Moving Evolution Education Forward: A Systematic Analysis of Literature to Identify Gaps in Collective Knowledge for Teaching.

Evolution is a unifying theory in biology and is challenging for undergraduates to learn. An instructor's ability to help students learn is influenced by pedagogical content knowledge (PCK), which is topic-specific knowledge of teaching and learning. Instructors need PCK for every topic they teach, which is a tremendous body of knowledge to develop alone. However, investigations of undergraduate thinking and learning have produced collective PCK that is available in peer-reviewed literature. Currently, it is unclear whether the collective PCK available adequately addresses the topics in evolution that college instructors teach. We systematically examined existing literature to determine what collective PCK for teaching evolution is available and what is missing. We conducted an exhaustive literature search and analyzed 316 relevant papers to determine: the evolutionary topics addressed; whether the focus was student thinking, assessment, instructional strategies, or goals; and the type of work (e.g., empirical, literature review). We compared the collective PCK available in the literature with the topics taught in a sample of 32 undergraduate evolution courses around the country. On the basis of our findings, we propose priorities for the evolution education research community and propose that PCK is a useful lens for guiding future research on teaching and learning biology.

Teacher Knowledge for Active-Learning Instruction: Expert-Novice Comparison Reveals Differences.

Active-learning strategies can improve science, technology, engineering, and mathematics (STEM) undergraduates' abilities to learn fundamental concepts and skills. However, the results instructors achieve vary substantially. One explanation for this is that instructors commonly implement active learning differently than intended. An important factor affecting how instructors implement active learning is knowledge of teaching and learning. We aimed to discover knowledge that is important to effective active learning in large undergraduate courses. We developed a lesson-analysis instrument to elicit teacher knowledge, drawing on the theoretical construct of teacher noticing. We compared the knowledge used by expert (n = 14) and novice (n = 29) active-learning instructors as they analyzed lessons. Experts and novices differed in what they noticed, with experts more commonly considering how instructors hold students accountable, topic-specific student difficulties, whether the instructor elicited and responded to student thinking, and opportunities students had to generate their own ideas and work. Experts were also better able to support their lesson analyses with reasoning. This work provides foundational knowledge for the future design of preparation and support for instructors adopting active learning. Improving teacher knowledge will improve the implementation of active learning, which will be necessary to widely realize the potential benefits of active learning in undergraduate STEM.

Low-dose intra-venous cyclophosphamide therapy in a patient with neurological complications of Behçet's disease.

Behçet's disease (BD) is a chronic relapsing-remitting inflammatory disorder of unknown origin, affecting multiple organs. Neurological involvement is one of the most devastating manifestations of BD and may be fatal. We report a 36-year-old woman with neuro-Behçet who was treated with low-dose pulse cyclophosphamide (St. Thomas' protocol) and methylprednisolone, with almost complete clinical remission.

Colleagues as Change Agents: How Department Networks and Opinion Leaders Influence Teaching at a Single Research University.

Relationships with colleagues have the potential to be a source of support for faculty to make meaningful change in how they teach, but the impact of these relationships is poorly understood. We used a mixed-methods approach to investigate the characteristics of faculty who provide colleagues with teaching resources and facilitate change in teaching, how faculty influence one another. Our exploratory investigation was informed by social network theory and research on the impact of opinion leaders within organizations. We used surveys and interviews to examine collegial interactions about undergraduate teaching in life sciences departments at one research university. Each department included discipline-based education researchers (DBERs). Quantitative and qualitative analyses indicate that DBERs promote changes in teaching to a greater degree than other departmental colleagues. The influence of DBERs derives, at least partly, from a perception that they have unique professional expertise in education. DBERs facilitated change through coteaching, offering ready and approachable access to education research, and providing teaching training and mentoring. Faculty who had participated in a team based-teaching professional development program were also credited with providing more support for teaching than nonparticipants. Further research will be necessary to determine whether these results generalize beyond the studied institution.

Effects of therapy with nifedipine GITS or atenolol on mental stress-induced ischemic left ventricular dysfunction.

