Progress in the enzyme diagnosis of liver disease: reality or illusion?

This paper discusses the progress of enzyme diagnosis by different examples. These include: the requirement for improved enzymological screening, despite the introduction of a test for hepatitis C; the imbalance between the popularity of "unexplained chronic aminotransferase elevations" and efforts to solve the inherent problems; the inadequate attempts to use the metabolic changes in the hepatocytes to improve diagnosis, prognosis, and pathophysiological understanding of viral liver diseases; the remarkable investigations into the 2'-5'-oligoadenylate synthetase for better control of interferon therapy in chronic viral hepatitis; the use of enzymes as markers of etiology, particularly for the detection of alcohol induced liver diseases; the continuing preference for the aminotransferases in this scenario although the ratios of aspartate aminotransferase over alanine aminotransferase, or of mitochondrial aspartate aminotransferase over total aspartate aminotransferase activity, largely depend on the severity and intralobular localization of damage and the stage of the liver disease.     

The cancer anorexia-cachexia syndrome: myth or reality?

Background  

Controversy exists as what constitutes the cancer anorexia-cachexia syndrome (CACS), and whether it truly is a distinct clinical disorder. In this study, we aimed to: (1) assess if CACS is a distinct clinical disorder, (2) identify the symptoms characteristic of CACS, (3) evaluate CACS impact on patient outcomes (symptom burden and survival time from referral).     

Physiotherapy following cardiac surgery: is it necessary during the intubation period?

This randomised controlled clinical trial investigated whether physiotherapy during the period of mechanical ventilation following cardiac surgery influenced subject outcomes. Two hundred and thirty-six subjects admitted to the intensive care unit (ICU) following elective or semi-urgent cardiac surgery were randomised to either a treatment group, which received physiotherapy during the intubated phase, or a control group where physiotherapy was commenced only once the subject was extubated. No significant differences between the two groups were detected for length of intubation period, length of ICU stay, length of hospital stay, maximal daily incentive spirometry values or the incidence of post-operative pulmonary complications. For individuals following routine uncomplicated cardiac surgery, the provision of physiotherapy interventions during the post-operative intubation period does not improve outcomes.     

‘Levels’ of attainment in nursing practice: reality or illusion?

In earlier research based on an analysis of course documentation, it had been found that there was little consensus among nurse educators concerning the parameters which distinguish levels of practice skills, particularly those which differentiate diploma and degree qualifications in the United Kingdom. This result was confirmed and strengthened in the current study. Lecturers in nursing, when presented with a sorting task using 40 statements derived from course documentation selected from the earlier study, were unable to distinguish statements describing diploma level from those describing degree level practice. Possible reasons for the difficulty are discussed. It is concluded that the attempt to represent practice skill in a hierarchy of assessment for degree or diploma qualifications is premature since the parameters of practice remain unreliably specified.     

Etomidate for anesthesia induction: friends or foe in major cardiac surgery?

Use of etomidate for anesthesia induction is still debated. In the previous issue of Critical Care, Heinrich and colleagues reported that etomidate for anesthesia induction had similar outcome in comparison with other drugs, in a specific population of 3,054 patients ahead of major cardiac surgery. For the authors, the similar outcomes for mortality and length of hospital stay add to the hemodynamic stability and the improved intubation conditions to support keeping etomidate in the emergency drugs armamentarium for induction of anesthesia in patients at risk of hemodynamic failure. This commentary reviews the results and implications of their study.     

The association of blood transfusion with mortality after cardiac surgery: cause or confounding? (CME)

BACKGROUND: Bleeding into the chest is a life‐threatening complication of cardiac surgery. Blood transfusion has been implicated as an important cause of harm associated with bleeding, based largely on studies demonstrating an independent association between transfusion and mortality. These studies did not, however, consider the possibility that bleeding may in itself be harmful, inasmuch as drains are inefficient at clearing blood from the chest and retained blood may compromise cardiac and lung function. STUDY DESIGN AND METHODS: We undertook a multivariate logistic regression analysis of the risk factors associated with mortality in 2599 consecutive patients undergoing cardiac surgery. Unlike previous studies the risk factors examined included the volume of chest tube drainage at 24 hours. A stratified analysis was also undertaken that compared the adjusted risk of death for patients exposed or not exposed to a postoperative blood transfusion. RESULTS: Blood transfusion was not an independent predictor of mortality (p = 0.4). Chest tube drainage was the strongest independent predictor of mortality (p < 0.001). In the stratified analysis, chest tube drainage remained an independent predictor of mortality for patients not exposed to a blood transfusion (p < 0.01). Furthermore, the risk of death of these patients was no different from patients exposed to a blood transfusion (p = 0.7 for interaction). CONCLUSIONS: Our results argue that for patients undergoing cardiac surgery bleeding contributes to mortality through mechanisms unrelated to blood transfusion.     

Nurse-academics' mentorship: rhetoric or reality?

Mentorship is generally identified in nursing literature as a positive strategy, and one that is said to be beneficial in increasing scholarly productivity. However, previous studies investigating the relationship of mentoring to scholarly productivity have produced equivocal findings. This relationship was examined as part of a study that considered constraints and/or facilitators of scholarly productivity among nurse academics. A survey questionnaire technique was used to establish current scholarly productivity levels, and frame and factor facilitating theory and analysis to identify major constraints and facilitators. Findings showed that while the majority of participants perceived mentoring as important to developing and increasing scholarly productivity, this was less so as academic rank increased. More than a quarter reported never having had a mentor. The burden of teaching and administrative over-load, and a cultural climate of non-support, were described as major disincentives to mentoring. Mentoring was more likely to occur where a collaborative and collegial network to support scholarly productivity existed. However, often it was seen as not available. A workplace environment that is appropriately supported by adequate resources may be as important as the research training that can occur through mentoring.     

Clopidogrel resistance: myth or reality?

Platelets have a central role in the development of arterial thrombosis and subsequent cardiovascular events. An appreciation of this complex process has made antiplatelet therapy the cornerstone of cardiovascular disease management. Dual antiplatelet therapy with aspirin and clopidogrel has been approved for the secondary prevention of cardiovascular events and is currently part of the postpercutaneous coronary intervention treatment regimen. However, subacute stent thrombosis continues to occur in 1% to 2% of patients despite dual antiplatelet therapy. Studies have shown interindividual variations in response to clopidogrel, where a cohort of patients seems to be resistant to the antithrombotic effects of clopidogrel. Furthermore, there is an apparent link between clopidogrel resistance and clinical outcomes. Currently, there is neither a universally accepted definition of clopidogrel resistance nor an agreement on the phenomenon's mechanism. This review highlights the origins of clopidogrel resistance, the current problems that exist with its definition, and discusses the future implications and relevant challenges it poses for the clinician.