Testosterone and cardiovascular disease – the controversy and the facts

Since November 2013, there has been a flurry of articles written in the media touting the risk of cardiovascular (CV) disease in men treated with testosterone, based on two recent reports. Since first synthesized in 1935, testosterone therapy has demonstrated substantial benefits for men with testosterone deficiency (also called hypogonadism). Testosterone has an acceptable safety profile and literature spanning more than 30 years, suggesting a decreased CV risk with low levels of testosterone and benefits associated with testosterone therapy. However, nonmedical media outlets have seized on reports of increased CV risk, and published scathing editorials impugning testosterone therapy as a dangerous and overprescribed treatment. Here, we review these recent studies, and find no scientific basis for assertions of increased CV risk. This article is intended to provide the clinician with the facts needed for an informed discussion with men who suffer from testosterone deficiency and who desire treatment for their symptoms.     

Cross Infection and the Nurse

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Migraine and Autonomic Dysfunction: Which Is the Horse and Which Is the Jockey?

Purpose of Review

Symptoms of autonomic dysfunction are common in patients with migraine, both during and between migraine attacks. Studies evaluating objective autonomic testing in patients have found significant, though somewhat conflicting results. The purposes of this review are to summarize and interpret the key findings of these studies, including those evaluating heart rate variability, autonomic reflex testing, and functional imaging in patients with migraine. The neuroanatomy of the central autonomic network as it relates to migraine is also reviewed.

Recent Findings

Several studies have evaluated autonomic balance in migraineurs, with conflicting results on the magnitude of sympathetic versus parasympathetic dysfunction. Most studies demonstrate sympathetic impairment, with a lesser degree of parasympathetic impairment.

Summary

Three trends have emerged: (1) migraine with aura tends to produce more significant autonomic dysfunction than migraine without aura, (2) sympathetic impairment is more common than parasympathetic impairment, and (3) sympathetic impairment is common in the interictal period, with increased sympathetic responsiveness during the ictal period, suggesting adrenoreceptor hypersensitivity.

     

Gastrointestinal motility and glycemic control in diabetes: the chicken and the egg revisited?

Upper gastrointestinal dysfunction occurs frequently in diabetes and potentially contributes to both abdominal symptoms and impaired glycemic control; conversely, variations in blood glucose concentration reversibly affect gut motility in humans. In this issue of the JCI, Anitha et al. report apoptosis of rodent enteric neurons under hyperglycemic conditions, both in vitro and in vivo, associated with impaired PI3K activity and preventable by glial cell line-derived neurotrophic factor. These observations add to recent insights gained from animal models regarding the etiology of diabetic gastrointestinal dysfunction, but investigators must strive to translate animal data to human diabetes.     

Testing the water – problem-based learning and the cultural dimension

This study reports the findings of a small case study using problem-based learning (PBL) as a teaching and learning strategy in a cultural awareness module, which forms part of a pre-registration diploma in nursing course.The study was carried out using a qualitative research methodology. It aimed to describe and explore 20 diplomat student nurses and their lecturers’ experience of undertaking PBL. The categories that emerged from the analysis were: knowledge development and PBL process. A selection of these categories and their sub-categories are described and discussed in relation to the literature on problem-based learning.The study concluded that undergoing PBL as a teaching and learning strategy had positive outcomes for the students. Prior knowledge was utilised in knowledge development in relation to the problem and was seen as beneficial. Students reported that they felt more confident and used the knowledge gained to care for patients’ cultural needs in practice. Students also identified lack of knowledge amongst staff in the clinical area in relation to cultural awareness. There were however some challenges in the transition to a PBL strategy from the perspective of the students and lecturers. Issues that were found to be difficult include the change to a different teaching and learning strategy, the implications of self-direction for the student and the role of the facilitator as a non-directive guide. The study recommends that the findings may be of use for other nurse educators implementing PBL as a teaching and learning strategy.     

The Research on the Correlation between the Numerical Rating Scale and Verbal Rating Scale and the Improvement on Pain Assessment

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Interdisciplinary and interprofessional education: what are the key issues and considerations for the future?

