Microalbuminuria: is it a valid predictor of cardiovascular risk?

Microalbuminuria strongly predicts cardiovascular morbidity and mortality, clinical nephropathy, and progression of renal disease in high-risk populations. We recommend screening patients with type 2 diabetes, older patients with type 1 diabetes, and older patients with stage 2 hypertension or higher (ie, > or = 160/100 mm Hg).     

Nursing diagnosis: is it time for a new definition?

PURPOSE:The Diagnosis Development Committee (DDC) of NANDA International frequently receives proposed "physiologic" and "surveillance diagnosis" submissions that may not meet the current definition of nursing diagnosis (NANDA, 2007, p. 332). There has been a request for a vote on newly proposed definitions of nursing diagnosis, risk diagnosis, and syndromes. The purpose of this article is to provide information which enables members and interested nurses to continue the dialogue and to share their thoughts and also to consider the thoughts and information generated by the participants in the NANDA-I interest survey on the definition of nursing diagnoses. DATA SOURCES: An electronic survey of the current NANDA-I definitions, and potential changes to those definitions, was distributed via the NANDA-I Web site. This article summarizes the overall findings of that survey and provides an overview of commentary received from the 269 participants. CONCLUSIONS: It is necessary to continue the dialogue on this important decision and to provide a mechanism for input from members and interested nurses before reaching any conclusions on this subject. NURSING IMPLICATIONS: NANDA-I has been recognized as the leader in the development and implementation of nursing diagnoses and must act responsibly in assessing the changing and emerging trends in nursing practice and in responding to these trends.     

The diagnosis and management of acute childhood illness: is there a role for health visitors?

Much of the published literature on nurse practitioners relates to nurses with backgrounds, training and nursing experience other than health visiting. Health visitors however may be ideally placed to develop their role in the identification and management of acute childhood illness, and such a development may benefit patients, the health service and health visitors themselves. This study examines the current practice and attitudes of heath visitors in identifying and managing acute childhood illness using a postal questionnaire survey in one community National Health Service (NHS) Trust. The majority of responding health visitors reported that they were already identifying and advising on a range of acute childhood illnesses. Their confidence in undertaking these activities varied by condition. They were less confident in identifying and advising on conditions requiring the use of diagnostic equipment, viral illnesses which are becoming increasingly rare, and those with potentially serious outcomes. More knowledge and more training were seen as methods for increasing confidence. Most health visitors could see advantages in taking on this role; almost two thirds felt it would become part of the role of the health visitor in the future and a high level of interest was expressed in developing such a role.     

Cerebrospinal fluid lactate: Is it a reliable and valid marker to distinguish between acute bacterial meningitis and aseptic meningitis?

Cerebrospinal fluid (CSF) lactate assay has been a subject of research since 1925. A systematic review by Huy and colleagues in the previous issue of Critical Care summarizes data from 25 studies evaluating the role of CSF lactate in the differential diagnosis between acute bacterial and aseptic meningitis. The authors concluded that CSF lactate is a good single indicator and a better marker compared with conventional markers. But concerns remain because of poor quality of included studies, lack of proper 'gold standard', and limited applicability. More studies with a rigorous design are needed to determine definitively whether CSF lactate assay is a reliable and valid marker to distinguish between acute bacterial meningitis and aseptic meningitis.     

Is urinary 5-hydroxyindoleacetic acid helpful for early diagnosis of acute appendicitis?

Objective

Acute appendicitis is the most common abdominal emergency in children and young adults. There are a lot of serotonin-containing cells in the appendix, which release serotonin into the bloodstream in response to inflammation. Consequently, serotonin is converted to 5-hydroxyindoleacetic acid (5-HIAA) and secreted into the urine. On this basis, urinary 5-HIAA could be a marker for acute appendicitis. In this study, we investigated the value of 5-HIAA levels in spot urine in the diagnosis of acute appendicitis.

Methods

The urinary 5-HIAA was measured by an enzyme-linked immunosorbent assay in the spot urine of 70 patients who presented to the emergency department with a clinical picture of acute appendicitis. Urine concentration results were correlated to final histopathologic reports, and the diagnostic value of this factor was measured.

Results

Diagnosis of appendicitis was confirmed by histopathologic reports in 59 of 70 patients with presumptive diagnosis of appendicitis. Considering 5.25 mg/L as the cutoff point for urinary 5-HIAA, 28 patients had high urinary 5-HIAA levels, whereas 42 patients had values within reference range. The sensitivity and specificity of this test was 44% and 81%, respectively.

Conclusions

The measurement of urinary 5-HIAA levels is not an ideal diagnostic tool for ruling out or determination of acute appendicitis.     

Use of clinical audit for revalidation: is it sufficiently accurate?

In order to provide better patient care, clinicians will be subject to revalidation and re-certification. This may be partially based on existing and ongoing data collection, yet many units fail to incorporate mechanisms that validate the data that may be used. The accuracy of audit data was evaluated in a unit that has been using commercially available audit software for over 10 years. A total of 655 consecutive surgical admissions were documented over a 6-month period and errors in data collection and entry were gathered and analyzed. An overall accuracy of 90.5% was confirmed but examination of the data found them to be open to misinterpretation. Moreover, 13% of errors were made during a single week when locum staff were involved. The study highlights the fallibility of data collection during audit, and urges caution if using such data when judging performance-related issues as part of the process of appraisal.     