OBJECTIVES: We sought to determine the effect of nifedipine gastrointestinal therapeutic system (GITS) or atenolol on ischemic left ventricular dysfunction induced by mental stress. BACKGROUND: The efficacy of conventional antianginal therapy in preventing myocardial ischemia induced by mental stress is unknown. METHODS: Nifedipine GITS, atenolol and placebo were administered to 15 subjects with stable angina in a double-blind crossover trial. Subjects underwent a series of mental stressors at the end of each treatment. Radionuclide ventriculography was performed at baseline and at peak mental stress. Other measured variables included time to ischemia on exercise treadmill testing, ischemia on 48-h ambulatory electrocardiogram (ECG) monitoring, and resting and mental stress-induced levels of plasma catecholamines, tissue plasminogen activator antigen, plasminogen activator inhibitor-1 and platelet aggregability. RESULTS: Mental stress resulted in a significant increase in plasma epinephrine and norepinephrine levels during each treatment phase. Atenolol therapy was associated with lower baseline and postmental stress rate-pressure product compared with nifedipine or placebo. Therapy with either nifedipine GITS or atenolol prevented the development of wall-motion abnormalities and the decline in regional ejection fraction (EF) in the segment with the largest deterioration in wall motion during placebo therapy. Both medications prevented the decrease in global EF in subjects who demonstrated at least a 5% fall in global EF on placebo therapy. No therapy exerted a statistically significant benefit on exercise performance or frequency of ischemia during ambulatory ECG monitoring. CONCLUSIONS: Both nifedipine GITS and atenolol are effective at preventing mental stress-induced wall-motion abnormalities, although the mechanisms may be different.

Relation between clinical, angiographic and ischemic findings at baseline and ischemia-related adverse outcomes at 1 year in the Asymptomatic Cardiac Ischemia Pilot study. ACIP Study Group.

OBJECTIVES: We attempted to investigate the relation between patient characteristics and adverse outcome in patients with ischemia and clinically stable coronary artery disease (CAD). BACKGROUND: Evidence suggests that cardiac ischemia, detected by exercise stress testing (ETT) and ambulatory electrocardiographic (AECG) monitoring during daily living, identifies a subgroup of patients at increased risk for adverse outcome, but the relation between these ischemia findings and clinical and angiographic characteristics is largely unknown. METHODS: We examined the relation between clinical, angiographic and ischemia characteristics at entry with adverse outcome observed at 1 year in the 558 patients enrolled in the Asymptomatic Cardiac Ischemia Pilot (ACIP) study. RESULTS: By the 12-month visit 13.1% of patients had an ischemia-related adverse clinical outcome that included death, nonfatal myocardial infarction or an ischemia-related hospital admission. Multivariate analysis identified only the number of AECG ischemic episodes at entry (odds ratio [OR] 1.06, 99% confidence interval [CI] 1.01 to 1.12, p = 0.002) as an independent predictor of outcome. Assignment to revascularization (as opposed to an initial medical treatment strategy) showed a trend (OR 0.56, 99% CI 0.26 to 1.2, p = 0.05). None of the other baseline clinical, exercise or angiographic variables examined provided additional information relative to adverse outcome. CONCLUSIONS: Determinants of adverse outcome, among clinically stable patients with CAD and ischemia induced by stress and daily life were magnitude of AECG ischemia before treatment and, possibly, initial treatment assignment. Among the many other characteristics examined, including age, symptom status and angiographic and exercise variables, none contributed additional independent prognostic information. These two simple variables, which may be modifiable, need further study in a larger trial.

Asymptomatic Cardiac Ischemia Pilot (ACIP) study: outcome at 1 year for patients with asymptomatic cardiac ischemia randomized to medical therapy or revascularization. The ACIP Investigators.

OBJECTIVES: This report discusses the outcome at 1 year in patients in the Asymptomatic Cardiac Ischemia Pilot (ACIP) study. BACKGROUND: Comparative efficacy of medical therapy versus revascularization in treatment of asymptomatic ischemia is unknown. The ACIP study assessed the ability of three treatment strategies to suppress ambulatory electrocardiographic (ECG) ischemia to determine whether a large-scale trial studying the impact of these strategies on clinical outcomes was feasible. METHODS: Five hundred fifty-eight patients with coronary anatomy amenable to revascularization, at least one episode of asymptomatic ischemia on the 48-h ambulatory ECG and ischemia on treadmill exercise testing were randomized to one of three treatment strategies: 1) medication to suppress angina (angina-guided strategy, n = 183); 2) medication to suppress both angina and ambulatory ECG ischemia (ischemia-guided strategy, n = 183); or 3) revascularization strategy (angioplasty or bypass surgery, n = 192). Medication was titrated atenolol-nifedipine or diltiazem-isosorbide dinitrate. RESULTS: The revascularization group received less medication and had less ischemia on serial ambulatory ECG recordings and exercise testing than those assigned to the medical strategies. The ischemia-guided group received more medication but had suppression of ischemia similar to the angina-guided group. At 1 year, the mortality rate was 4.4% in the angina-guided group (8 of 183), 1.6% in the ischemia-guided group (3 of 183) and 0% in the revascularization group (overall, p = 0.004; angina-guided vs. revascularization, p = 0.003; other pairwise comparisons, p = NS). Frequency of myocardial infarction, unstable angina, stroke and congestive heart failure was not significantly different among the three strategies. The revascularization group had significantly fewer hospital admissions and nonprotocol revascularizations at 1 year. The incidence of death, myocardial infarction, nonprotocol revascularization or hospital admissions at 1 year was 32% with the angina-guided medical strategy, 31% with the ischemia-guided medical strategy and 18% with the revascularization strategy (p = 0.003). CONCLUSIONS: After 1 year, revascularization was superior to both angina-guided and ischemia-guided medical strategies in suppressing asymptomatic ischemia and was associated with better outcome. These findings require confirmation by a larger scale trial.

