"CF asthma": what is it and what do we do about it?

The diagnosis of "CF asthma" is problematic and it is difficult to determine which patients have a combination of CF and asthma and which have asthma like symptoms caused by inflammation of the CF lung. This may not matter, however; the relevance lies in the possible approaches to treatment.     

Comparative effectiveness research: what is it and why do we need it in nephrology?

The USA leads other industrialized countries in health care spending but lags behind in terms of health outcomes. There has been growing interest in comparative effectiveness research (CER) as a means to identify best practices to create a more efficient and effective health care system. Two key concepts of CER are that it should (i) compare two or more alternative tests, therapies or procedures and (ii) be conducted in persons, clinical settings and conditions that are representative of the real world. The goal of CER is to provide evidence for clinicians, patients, policy makers and others to make informed decisions that will ultimately improve the overall health of specific subgroups and of the population as a whole. In this narrative review, we first describe the strengths and limitations of various types of studies that constitute CER, including randomized clinical trials, observational studies and systematic reviews, providing examples from the nephrology literature. Because of the concerns regarding confounding in observational CER, we also provide an overview of methods to reduce confounding in these types of studies. Finally, we will discuss why CER pertaining to kidney disease care needs to be a top priority in order to move our field from a largely opinion-based specialty to an evidence-based specialty.     

Urodynamics: What to do and when is it clinically necessary?

The role of urodynamics in the evaluation and treatment of men with lower urinary tract symptoms is not well defined. Symptoms do not correlate very well with urodynamic findings, but patients with prostatic obstruction fare better after ablative prostatic surgery than those with impaired detrusor contractility. The only proven method for distinguishing between the two is urodynamics, ie, the detrusor pressure/uroflow study. This article reviews urodynamic techniques and the literature pertaining to urodynamics, along with their clinical utility in benign prostatic hyperplasia. The role of urodynamics in clinical practice is discussed as well.     

A third renal transplantation: is it relevant and is it worth it?

INTRODUCTION: The aim of this retrospective study was to determine the outcome of third cadaveric renal transplantations performed between 1989 and 2004 among a cohort of 35 patients whose immunosuppression included induction therapy and calcineurin inhibitors. Most patients were highly sensitized with 1 (0-4) HLA (classes I + II) incompatibility between donor and recipient. RESULTS: The median follow-up time was 57 months (range, 1-190). Fourteen patients experienced delayed graft function that required posttransplantation hemodialysis. The current patient and graft survival rates were 91.4% and 82.8%, respectively. At last follow-up, 6 grafts had been lost: 1 due to primary nonfunction; 1 due to an urinary leak (day 45); 2 deaths with functioning grafts; and 2 chronic allograft nephropathies (CAN) at 85 and 60 months posttransplantation, respectively. Among the 10 patients who experienced acute rejection episodes, half were steroid-sensitive, whereas the others required OKT3 therapy. Overall, when excluding the 2 patients who presented with early loss of their grafts, 13 of 33 patients (39.4%) developed CAN, which led to the graft loss in only 2 cases. The mean creatinine clearance was 57 +/- 23 mL/min at year 5. Of the 35 recipients, 12 (34.3%) developed graft/perigraft complications, among whom 10 (83.3%) required treatment. The most frequent complication was lymphocele (M = 4; 11.4%) or infections that led to rehospitalization (n = 17). CONCLUSION: Results from third transplantations were encouraging. Thus, despite the organ shortage, a third graft was worth it!     

Prospective trial registration for clinical research: what is it, what is it good for, and why do I care?

Optimizing evidence-based medicine--and therefore the care of our patients--requires a public record of both the benefits and the risks of various medical interventions. Unfortunately, available evidence is often skewed because some clinical trials are withheld from publication; only selected data are reported, and statistical techniques are often inappropriately determined following data analysis. Prospective clinical trial registration (PCTR) is the public documentation of trial protocols--today primarily on the Internet--before data analysis (and ideally before trial commencement). The primary goals of PCTR are to reduce selective reporting and improve data analysis transparency, but it may also promote trial awareness for the public and other investigators. Prospective clinical trial registration is certainly not without problems, but many have been resolved, and the remainder is relatively minor in nature and easily overcome. Multiple organizations endorse (in some cases mandate) PCTR, including prominent committees of medical editors, the World Health Organization, the World Medical Association (responsible for the Helsinki Declaration), and, more recently, the US Food and Drug Administration. Although Regional Anesthesia and Pain Medicine does not currently require registration for published articles, PCTR in this and other anesthesiology and pain journals may become mandatory within the next few years. Potential authors/investigators will therefore benefit from becoming familiar with PCTR before mandatory registration implementation, and familiarity among readers may improve interpretation and understanding of clinical research results.     

Who is responsible for operating room management and how do we measure how well we do it?

