Systematic review of grading practice: Is there evidence of grade inflation?

This paper describes the outcomes of a systematic review of literature pertaining to the grading of practice within nursing, midwifery, medicine and allied health professions. From a total of 215 papers, 147 were included and data were extracted using a systematic data extraction tool. The focus of this paper relates to one of the emerging themes: the issue of grade inflation. The paper examines the grade inflation phenomenon: it discusses the reasons for grade inflation from a variety of perspectives. The paper reports on the suggestions made within the literature on how to control grade inflation, but these, the authors conclude, are not fully evaluated and should be adopted only where rigorous evaluation can carried out. It is imperative that evaluations include the usefulness, reliability and validity testing of rubrics or any other solutions to grade inflation that are adopted by clinicians and educators.     

Review of management of primary spontaneous pneumothorax: Is the best evidence clearer 15 years on?

In 1993 Emergency Medicine Australasia (then Emergency Medicine [Fremantle]) published a therapeutic review on the management of spontaneous pneumothorax. That review found a lack of high-quality evidence on which to base management decisions and a variety of therapeutic options without clear superiority one over another. Now, almost 15 years later, the present paper aims to revisit the evidence base to see if management choices are clearer.     

Intriguing enigma of nitrobenzofuroxan's ‘Sphinx’: Boulton–Katritzky rearrangement or unusual evidence of the N-1/N-3-oxide rearrangement?

The S_EAr/S_NAr reaction between 7-chloro-4,6-dinitrobenzofuroxan (ClDNBF) and 2-morpholinyl-, 2-piperidinyl-, or 2-pyrrolidinylthiazole afforded unexpectedly two isomeric products, bearing the benzofuroxanyl moiety bound to the C-5 carbon atom of the thiazole ring. The relative ratio for the two isomers was dependent on temperature and solvent, suggesting the occurrence of an equilibrium between the two novel species. In order to investigate their structure and to design a plausible mechanistic pathway, a series of synthetic and spectroscopic experiments was planned. The isomer''s structure was unambigously assigned when the reduction of furoxanyl to the furazanyl ring of the products gave exclusively a single species whose NMR data were coincident with those obtained by reacting the starting 2-aminothiazole derivatives with the 7-chloro-4,6-dinitrobenzofurazan (ClDNBZ). Possible mechanistic pathways might involve N-1-/N-3 oxide tautomerism or Boulton–Katritzky rearrangement and the current study is the first attempt to compare these two reactions. The data collected agree with the first one and DFT calculations permitted also a significant correlation with ¹³C NMR experimental data and the assignment of the structure of each isomer. Finally, only one Meisenheimer intermediate for each electrophile/nucleophile combination was isolated by coupling the 2-aminothiazole derivatives with 4,6-dinitrobenzofuroxan (DNBF).

The first attempt to compare Boulton–Katritzky rearrangement with N-1/N-3-oxide tautomerism: formation of isomeric products in the reaction between 2-aminothiazoles and 7-chloro-4,6-dinitrobenzofuroxan.     

Ultrasound evaluation of the fetal heart: Is it possible?

Ultrasound evaluation of the fetal heart can be performed. Knowledge of the embryology, anatomy, and function of the heart have led us to understand the pathophysiology of congenital heart disease. In this review we discuss the indications as well as some basic principles of fetal echocardiography.     

How can the variability in ultrasound measurement of intima-media thickness be reduced? Studies of interobserver variability in carotid and femoral arteries

A critical component in scientific studies of most biological variables is the variation or error in measurements which leads to non-identical results of repeated measurements from the same subject. The aim of this study was to investigate whether the interobserver error (s) in measurement of intima-media thickness (IMT) in carotid and femoral arteries could be decreased if the mean value obtained using two ultrasound images from each of the right and left arteries was used in the analyses instead of the mean value obtained using images from only the right artery. In addition, we wished to evaluate two different reading procedures, one based on manual tracing of echo interfaces and the other on automated edge detection. In a methodological study, 50 subjects were examined with ultrasound twice in the same day by two independent laboratory technologists. The ultrasound images were analysed in two ways: using a computerized manual tracing analysing system and an automated analysing system. When both right and left carotid arteries were examined (manual reading), the interobserver error was smaller than that determined for the examination of only the right artery, for IMT_mean in both the common carotid artery (P = 0·06) and the carotid artery bulb (P<0·05). The interobserver error was also significantly smaller for double-sided vs. one-sided examination with automated reading of IMT_mean in the common carotid artery (P<0·01) and in the carotid artery bulb (P<0·01). The coefficient of variation (CV) for measurement in the common carotid artery decreased from 8·6% (one-sided, manual reading) to 5·3% (double-sided, automated reading). The interobserver error in measurement of IMT in the common femoral artery did not improve by examination of both right and left arteries. The results from this study show that the interobserver errors in measurement of IMT can be decreased by using ultrasound images from both the right and the left carotid arteries, and that the use of an automated analysing system greatly simplifies the reading of ultrasound images with sustained low variability.     