Achieving and maintaining National Cholesterol Education Program low-density lipoprotein cholesterol goals with five statins.

PURPOSE: Most patients fail to achieve and maintain low-density lipoprotein (LDL) cholesterol goals established by the National Cholesterol Education Program (NCEP). The Atorvastatin Comparative Cholesterol Efficacy and Safety Study (ACCESS) was a randomized study comparing the efficacy and safety of five statins and their ability reduce LDL cholesterol to the NCEP target level. SUBJECTS AND METHODS: Of 7542 patients screened, 3916 hypercholesterolemic patients were randomly assigned to treatment with a statin, beginning with the lowest recommended dose (atorvastatin, pravastatin, and simvastatin, 10 mg; fluvastatin and lovastatin, 20 mg). If the NCEP target was not achieved, the dose was titrated up to the recommended maximum (atorvastatin, fluvastatin, and lovastatin, 80 mg; pravastatin and simvastatin, 40 mg). The total duration of treatment was 54 weeks. RESULTS: Atorvastatin achieved the greatest mean reduction in LDL cholesterol: 36% +/- 11% at 6 weeks (initial dose) and 42% +/- 13% at 54 weeks. More patients receiving atorvastatin at its initial dose (53%, 997 of 1888) achieved their NCEP target levels than patients receiving simvastatin (38%, 174 of 462), lovastatin (28%, 134 of 472), pravastatin (15%, 71 of 461), or fluvastatin (15%, 69 of 474) at the initial dose. Atorvastatin-treated patients were more likely to maintain their target levels from week 6 to week 54. The percent reduction in LDL cholesterol achieved at the initial dose correlated strongly with the proportion of patients who maintained their goals at 54 weeks (r = -0.84). CONCLUSION: For patients treated with statins, providing a greater margin between the NCEP target level and the achieved LDL cholesterol level enhances the likelihood of maintaining NCEP goal levels.

Electron-beam computed tomography in the evaluation of patients with chest pain.

Electron-beam computed tomography is a promising technology for the noninvasive evaluation of patients with suspected coronary artery disease. However, at the present time there is insufficient clinical evidence to support its widespread use as a screening tool for evaluation of patients with chest pain.

Effect of the menstrual cycle on endothelium-dependent vasodilation of the brachial artery in normal young women.

In normal young women, endothelium-dependent, flow-mediated vasodilation is enhanced when serum estradiol levels are elevated and unopposed by elevated levels of progesterone.

Effects of withdrawal of chronic estrogen therapy on brachial artery vasoreactivity in women with coronary artery disease.

Withdrawal of oral estrogen therapy is associated with a deterioration in endothelial function in postmenopausal women with coronary artery disease. Our data also suggest that withdrawal of estrogen results in enhanced hyperemic flow, although this observation will require validation with further study.

Intravenous versus subcutaneous vitamin K1 in reversing excessive oral anticoagulation.

Our data suggest that compared with the subcutaneous route of administration, intravenous vitamin K1 results in a more prompt reduction in the international normalized ration. However, for most patients, subcutaneous vitamin K1 is an effective and safe alternative when used in conjunction with modification of subsequent warfarin dosing, because virtually all patients achieved a safe level of anticoagulation within 72 hours with this route of administration.

Effect of gemfibrozil +/- niacin +/- cholestyramine on endothelial function in patients with serum low-density lipoprotein cholesterol levels <160 mg/dl and high-density lipoprotein cholesterol levels <40 mg/dl.