BACKGROUND: Managing the surgical process in the operating suite - often the most expensive unit in the hospital - is vital, yet challenging. While sensible management can improve efficiency, unclear managerial structures can hinder the optimal use of resources. Despite that, no previous data exists as to how the operating room management is organized and the performance monitored in our country. METHODS: A survey was sent to chief anesthesiologists and head nurses of 103 surgery units of 60 public hospitals regarding the current structures of daily management, as well as metrics and tools used for monitoring the performance of the operating room. RESULTS: The overall response rate was 87%. Nurses' and anesthesiologists' perceptions differed significantly on which care provider they held responsible for the daily operative management of the operating room. In doctors' opinion, that person was an anesthesiologist - either alone or in combinations - more often than in nurses' opinion (66% vs. 35%, P < 0.001). Anesthesiologists' involvement increased by the type and size of the hospital, being greatest in the university hospitals. Operating room performance was measured most often by number of procedures in a time unit, utilization and turnover time. Monitoring was complicated by old-fashioned information systems, and seldom seemed to lead to organizational changes. CONCLUSION: The structure of the daily operative management of an operating room needs redefining. There should be more focus on collaboration and communication between the care providers.     

Surgical bypass: when is it best and do angiosomes play a role?

The etiology of foot lesions in diabetics is multifactorial. Arterial insufficiency, neuropathy, and susceptibility to infection are major factors contributing to the formation of nonhealing diabetic foot lesions. These factors lead to a 15% ulceration rate in diabetics with 20% resulting in amputation. This amputation rate, 4.1 per 1,000 per year, represents a risk 40 times greater for diabetics, with a subsequent second amputation in 60% by 5 years. Conversely, more than half of all lower-extremity amputations are performed in diabetic patients. Therefore, the primary goal in diabetic lower-extremity care is to heal foot ulcerations and prevent amputations and major disabilities. Lower-extremity revascularization is a major facet of achieving the goal of healing and amputation prevention. Due to the severity, distribution, and complexity of diabetic vascular disease, surgical bypass continues to play a role in attaining this goal. Surgical bypass might be the best option for diabetic patients with significant tissue loss or to revascularize the appropriate angiosome of the foot and maximize healing potential. In order to offer surgical bypass to these patients, innovative techniques might need to be considered, including venous patches and cuffs, heparin-bonded grafts, and adjunctive distal arteriovenous fistulas.     

Why is it so hard to do the right thing in wound care?

“Doing the right thing” in wound care is not an easy task. Studies suggest that 3 factors determine compliance with performing basic wound care from an evidence‐based medicine perspective: complexity, cognitive effort, and the compensation system. Two models were explored to investigate compliance with basic wound care at hospital based wound centers: offloading of diabetic foot ulcers (DFUs) and compression bandaging for venous leg ulcers. Using a very large wound‐care registry it was determined that only 6% of DFU patients received the gold standard of care for offloading, i.e., total contact casting (TCC), but among those patients who received it, the average cost of treatment was half the cost of those who did not. Although inexpensive to administer, TCC is a relatively time‐consuming procedure which is poorly reimbursed. Other DFU treatments such as bilaminate skin, are more costly but are reimbursed much more generously. Thus, the reimbursement system favors the use of more expensive therapies over more economical ones. In the case of venous leg ulcers (VLUs), only 17% of patients received adequate compression. Provision of adequate compression among VLU patients has been similarly hindered by inadequate reimbursement policy. Lack of familiarity with clinical practice guidelines increases the cognitive effort for clinicians. Improving the economic model to favor the provision of effective basic care, creating easier‐to‐use products, and making clinical practice guidelines available at the point of service may make it easier to “do the right thing(s)” in wound care.     

Femoral neck non-unions: how do I do it?

Femoral head necrosis and non-union are frequent complications after femoral neck fracture. The main reason for failure leading to non-union is an inadequate osteosynthesis and/or poor mechanical conditions, leading to instability. Criteria for optima reduction and fixation techniques, which can prevent non-union in the majority of cases, are described. This knowledge is mandatory for each surgeon as in the non-expert situation up to 30% inadequacy of the "simple" procedure occurs! Although in the elderly endoprosthetic replacement is the treatment of first choice, in the younger and active patients the treatment should be directed towards salvage of the own hip. In non-complex cases a valgisation osteotomy according to Pauwels will lead to very good results. The technique of this secondary procedure is demonstrated by a case report. In case of combined pathology with (complete) a vascular necrosis of the femoral head, the age threshold for endoprosthetic replacement will be far lower nowadays, but even in those cases, especially below the age of 50, salvage procedures with free fibular grafting lead to a good outcome and form a useful alternative.     

Inflamed solitary caecal diverticulum - it is not appendicitis, what should I do?

We describe three cases that presented with symptoms suggestive of appendicitis but were found at operation to have an inflamed solitary caecal diverticulum. All were treated successfully with diverticulectomy or inversion of the diverticulum. We wish to highlight this diagnosis and its surgical management so that informed decisions can be made if this is first encountered in the operating theatre.