Is there evidence of the International Classification of Functioning,Disability and Health in undergraduate nursing students’ patient assessments?

This paper reports on a secondary analysis of undergraduate nursing students' patient assessments while on clinical placement in a rehabilitation setting in search of evidence of the International Classification of Functioning, Disability and Health (ICF). It describes the evolution of the original World Health Organization's International Classification of Impairment, Disability and Handicap into the ICF. Data was analysed using the ICF categories of function, activity, participation, environmental factors and personal factors. Some evidence of ICF was revealed. Nurses are encouraged to further explore the relevance of ICF for nursing.     

ACR TI-RADS: An advance in the management of thyroid nodules or Pandora's box of surveillance?

Numerous sets of guidelines have been proposed regarding ultrasound of thyroid nodules. None has been universally accepted. American College of Radiology-Thyroid Imaging, Reporting and Data System (ACR-TIRADS) has been promoted as an improvement to existing guidelines such as the 2015 revised American Thyroid Association (ATA) guidelines. This commentary compares and contrasts these two guidelines. Adoption of TI-RADS is likely to result in large-scale, costly surveillance without clear benefit. Replacement of 2015 revised ATA guidelines by TI-RADS is not justified. The shortcomings that exist in the ATA guidelines can be addressed as described in this commentary.     

Caffeine as a promoter of analgesic‐associated nephropathy – where is the evidence?

Individual groups of nephrologists - in their responsibility for their patients - initiated a most controversial discussion whether or not caffeine - coformulated to analgesics - might initiate or sustain analgesic overdosing. The original sources (data) of such suspicion have got lost during the debate of the last two decades. Therefore, it seemed to be appropriate to investigate the original data background and the reasons why nephrologists started to suspect caffeine as a stimulant of analgesic overdosing by employing a systematic and exhaustive review of primary nephrological publications. Their selection followed a precise selection plan, including all epidemiological studies on analgesic-associated nephropathy, the original papers of all groups having been involved in those studies, further originals from the mainly involved countries (academically, politically), and any literature thereof cited as a proof. The following results emerged from the investigation: (i) The epidemiological studies warranted no conclusion about a role of caffeine in prompting excessive analgesic use. (ii) The identified groups of nephrologists provided not substantial data to advocate the said suspicion, except for the observation of a preferential choice of phenacetin-containing combinations, especially powder preparations. (iii) Only two cited original data sources revealed drug-seeking behaviour with phenacetin-containing preparations which subsided, after phenacetin was banned from the respective markets. Conclusively, it appears that there is no substantial data to support a pivotal role of caffeine in initiating or sustaining analgesic overdosing. However, there is strong data that phenacetin, by its psychotropic properties, may have caused drug-seeking behaviour and thus led to analgesic overdosing. This conclusion is convincingly supported by thorough pharmacokinetic investigations. Note: All caffeine-related statements within the reviewed literature have been collected in tables (referred to as Table SX) which are provided in full text for check on the following website: http://www.blackwellpublishing.com/products/journals/suppmat/FCP/FCP174/FCP174sm.htm     

Is there evidence to support the use of direct Factor Xa inhibitors in coronary artery disease?

As coronary artery disease (CAD) remains a leading cause of death in the world, the development of anti-coagulants to prevent CAD progressing to myocardial infarction and death is a high priority. A number of direct Factor Xa (FXa) inhibitors are being developed for use in CAD. Despite being developed to the stage of Phase II clinical trials, DX-9065a is no longer a priority with its developing company for further development, possibly because the Phase II trials did not show any major benefit of DX-9065a over heparin in subjects undergoing percutaneous coronary interventions (PCI) or with non-ST-elevation acute coronary syndromes (ACS). ZK-807834, otamixaban, apixaban, and rivaroxaban are all direct FXa inhibitors that have undergone preclinical and some clinical testing for use in CAD. In a large Phase II clinical trial of subjects with ACS, some doses of otamixaban had a better benefit/risk profile than the unfractionated heparin/eptifibatide combination. However, neither ZK-807834 nor otamixaban appear to be undergoing further clinical development at present. In ACS, placebo-controlled large Phase II clinical trials with apixaban and rivaroxaban have not shown clear cut benefits. Nevertheless, apixaban and rivaroxaban are presently in placebo-controlled Phase III clinical trials for ACS. Presently, there is no compelling evidence to support the use of direct FXa inhibitors in ACS.     

