Study design and hierarchy of evidence for surgical decision making

This article provides a historical overview of the hierarchy of evidence for surgical decision making and discusses key study designs in the hierarchy of evidence. This encompasses meta-analyses, randomized controlled trials, and observational studies, including cohort and case-controlled studies, case series and case reports, and basic science studies. This article also reviews the principles and importance of evidence-based plastic surgery and describes several systems to rate the strength of the scientific evidence.     

The role of inter-professional relationships and support for nurse prescribing in acute and chronic pain

Title.  The role of inter-professional relationships and support for nurse prescribing in acute and chronic pain.
Aim.  This paper is a report of a study to explore nurse prescribers' views on the role of inter-professional relationships and other means of support for nurse prescribing for patients in acute and chronic pain.
Background.  Research indicates that good team relationships are important for supporting nurse prescribing but that poor understanding of the role by other healthcare professionals can act as a barrier. While collaborative working is central to the role of pain nurses, there is a lack of research on the impact of nurse prescribing on inter-professional working or the support needs of these nurses.
Method.  A qualitative approach was adopted using thematic analysis of semi-structured interview data collected during 2006 and 2007. Participants were 26 nurses who prescribed medicines for patients with acute and/or chronic pain.
Findings.  Nurses' believed that prescribing encouraged collaborative working and sharing of knowledge across professional boundaries and that this helped to broaden understanding of the wider remit of pain management. Collaboration with doctors served a number of functions, including support and continuous learning. Barriers to effective nurse prescribing were a lack of understanding of its role amongst healthcare professionals and inadequate support. Formal support structures, such as regular clinical supervision, were seen as crucial to meeting nurses' ongoing learning.
Conclusion.  Factors that promote understanding of nurse prescribing and support inter-professional relationships are likely to have a positive impact on the effectiveness of nurse prescribing. A more consistent approach is required within organisations to support nurse prescribing.     

Influence of dietary fats on Ecstasy-induced hyperthermia

BACKGROUND AND PURPOSE: Studies were designed to examine the effects of dietary fats on metabolic effects of 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy). These effects included hyperthermia, expression of uncoupling protein (UCP1 and 3) in brown adipose tissue or skeletal muscle and plasma free fatty acid (FFA) levels. EXPERIMENTAL APPROACH: Male Sprague-Dawley rats were fed either a high-fat diet (HFD, 60% kcal) or a lower fat isocaloric controlled diet (LFD, 10% kcal) for 28 days before MDMA challenge. KEY RESULTS: No significant differences were observed between LFD and HFD groups in terms of body weight, plasma thyroxine (T4) levels and expression of brown fat UCP1 or skeletal muscle UCP3 protein. HFD significantly raised levels of circulating FFA and potentiated the thermogenesis induced by MDMA (10 mg kg(-1), s.c.), compared to the effects of the LFD. Moreover, 30 and 60 min after MDMA administration, plasma FFA levels decreased in HFD animals, but were markedly elevated in the LFD group. CONCLUSIONS AND IMPLICATIONS: These results indicate that high-fat feeding regulates MDMA-induced thermogenesis by augmenting the activation of UCP rather than its expression.     

Surgical management of cerebral palsy.

Musculoskeletal manifestations of cerebral palsy (CP) change with growth, necessitating orthopaedic management. The goal of orthopaedic management, which may involve surgical and/or rehabilitative intervention, is to help each individual reach optimal functional ability and prevent deformity. Goals of surgical intervention are to improve function, decrease discomfort, and prevent structural changes that may become disabling. Knowledge of the basic surgical procedures to correct deformities as well as understanding the special needs of CP patients will help nurses successfully care for these individuals.     

Roles of norepinephrine, free Fatty acids, thyroid status, and skeletal muscle uncoupling protein 3 expression in sympathomimetic-induced thermogenesis

Thyroid hormone (TH) plays a fundamental role in thermoregulation, yet the molecular mediators of its effects are not fully defined. Recently, skeletal muscle (SKM) uncoupling protein (UCP) 3 was shown to be an important mediator of the thermogenic effects of the widely abused sympathomimetic agents 3,4-methylenedioxymethamphetamine (MDMA; Ecstasy) and methamphetamine. Expression of UCP3 is regulated by TH. Activation of UCP3 is indirectly regulated by norepinephrine (NE) and is dependent upon the availability of free fatty acids (FFAs). We hypothesized that UCP3 may be a molecular link between TH and hyperthermia, requiring increased levels of both NE and FFAs to accomplish the thermogenic effect. Here, we demonstrate that MDMA (40 mg/kg s.c.) significantly increases plasma FFA levels 30 min after treatment. Pharmacologically increasing NE levels through the inhibition of phenylethanolamine N-methyltransferase with +/-2,3-dichloro-alpha-methylbenzylamine potentiated the hyperthermic effects of a 20 mg/kg dose of MDMA. Using Western blots and regression analysis, we further illustrated that chronic hyperthyroidism in rats potentiates the hyperthermic effects of MDMA and increases levels of SKM UCP3 protein in a linear fashion according to levels of circulating plasma TH. Conversely, chronic hypothyroidism results in a hypothermic response to MDMA that is directly proportionate to decreased UCP3 expression. Acute TH supplementation did not change the skeletal muscle UCP3 expression levels or temperature responses to MDMA. These findings suggest that, although MDMA-induced hyperthermia appears to result from increased NE and FFA levels, susceptibility is ultimately determined by TH regulation of UCP3-dependent thermogenesis.     