We studied endothelial function using the brachial artery ultrasound model in 100 subjects from the Armed Forces Regression Study, a placebo-controlled, angiographic regression trial in subjects with normal or modestly elevated low-density lipoprotein (LDL) cholesterol and low levels of high-density lipoprotein (HDL) cholesterol treated for 30 months with gemfibrozil and (if necessary) niacin and/or cholestyramine to raise HDL by 25% and lower LDL to < 110 mg/dl. Although the treatment group had highly significant improvements in LDL and HDL cholesterol, there was no difference between the 2 groups in flow-mediated dilation (treatment vs control 6.9 +/- 6.5% vs 6.3 +/- 7.3%) or nitroglycerin-induced dilation (12.4 +/- 9.6% vs 11.9 +/- 7.4%, all p = NS). Treatment and control subjects without a history of hypertension had flow-mediated dilation similar to that of a normal reference population (10.6 +/- 8.3% vs 8.4 +/- 4.5%), whereas subjects with a history of systemic hypertension had markedly impaired flow-mediated dilation that was not significantly improved with treatment (treatment vs control, 6.0 +/- 5.5% vs 4.3 +/- 5.9%, p = 0.2). Thus, nonhypertensive subjects with angiographic coronary disease and low HDL cholesterol had normal endothelial function in the brachial artery model. Patients with a history of hypertension had marked endothelial dysfunction despite blood pressure treated to normal levels, and this dysfunction is not attenuated by pharmacologic therapy for dyslipidemia.

Association between C-reactive protein, anti-Chlamydia pneumoniae antibodies, and vascular function in healthy adults.

Abnormalities of vascular function occur in patients with risk factors for atherosclerosis before the development of obstructive disease. Our pilot data suggest that elevated serum markers of infection and/or inflammation are associated with functional abnormalities of the vasculature in subjects at otherwise low risk for atherosclerosis.

Correlation of non-high-density lipoprotein cholesterol with apolipoprotein B: effect of 5 hydroxymethylglutaryl coenzyme A reductase inhibitors on non-high-density lipoprotein cholesterol levels.

Apolipoprotein B has been shown to be a better predictor of coronary heart disease than low-density lipoprotein (LDL) cholesterol, and non-high-density lipoprotein (non-HDL) cholesterol may also be a better parameter for coronary heart disease risk assessment and as a target for therapy. Data from the Atorvastatin Comparative Cholesterol Efficacy and Safety Study (ACCESS) were used to assess the correlation between lipid and apolipoprotein B levels before and after lipid-lowering therapy and to examine the effects of 5 hydroxymethylglutaryl coenzyme A reductase inhibitors on lipids and apolipoprotein B. The 54-week study randomized 3,916 hypercholesterolemic patients to atorvastatin, fluvastatin, lovastatin, pravastatin, or simvastatin, initiated at recommended starting doses with titrations as needed at weeks 6, 12, and 18 to achieve National Cholesterol Education Program LDL targets. Compared with LDL cholesterol, non-HDL cholesterol correlated better with apolipoprotein B levels at baseline (r = 0.914, p <0.0001) and at week 54 (r = 0.938, p <0.0001), and the correlation was strong across all baseline triglyceride strata. At starting doses, atorvastatin (10 mg) lowered non-HDL cholesterol by 33.3% compared with 26.6% with simvastatin (10 mg), 24.1% with lovastatin (20 mg), 17.2% with fluvastatin (20 mg), and 17.0% with pravastatin (10 mg). Atorvastatin also provided greater reductions in non-HDL cholesterol after dose titration, and a greater percentage of patients taking atorvastatin achieved non-HDL cholesterol targets. Baseline triglyceride did not affect non-HDL cholesterol reductions with any of the 5 hydroxymethylglutaryl coenzyme A reductase inhibitors. Fewer patients achieved non-HDL cholesterol targets than LDL cholesterol targets, particularly among high-risk patients, implying that if non-HDL cholesterol was used as a target for treatment, more patients would need to be treated more aggressively than National Cholesterol Education Program guidelines require.

Initial energy for elective external cardioversion of persistent atrial fibrillation.

We conducted a prospective randomized study to determine the safety and efficacy rate of 3 commonly used energy levels (100, 200, and 360 J) for elective direct-current cardioversion of persistent atrial fibrillation. When compared with 100 and 200 J, the initial success rate with 360 J was significantly higher (14%, 39%, and 95%, respectively), and patients randomized to 360 J ultimately required less total energy and a lower number of shocks.