Is color Doppler a reliable method for the diagnosis of malrotation?

Purpose

The gold standard for the diagnosis of malrotation is barium contrast study of the upper gastrointestinal system (UGCS), while color Doppler ultrasonography (CDUS) is another method used in the diagnosis. We investigated the value of CDUS for the diagnosis of malrotation in this study.

Methods

UGCS images, CDUS images, plain abdominal images, demographic data, and symptoms of 82 patients who were investigated for presumed malrotation during a 7-year period were evaluated, retrospectively.

Results

All patients underwent CDUS, and 18% of these patients were diagnosed with malrotation as the superior mesenteric vein was seen to be on the left of the superior mesenteric artery. We found that 16% of the 75 patients who underwent UGCS were diagnosed with malrotation. The sensitivity and specificity of CDUS in the diagnosis of malrotation was found to be 93.8 and 100%, respectively. The respective values for UGCS were 91.7 and 98.4%.

Conclusion

Current data in the literature and our results underline that UGCS may yield false-positive and false-negative results. Although CDUS was found to be a reliable method for the diagnosis of malrotation in our study, the limitations of UGCS are also recognized for CDUS. Prospective studies are needed to determine the more valuable method.

     

The subjective dimension of functioning and disability: what is it and what is it for?

The International Classification of Functioning, Disability and Health (ICF, WHO 2001) made a great advancement over ICIDH of 1980 in the understanding of the human functioning and disability. However, in both of them there is an important 'missing' element. That is the subjective dimension of functioning and disability. One of the authors (S. Ueda) published on this topic in 1981 both in Japanese and English. It had originated from his clinical experience in rehabilitation medicine. The understanding of the inner world of the client has proved a great asset in clinical practice. This paper explains its importance and provides a definition. It also proposes a tentative framework of a classification of subjective dimension of functioning and disability as the starting point for more intensive and extensive discussion on this important problem, and for its future inclusion into ICF.     

Biomarkers for acute kidney injury: is NGAL ready for clinical use?

The RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) criteria were introduced in 2004, defining the clinical stage of acute kidney injury (AKI) and outcome measures based on serum creatinine, glomerular filtration rate, and urine output. However, a growing body of evidence suggests that these markers are insufficient in drawing an accurate illustration of kidney injury. Indeed, mortality and morbidity remain high in AKI, suggesting that accuracy and speed of patient evaluation are lacking. A great deal of evidence indicates that neutrophil gelatinase-associated lipocalin (NGAL) is a sensitive and specific early marker of various etiological classes of AKI and would be highly valuable in conjunction with existing markers of AKI for better classifying renal injury as well as dysfunction (kidney attack). Improvements in diagnosis, risk identification, stratification, prognosis, and therapeutic monitoring will benefit clinical decision-making in the individualized bundling of therapies and ongoing patient management. In particular, kidney protection and AKI prevention may become feasible if an earlier and more accurate diagnosis is made for AKI. Here, we discuss the opportunity to consider whether NGAL is ready for routine clinical use in a number of etiologies of AKI.     

A clinical assessment tool used for physiotherapy students--is it reliable?

Educational institutions providing professional programs such as physiotherapy must provide high-quality student assessment procedures. To ensure that assessment is consistent, assessment tools should have an acceptable level of reliability. There is a paucity of research evaluating the reliability of clinical assessment tools used for physiotherapy students. This study evaluated the inter- and intrarater reliability of an assessment tool used for physiotherapy students during a clinical placement. Five clinical educators and one academic participated in the study. Each rater independently marked 22 student written assessments that had been completed by students after viewing a videotaped patient physiotherapy assessment. The raters repeated the marking process 7 weeks later, with the assessments provided in a randomised order. The interrater reliability (Intraclass Correlation Coefficient) for the total scores was 0.32, representing a poor level of reliability. A high level of intrarater reliability (percentage agreement) was found for the clinical educators, with a difference in section scores of one mark or less on 93.4% of occasions. Further research should be undertaken to reevaluate the reliability of this clinical assessment tool following training. The reliability of clinical assessment tools used in other areas of physiotherapy education should be formally measured rather than assumed.     

Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid?

