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There is strong consensus that the diagnosis of CSS requires both the reproduction of spontaneous symptoms during CSM and clinical features of spontaneous syncope compatible with a reflex mechanism. The quality of evidence is moderate and is given by studies of ECG correlation between CSM and spontaneous events, and indirectly by studies of efficacy of cardiac pacing. Further research is likely to have an important impact on our confidence in the estimation of effect and may change the estimate.

Cardiac sinus massage

BP = blood pressure; CSM = carotid sinus massage; CSS = carotid sinus syndrome; TIA = transient ischaemic attack.


Cardiac sinus massage

BP = blood pressure; CSM = carotid sinus massage; CSS = carotid sinus syndrome; TIA = transient ischaemic attack.


Changing from the supine to the upright position produces a displacement of blood from the thorax to the lower limbs and abdominal cavity that leads to a decrease in venous return and cardiac output. In the absence of compensatory mechanisms, a fall in BP may lead to syncope. 20 , 103 , 104 The diagnostic criteria for OH have been defined by consensus. 6

Currently, there are three methods for assessing the response to change in posture from supine to erect 20 , 103 , 104 : active standing (see section, head-up tilt (see section, and 24-h ambulatory BP monitoring (ABPM) (see section

This test is used to diagnose different types of orthostatic intolerance (see Web Practical Instructions Web Table 1 ). A sphygmomanometer is adequate for routine clinical testing for classical OH and delayed OH because of its ubiquity and simplicity. Automatic arm-cuff devices, which are programmed to repeat and confirm measurements when discrepant values are recorded, are at a disadvantage due to the rapidly falling BP during OH. With a sphygmomanometer, more than four measurements per minute cannot be obtained without venous obstruction in the arm. When more frequent readings are required, as for initial OH, continuous beat-to-beat non-invasive BP measurement is needed. 20 , 103 , 104

Abnormal BP fall is defined as a progressive and sustained fall in systolic BP from baseline value ≥20 mmHg or diastolic BP ≥10 mmHg, or a decrease in systolic BP to <90 mmHg. This definition of OH differs from the 2011 consensus 6 in adding the 90 mmHg threshold. This Task Force believes that an absolute threshold of 90 mmHg of systolic BP is useful, especially in patients with a supine BP <110 mmHg. An isolated diastolic BP drop is very rare and its clinical relevance for OH diagnosis is limited. Orthostatic heart rate (HR) increase is blunted or absent [usually not >10 beats per minute (b.p.m.)] in patients with neurogenic OH, but increases or even exaggerates with anaemia or hypovolaemia. The probability that syncope and orthostatic complaints are due to OH can be assessed using the information given in Table 8 .

Compliance was monitored at fortnightly intervention refills and with home visits. The home visits were performed by trained local village health aids and nurses. Instructions were reviewed during these visits to improve compliance. Each home received an unscheduled visit at least twice in the first 6 wk and once every 4 wk thereafter for the duration of the study period. The 4 measures of compliance were mother's report, examination of fortificant containers fortnightly, mother's usage report, and examination of fortificant containers during unscheduled home visits.

After 12 and 24 wk of supplementation, participants returned to the community site for a follow-up dual sugar absorption test. The same 85 children who had PUFA content assessed initially had a second test after 12 wk.

The multiple MN supplement was a powder composed of vitamins and minerals which provided the recommended nutrient intake from the World Health Organization of most nutrients needed for normal child growth and health ( Supplemental Table 1 ) ( 22 , 23 ). The MNs were provided in a dose of 2.7 g/d mixed with icing sugar. Caretakers were instructed to mix the MNs into the child's morning porridge. A plastic scoop with a clear demarcation of the daily dosing was provided to each caregiver.

Supplemental Table 1

The FO supplement consisted of 1 mL of highly purified FO (ProOmega Fish Oil; Nordic Naturals) produced from deep-sea anchovies and sardines. One milliliter of this FO contains ∼225 mg of DHA and 325 mg of EPA. Each caregiver was provided a plastic syringe demarcated at 1 mL with instructions on how much FO to be given by mouth each morning after practicing filling and emptying the syringe at the study site.

The placebo for FO was palm oil and for MNs the placebo was icing sugar.

A random subset of 235 participants was chosen to participate in two 24-h dietary recalls conducted 20 wk apart within the study period. Caregivers were prompted to recount the quantity of foods consumed by the child in the previous 24-h period by using food models of commonly consumed foods and recipes ( 24 , 25 ). This information was then used to calculate dietary nutrient intake ( 26 ). Data from both recalls among all children were aggregated in the analysis, to yield an assessment of the dietary intake of the study population. Dietary intake data did not include the nutrients provided in the interventions.