Comparison of subgroups assigned to medical regimens used to suppress cardiac ischemia (the Asymptomatic Cardiac Ischemia Pilot [ACIP] Study).

This report focuses on the subset of 235 patients from the Asymptomatic Cardiac Ischemia Pilot (ACIP) study receiving randomly assigned medical therapy to treat angina and suppress ischemia detected on ambulatory electrocardiography: 121 patients received the sequence of atenolol and nifedipine, and 114 diltiazem and isosorbide dinitrate. After 12 weeks of therapy, the primary end point (absence of ambulatory electrocardiographic (ECG) ischemia and no clinical events) was reached in 47% of atenolol/nifedipine- versus 31% of diltiazem/isosorbide dinitrate-treated patients (adjusted p = 0.03). A trend to increased exercise time to ST depression was seen in the atenolol and nifedipine versus diltiazem and isosorbide dinitrate regimens (median treadmill duration 5.8 vs 4.8 minutes; p = 0.04). However, when adjusted for baseline imbalances in ambulatory ECG ischemia, the 2 medical combinations were similar in suppression of ambulatory ECG ischemia. In both medication regimens, an association between mean heart rate and ischemia on ambulatory electrocardiography after 12 weeks of treatment was observed so that patients on either regimen with a mean heart rate > 80 beats/min had ischemia detectable almost twice as often as those with a mean heart rate < 70 beats/min (p < 0.001).

Prognostic significance of myocardial ischemia detected by ambulatory electrocardiography, exercise treadmill testing, and electrocardiogram at rest to predict cardiac events by one year (the Asymptomatic Cardiac Ischemia Pilot [ACIP] study)

Myocardial ischemia identified by ambulatory electrocardiography (AECG), exercising treadmill testing, (ETT), or 12-lead electrocardiogram at rest is associated with an adverse prognosis, but the effect of improving these ischemic manifestations by treatment on outcome is unknown. The Asymptomatic Cardiac Ischemia Pilot (ACIP) study was a National Heart, Lung, and Blood Institute funded study to determine the feasibility of conducting a large-scale prognosis study and to assess the effect of 3 treatment strategies (angina-guided strategy, AECG ischemia-guided strategy, and revascularization strategy) in reducing the manifestations of ischemia as indicated by AECG and ETT. The study cohort for this database study consisted of 496 randomized patients who performed the AECG, ETT, and 12-lead electrocardiogram at rest at both the qualifying and week 12 visits. The effect of modifying ischemia by treatment on the incidence of cardiac events (death, myocardial infarction, coronary revascularization procedure, or hospitalization for an ischemic event) at 1 year was examined. In the 2 medical treatment groups (n = 328) there was an association between the number of ambulatory electrocardiographic ischemic episodes at the qualifying visit and combined cardiac events at 1 year (p = 0.003). In the AECG ischemia-guided patients there was a trend associating greater reduction in the number of ambulatory electrocardiographic ischemia episodes with a reduced incidence of combined cardiac events (r = -0.15, p = 0.06). In the revascularization strategy patients this association was absent. In the medical treatment patients the exercise duration on the baseline ETT was inversely associated with an adverse prognosis (p = 0.02). The medical treatment strategies only slightly improved the exercise time and the exercise duration remained of prognostic significance. In the revascularization group strategy patients this association was absent. Thus, myocardial ischemia detected by AECG and an abnormal ETT are each independently associated with an adverse cardiac outcome in patients subsequently treated medically.

Complications of warfarin therapy monitored by the International Normalized Ratio versus the prothrombin time ratio.

The objective of our study was to determine the rates of bleeding complications and thromboembolic events in patients receiving oral anticoagulant therapy monitored with the prothrombin time (PT) ratio versus therapy monitored with the International Normalized Ratio (INR) using a retrospective time-series study design. Over 650 patients enrolled in a large anticoagulation clinic were studied during two time periods corresponding to the use of the PT ratio versus the INR to guide anticoagulant therapy, with over 400 patient-years of follow-up for each time period. The rate of bleeding complications using the PT ratio to guide therapy was 6.7% (1.2% major, 5.5% minor) per patient-year, compared with 2.9% (0% major, 2.9% minor) using the INR (p = 0.02). The rate of thromboembolic complications was 1.0% using the PT ratio, compared with 0.2% using the INR (p = NS). Therapy monitored with the INR required 19.8 visits per year, compared with 20.7 visits per year using the PT ratio. We conclude that the INR should be used to monitor oral anticoagulant therapy in an effort to reduce bleeding complications while maintaining an acceptable rate of thromboembolic events.