OBJECTIVE: To examine the test-retest reliability, validity, and responsiveness of several outcome measures in the treatment of patellofemoral pain. DESIGN: Evaluation of the clinimetric properties of individual outcome measures for patellofemoral pain treatment, using data collected from a previously published randomized controlled trial (RCT). SETTING: General community and private practice. PARTICIPANTS: The data from 71 persons enrolled in an RCT of a conservative intervention for patellofemoral pain were used to evaluate the measures' validity and responsiveness. A subset of this cohort (n=20) was used to assess reliability. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Three 10-cm visual analog scales (VASs) for usual pain (VAS-U), worst pain (VAS-W), and pain on 6 aggravating activities (walking, running, squatting, sitting, ascending and descending stairs) (VAS-activity); the Functional Index Questionnaire (FIQ); the Anterior Knee Pain Scale (AKPS); and the global rating of change. RESULTS: The test-retest reliability ranged from poor (intraclass correlation coefficient [ICC]=.49) to good (ICC=.83), and the measures correlated moderately with each other (r range,.56-.72). Median change scores differed significantly between improved and unimproved persons for all measures. The effect sizes for VAS-U (.79), VAS-W (.88), and the AKPS (.98) were large, indicating greater responsiveness than the FIQ (.37) and VAS-activity (.66). Similarly, the AKPS and VAS-W were the most efficient measures for detecting a treatment effect when compared with a reference measure (VAS-U, which was assigned a value of 1). The minimal difference that patients or clinicians consider clinically important for the AKPS is 10 (out of 100) points and for the VAS it is 2cm (out of 10cm). CONCLUSIONS: The AKPS and VAS for usual or worst pain are reliable, valid, and responsive and are therefore recommended for future clinical trials or clinical practice in assessing treatment outcome in persons with patellofemoral pain.     

Is endoscopic retrograde appendicitis therapy a better modality for acute uncomplicated appendicitis? A systematic review and meta-analysis

BACKGROUNDPrevious studies had shown endoscopic retrograde appendicitis therapy (ERAT) is an effective treatment for acute appendicitis. However, different studies reported conflicting outcomes regarding the effectiveness of ERAT in comparison with laparoscopic appendectomy (LA).AIMTo compare the effectiveness of ERAT with LA. METHODSRandomized controlled trials (RCTs) and retrospective studies of ERAT for acute uncomplicated appendicitis were searched in PubMed, Cochrane Library, Web of Science, Embase database, China National Knowledge Infrastructure (CNKI), the WanFang Database, and Chinese Scientific Journals Database (VIP) from the establishment date to March 1 2021. Heterogeneity was assessed using the I-squared statistic. Pooled odds ratios (OR), weighted mean difference (WMD), and standard mean difference (SMD), with 95% confidence intervals (CI) were calculated through either fixed-effects or random-effects model. Sensitivity analysis was also performed. Publication bias was tested by Egger''s test, and Begg’s test. The quality of included RCT were evaluated by the Jadad scale, while Newcastle-Ottawa scale is adopted for assessing the methodological quality of case-control studies. All statistical analysis was performed using Stata 15.1 statistical software. All statistical analysis was performed using Stata 15.1 statistical software. This study is registered with PROSPERO, CRD42021243955. RESULTSAfter screening, 10 RCTs and 2 case-control studies were included in the current systematic review. Firstly, the length of hospitalizations [WMD = -1.15, 95%CI: -1.99, -0.31; P = 0.007] was shorter than LA group. Secondly, the level of post-operative CRP [WMD = -10.06, 95%CI: (-17.39, -2.73); P = 0.007], TNF-α [WMD = -7.70, 95%CI: (-8.47, -6.93); P < 0.001], and IL-6 Levels [WMD = -9.78, 95%CI: (-10.69, -8.88); P < 0.001; P < 0.001] in ERAT group was significantly lower than LA group. Thirdly, ERAT group had a lower incidence of intestinal obstruction than LA group. [OR = 0.19, 95%CI: (0.05, 0.79); P = 0.020]. Moreover, the quality of 10 RCTs were low with 0-3 Jadad scores, while the methodological quality of two case-control studies were fair with a score of 2 (each). CONCLUSIONCompared with LA, ERAT reduces operation time, the level of postoperative inflammation, and results in fewer complications and shorter recovery time, with preserving the appendix and its immune and biological functions.     

Carcinoembryonic antigen as a marker for colorectal cancer: is it clinically useful?

BACKGROUND: Carcinoembryonic antigen (CEA) is one of the most widely used tumor markers worldwide. Its main application is mostly in gastrointestinal cancers, especially in colorectal malignancy. Although in use for almost 30 years, the clinical value of CEA in colorectal cancer is still not clear. METHODS: The literature relevant to the clinical value of CEA in colorectal cancer was reviewed. Particular attention was paid to studies involving metaanalyses and guidelines issued by Expert Panels. RESULTS: Although of little use in detecting early colorectal cancer, high preoperative concentrations of CEA correlate with adverse prognosis. Serial CEA measurements can detect recurrent colorectal cancer with a sensitivity of approximately 80%, a specificity of approximately 70%, and can provide a lead time of approximately 5 months. CEA is the most frequent indicator of recurrence in asymptomatic patients and currently is the most cost-effective test for the preclinical detection of resectable disease. CEA is most useful for the early detection of liver metastasis in patients with diagnosed colorectal cancer. Overall, however, little evidence is available that monitoring of all patients with diagnosed colorectal cancer leads to enhanced patient outcome or quality of life. CONCLUSIONS: Currently, the most useful application of CEA is in the detection of liver metastasis from colorectal cancers. Because of the relative success of surgery in resecting hepatic metastases, serial determinations of the marker are recommended for detecting cancer spread to the liver. In the future, preoperative concentrations of CEA may be included with the standard staging procedures for assessing prognosis.