Caregivers were instructed to give children nothing by mouth after going to sleep the night before the sugar absorption tests and to assemble at the village research site at sunrise on the testing days. On arrival in the morning, each child was given 20 mL of sugar solution that contained 5 g of lactulose and 1 g of mannitol to drink. All children were carefully supervised and any spilling of the sugar solution was noted. If any such losses occurred, the child was asked to return the next day to attempt the test again. Each child then had a sterile urine bag attached and the child remained on site for 4 h to collect urine. A 4-h time period was chosen because the L:M has been found to vary <10% for urine collections that range from 4 to 24 h in our previous work and in the United States ( 8 ). When any urine was voided, the urine was emptied into a sterile cup that contained 10 mg of merthiolate and a new bag was placed immediately. During this time period, children were encouraged to drink water. Each child was required to void a final time at least 4 h after the sugar solution was consumed for the urine collection to be considered complete. The total urine volume for each child was recorded, and a 3-mL aliquot of urine was transferred to a cryovial, flash-frozen in liquid nitrogen, transported in a dry shipper, and stored in freezers at −80°C before analysis.

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Get the Word Out About Costly, Unnecessary Lab Tests

More blood tests may not be better for hospitalized patients, a widely publicized national report proclaims.

Also drawing attention to laboratory tests’ costs and use: healthcare reform, pay-for-value reimbursement models and other market forces.

But how can ordering physicians be certain of their decisions? How can they order the right test for the right patient at the right time?

Fortunately, research suggests appropriate messages and electronic alerts to physicians can result in less unnecessary lab testing and treatments. Hospitals contain costs, as well.

Pathologists and lab leaders have an opportunity to educate their colleagues. And the lab must also be equipped with the strategic resources necessary for enabling better decisions about tests orders.

Teach Doctors, Decrease Tests Costs

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report, the Society of Hospital Medicine (SHM) ranked repetitive complete blood count (CBC) testing and chemistry testing among the top five practices to question in adult medicine. Read full blog post . . .

The data inspired a process improvement initiative at Vanderbilt University Medical Center, Nashville. Researchers there found education and feedback helped doctors to order less blood tests for hospitalized patients; medical center costs decreased, too, according to a Medscape article about the study.

Staff teams and direct-care hospitalists received presentation fliers and e-mails. Messages encouraged them to “order blood tests mindfully rather than reflexively,” Medscape reported on the study, which was presented earlier this year at a SHM annual meeting.

Costs of CBCs ($88) and basic metabolic profiles ($160) were prominently displayed at workstations, as well.

The study showed a decrease in tests ordered by the house-staff teams resulted in a weekly cost savings of about $20,288. The hospitalist teams averaged a weekly cost savings of $16,733.

”Reducing inappropriate phlebotomy is a strategy for cost-containment and may also improve the patient experience,” said Kelly Cunningham Sponsler, MD, of Vanderbuilt University, in the Medscape news story.

Electronic Alerts Advise Physicians

Still other reports reveal how sophisticated electronic medical systems can impact lab tests costs, treatment orders and providers’ bottom lines.

At Cedars-Sinai Health System, Los Angeles, Choosing Wisely recommendations are included in the hospital’s electronic health record (EHR) system. The hospital leaders aimed to ensure patients received care they needed but “nothing more,” according to an article, posted earlier this year, on the Healthcare Financial Management Association Leadership blog.

Pop-up alerts remind doctors when their orders deviate from Choosing Wisely recommendations. Hospital officials estimate they will save about $3 million each year as a result of including the messages in the EHR.

And in Massachusetts, primary care physicians affiliated with Atrius Health obtained real-time information on lab costs for 27 tests as they electronically ordered them. Another group of doctors in the study did not.

The ordering rates of both high and low cost-range tests significantly decreased when doctors saw in real-time the cost of them, pointed out a ScienceDaily article on the research.

“It’s like putting price labels on goods you buy in the supermarket. When you know the prices, you tend to buy more strategically,” Thomas D. Sequist, MD, MPH, of Atrius Health, told Science Daily. He is the senior author of the study published in the Mens Shorts Won Hundred Sale Lowest Price Store Sale Online Clearance Order 9d8NzQ

ATLAS Utilization Optimization Popular

Indeed, doctors are price-checking. So, it’s no surprise that Atlas Medical has seen its Utilization Optimization solution grow in popularity among forward-thinking lab leaders. Powered by the Company’s Coordinated Diagnostics Platform™ (Platform), ATLAS Utilization Optimization makes it possible to electronically share important test cost messages and more content about best practice recommendations with ordering doctors.

How does it do it? An easy-to-use algorithm and rule-authoring environment enables providers to develop messages. For instance, an expensive test algorithm may have an intervention description as follows: “You are ordering a test that is over $900. In order to order this test, you will need pre-authorization.”

The Atlas Medical Platform solutions are not only aimed at aiding healthcare executives in managing overutilization of tests. The solutions also enable opportunities to improve underutilization of tests and care outcomes, according to Robert Atlas, President and CEO of Atlas Medical. “Our Platform helps providers leverage diagnostics data to better optimize lab testing,” he says.

Sharing: Ask a question, reply or share your experience:

How do you educate doctors about costs of lab tests?

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Improve Lab Orders by Educating Physicians Optimizing Utilization

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