The identification of key issues and considerations for interdisciplinary and interprofessional education are explored. Both benefits and barriers to interprofessional education are discussed. The concept of simulation is reviewed relative to interprofessional education primarily as a catalyst for implementation of collaboration. The promise of interprofessional education and outcome studies direct where the future is headed.     

Analysis of the relation between the evaluation and the passed rate of health education

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Research in public health and end-of-life care – Building on the past and developing the new

Introduction: Public health approaches offer the opportunity to move beyond clinical and health services approaches to end-of-life (EoL) care, to focus on whole populations, individuals and communities rather than patients and carers. They also allow concepts such as capacity, resilience, and wellbeing to come to the fore.

Methods: This paper, drawing on the experience of a diverse group of academics and practitioners from three countries in Europe, considers the research challenges related to examining new public health approaches to EoL care and how learning from more traditional or classic public health research can influence a future research agenda. Additional opportunities provided by the new public health approach to broaden learning and participation in research are considered.

Results: By bringing together strong traditional methods such as analysis of longitudinal population-level data with participatory approaches that draw on communities' experience and aspirations for care, the authors suggest that new and improved opportunities exist to evaluate the impact of participatory approaches.

Discussion: In conclusion, the paper urges researchers from classic and new public health to work in partnership to generate and respond to the emerging research agenda around new public health initiatives. There is much to be learned from both.     

Does the Golem Feel Pain? Moral Instincts and Ethical Dilemmas Concerning Suffering and the Brain

Pain has variously been used as a means of punishment, extracting information, or testing commitment, as a tool for education and social control, as a commodity for sacrifice, and as a draw for sport and entertainment. Attitudes concerning these uses have undergone major changes in the modern era. Normative convictions on what is right and wrong are generally attributed to religious tradition or to secular‐humanist reasoning. Here, we elaborate the perspective that ethical choices concerning pain have much earlier roots that are based on instincts and brain‐seated empathetic responses. They are fundamentally a function of brain circuitry shaped by processes of Darwinian evolution. Social convention and other environmental influences, with their idiosyncrasies, are a more recent, ever‐changing overlay. We close with an example in which details on the neurobiology of pain processing, specifically the question of where in the brain the experience of pain is generated, affect decision making in end‐of‐life situations. By separating innate biological substrates from culturally imposed attitudes (memes), we may arrive at a more reasoned approach to a morality of pain prevention.     

Poison center surveillance data: the good,the bad and … the flu

Background.?Poison center data are increasingly used by state health departments and the Centers for Disease Control and Prevention for public health surveillance. Forrester and colleagues evaluated the ability of 6 Texas poison centers covering a population of 24 million to accurately code and report the number of H1N1 calls received over a 5-month period.?Discussion.?The Texas poison centers generated new coding and began work within 24 h of notification of the surveillance need. No additional staff were added for call management, coding, or quality assurance, and no H1N1 training was provided ahead of time. A triple-redundancy coding method was used to prevent underreporting of calls. This allowed the Texas poison centers to accurately flag over 90% of H1N1 cases. Results were available in real time, allowing day-to-day monitoring by poison centers and the state public health department for surges, location, ages of callers and/or patients, and type of question.?Conclusion.?The accuracy of poison center near real-time toxicosurveillance data coding was sufficient to monitor emerging trends. The data generated by poison centers are flexible, immediate, unique from other data sources, and useful for trend monitoring. As health departments and other collaborative partners rely more on the data from poison centers, consideration must be given to appropriate funding to support coding training, monitoring, and quality assurance to further enhance this valuable system.

This commentary should have been published alongside the following article: Coding of influenza A H1N1 virus calls received by Texaspoison centers Mathias B. Forrester and Jeanie E. Jaramillo Clinical Toxicology, Vol. 48, No. 4: 359–364.     

What are the benefits and the pitfalls of preoperative fasting?

Preoperative fasting has been a traditional practice for many years to reduce the risk of aspiration while the patient is under general anaesthetic and to eliminate the risk of postoperative nausea and vomiting. Although it is generally accepted that fasting is beneficial, the fasting regimens that patients undergo are not dependent on the individual patient or the timing of their operation.