULTS: Participants (n = 324) spent a similar number of hours studying for TBL vs. lectures with a mean of 3.1 h/week. Collaborative study was minimal outside class (median 0.1 h/week). Results remained similar with pass-fail grading. If in-class time were reduced, 18% of participants said they would have used freed-up time to study for TBL. Studying for TBL generated similar extraneous cognitive load and lower intrinsic load compared to studying for lectures; students were less stressed, and maintained high levels of motivation and self-perceived learning. CONCLUSIONS: Three weeks of lectures were replaced by TBL without reducing in-class time. Students did not report overload in study hours or in cognitive load. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01314-x.

Sodium and urea excretion as determinants of urine output in autosomal dominant polycystic kidney disease patients on V2 receptor antagonists: impact of dietary intervention.

PURPOSE: Tolvaptan, a vasopressin V2 receptor antagonist, slows the decline in renal function in autosomal dominant polycystic kidney disease (ADPKD). However, it increases urine output such that patient adherence could be compromised. In a cohort of patients with ADPKD on tolvaptan, we aimed to identify the contribution of sodium and urea excretion rate to daily urine output, and to evaluate the effectiveness of dietary counseling on sodium and urea excretion rates. METHODS: Retrospective analysis of 30 ADPKD patients who underwent a single session of personalized dietary counseling to reduce sodium and protein intake before initiation of tolvaptan. Creatinine and 24-h urine were obtained regularly on treatment. Generalized estimation equations were used. RESULTS: Mean age and median eGFR were 44 ± 11 years and 52 (43-74) ml/min/1.73 m2. Tolvaptan increased diuresis from 2.5 to 5.2 l/day. After adjusting for the dose of tolvaptan, an increase in sodium and urea excretion rate by 50 mmol/day was associated with an estimated additional urine volume of 0.6 l/day (95% CI 0.4-0.8 l/day; P < 0.001) and 0.25 l/day (95% CI 0.11-0.39 l/day; P < 0.001), respectively. Dietary counseling resulted in a transient reduction of sodium excretion by 19 mmol/day during the first 4 months (P = 0.016) but resulted in a more sustained reduction in urea excretion by 69 mmol/day (P = 0.008). CONCLUSION: Both sodium and urea excretion rates contribute significantly to daily urine volume in patients treated with tolvaptan, and a single session of dietary counseling was transiently effective in reducing sodium intake but achieved a more sustained reduction in protein intake. Dietary counseling should be considered in the management of ADPKD patients treated by tolvaptan.

The evolution of angiotensin blockade in the management of cardiovascular disease.

Dysregulation of the renin-angiotensin system is implicated in many cardiovascular and renal pathologies. Discovery of the renin-angiotensin system represents a major advance in the understanding of hypertension and cardiovascular disease, leading to the development of the anti-angiotensin medications: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and direct renin inhibitors. Clinical trials have shown that drugs in each of these classes have a protective effect on vascular organs that surpass the protection associated with the lowering of blood pressure alone.

Supramaximal dose of candesartan in proteinuric renal disease.

High levels of proteinuria predict renal deterioration, suggesting that interventions to reduce proteinuria may postpone the development of severe renal impairment. This multicenter Canadian trial evaluated whether supramaximal dosages of candesartan would reduce proteinuria to a greater extent than the maximum approved antihypertensive dosage. The authors randomly assigned 269 patients who had persistent proteinuria (> or =1 g/d) despite 7 wk of treatment with the highest approved dosage of candesartan (16 mg/d) to 16, 64, or 128 mg/d candesartan for 30 wk. The median serum creatinine level was 130.0 micromol/L (1.47 mg/dl), and the median urinary protein excretion was 2.66 g/d; most (53.9%) patients had diabetic nephropathy. The mean difference of the percentage change in proteinuria for patients receiving 128 mg/d candesartan compared with those receiving 16 mg/d candesartan was -33.05% (95% confidence interval -45.70 to -17.44; P < 0.0001). Reductions in BP were not different across the three treatment groups. Elevated serum potassium levels (K+ > 5.5 mEq/L) led to the early withdrawal of 11 patients, but there were no dosage-related increases in adverse events. In conclusion, proteinuria that persists despite treatment with the maximum recommended dosage of candesartan can be reduced by increasing the dosage of candesartan further, but serum potassium levels should be monitored during treatment.