Effect of Cinacalcet and Vitamin D Analogs on Fibroblast Growth Factor-23 during the Treatment of Secondary Hyperparathyroidism

Background and objectives

Cinacalcet and vitamin D are often combined to treat secondary hyperparathyroidism (SHPT) in patients on dialysis. Independent effects on fibroblast growth factor-23 (FGF-23) concentrations in patients on hemodialysis administered cinacalcet or vitamin D analogs as monotherapies during treatment of SHPT are evaluated.

Design, setting, participants, & measurements

A multicenter, randomized, open-label study to compare the efficacy of cinacalcet versus traditional vitamin D therapy for management of secondary hyperparathyroidism among subjects undergoing hemodialysis (PARADIGM) was a prospective, phase 4, multicenter, randomized, open-label study conducted globally. Participants (n=312) were randomized 1:1 to cinacalcet (n=155) or vitamin D analog (n=157) for 52 weeks. Levels of FGF-23 were measured at baseline and weeks 20 and 52. The absolute and percentage changes from baseline in plasma FGF-23, parathyroid hormone (PTH), calcium (Ca), phosphorus (P), and calcium-phosphorus product (Ca×P) were assessed. Correlations and logistic regression were used to explore relationships between changes in FGF-23 and changes in PTH, Ca, P, and Ca×P from baseline to week 52 by treatment arm.

Results

Median (quartiles 1, 3) decrease in FGF-23 concentrations was observed in the cinacalcet arm (−40%; −63%, 16%) compared with median increase in the vitamin D analog arm (47%; 0%, 132%) at week 52 (P<0.001). Changes in FGF-23 in both arms were unrelated to changes in PTH (cinacalcet: r=0.17, P=0.11; vitamin D analog: r=−0.04, P=0.70). Changes in FGF-23 in the vitamin D analog but not the cinacalcet arm were correlated with changes in Ca (cinacalcet: r=0.11, P=0.30; vitamin D analog: r=0.32, P<0.01) and P (cinacalcet: r=0.19, P=0.07; vitamin D analog: r=0.49, P<0.001). Changes in FGF-23 were correlated with changes in Ca×P in both arms (cinacalcet: r=0.26, P=0.01; vitamin D analog: r=0.57, P<0.001). Independent of treatment arm, participants with reductions in P or Ca×P were significantly more likely to show reductions in FGF-23.

Conclusions

During treatment of SHPT, cinacalcet use was associated with a decrease in FGF-23 concentrations, whereas vitamin D analogs were associated with an increase. The divergent effects of these treatments on FGF-23 seem to be independent of modification of PTH. It is possible that effects of cinacalcet and vitamin D analogs on FGF-23 may be mediated indirectly by other effects on bone and mineral metabolism.     

Postoperative Urinary Retention Rates after Autofill versus Backfill Void Trial following Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study ObjectiveTo compare the rate of postoperative urinary retention (POUR) after total laparoscopic hysterectomy (TLH) using the autofill vs the backfill void trial. Secondary objectives were to compare the time to discharge from the recovery room, rate of postoperative urinary tract infection (UTI), perceived bladder condition, the effect of bladder function on life, and patient satisfaction.DesignRandomized controlled trial.SettingSingle academic medical center.PatientsWomen who underwent TLH by conventional laparoscopy or robotic-assisted laparoscopy for benign non-urogynecologic indications.InterventionsAfter TLH, participants were randomized to have an autofill void trial (group A) or a backfill void trial once they were able to ambulate (group B). Failure rate, time to discharge, and UTI rate were assessed. Participants completed the patient perception of bladder condition and the incontinence impact questionnaire-short form questionnaires. Patient satisfaction was assessed. Multiple regression analysis was performed to determine the predictors of POUR.Measurements and Main ResultsEighty-two participants completed the study after randomization, 42 in group A and 40 in group B. There were no statistically significant differences in demographic or perioperative outcomes. Seven participants had POUR in group A (16.7%) and 11 in group B (27.5%) (p = .36), respectively. The median time to discharge was 176 minutes for group A (160.5, 255.5) and 218 minutes for group B (180, 265) (p = .01), respectively. There were no statistically significant differences in rate of postoperative UTI (p >.99), patient perception of bladder condition scores (p = .24), incontinence impact questionnaire-short form scores (p = .23), and patient satisfaction scores (p = .26). A stepwise logistic regression analysis did not demonstrate any predictors of POUR.ConclusionBackfill void trial once the participant was able to ambulate was not superior to the autofill void trial with respect to the rate of POUR. The autofill void trial resulted in faster same-day discharge.