Is there scientific evidence that suppression of acute diseases in childhood induce chronic diseases in the future?

Seeking to understand the individual in his symptomatic totality has been an aim of homeopathy since its beginning. Throughout its history, homeopaths have been concerned that inadequate treatment of acute diseases in childhood may lead to future chronic diseases. Hahnemann cautioned that by treating acute diseases with allopathic medicine, with strong doses of drugs, or suppressing local symptoms of those diseases, would increase the risk of future chronic diseases. Burnett proposed the theory of vaccinosis and warned of chronic manifestations subsequent to smallpox vaccination. French homeopaths, seeking the physiopathological origin of chronic diseases, correlated it to the abnormal reaction of the reticuloendothelial system (RES). Through the study of experimental pathology, Maffei attributed symptomatic manifestations to the imbalance between the immunological phenomena of allergy and immunity. He termed the sensitizing and pathogenic effects of medications and vaccines, 'metallergy' and 'parallergy', respectively. The hygiene hypothesis is based on evidence that the imbalance of immunological response in childhood, specifically among the Th1 and Th2 lymphocyte subpopulations, is responsible for the development of some allergic and chronic diseases in the future. The deranging factor for the predisposition to future allergic response (Th2) is the obstruction of natural manifestations of infectious diseases (Th1 response) in young children. Homeopathic treatment aims to equilibrate vital reaction, corresponding to an integrative physiological response, it may regulate Th1/Th2 imbalance. However, clinical trials to support this hypothesis are lacking.     

Is there convincing evidence for the use of chemotherapy alone in patients with limited stage Hodgkin's lymphoma?

Standard practices for patients with stages I and IIA non-bulky Hodgkin's lymphoma have evolved to include combined-modality therapy consisting of two or three cycles of ABVD and radiation therapy to the involved field. Long-term disease control can be expected in more than 90% of patients. However, long-term survival will also be dependent on the occurrence of treatment-related toxicities (late-effects) that include second cancers and cardiovascular events; deaths from these causes will outnumber those due to progressive Hodgkin's lymphoma. Data from randomized trials testing the role of chemotherapy alone are now available. These trials are based on the hypothesis that avoidance of radiation therapy will result in fewer deaths from late-effects, and that long-term survival will be at least comparable and possibly superior. With intermediate periods of follow-up, the results of these randomized trials demonstrate that with chemotherapy alone, disease control is reduced by approximately 5-7%, but this difference has not translated into a survival advantage. While further follow-up is required to evaluate longer term overall survival, current data can be interpreted as showing that a trade-off exists that requires balancing the advantage of superior disease control achieved with inclusion of radiation therapy and minimization of late-effects resulting from use of chemotherapy alone. The balance associated with this trade-off makes chemotherapy alone a legitimate treatment option; patients and clinicians need to be aware of these options in when making treatment decisions.     

Is hypertension a disorder of volume control? What is the evidence?

The etiological factors responsible for the hypertensive phenotype are complex and several experimental and clinical observations point to a major role of the kidney as being responsible. Genetic studies of uncommon diseases which express monogenetic inheritance all have in common a dysregulation of Na+ balance and volume expansion. Furthermore, epidemiological data suggest an increased incidence of hypertension in communities with high excretory rates of Na+. Experimental data also suggest that low birth weight is associated with an increase in the frequency of hypertension later in life and raises the possibility that intrauterine imprinting may contribute to the expression of the phenotype. Upregulation of the Na+/K+/2Cl- and thiazide-sensitive transporters in low birth weight animals may provide the physiological basis for these observations. In addition, low birth weight is associated with a decrease in nephron number. Therefore, low nephron number may induce adaptive changes in utero which influence volume homeostasis later in life and subtle gain of function mutations in one or more of these transporters may unmask defects in volume homeostasis with increasing salt intake. Finally, the high prevalence of hypertension in functionally anephric patience seems to respond to sustained maintenance of 'dry weight' through ultrafiltration.