JOURNAL Watch strategies to reduce turnover among both licensed nurses and CNAs in nursing homes. Lerner NB, et al. J Am Med Dir Assoc 2014; 15(2):102-7.

SURGICAL TECHNIQUES FOR APICAL VAGINAL PROLAPSE According to this study: • • Two years after surgery, sacrospinous ligament fixation and uterosacral ligament suspension used to improve urinary incontinence had comparable outcomes. Pelvic floor–muscle training had no effect on incontinence.


pical prolapse, a prolapse of the upper vaginal walls that can lead to urinary incontinence, can be corrected with either of two transvaginal surgical approaches: sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (ULS). The Operations and Pelvic Muscle Training in the Management of Apical Support Loss trial is the first randomized study to compare two-year postprocedural outcomes of each approach and the impact of perioperative behavioral therapy with pelvic floor–muscle training (BPMT) on reported urinary symptoms. The five-year study involved nine U.S. institutions that were all members of the Pelvic Floor Disorders Network. Women with vaginal or uterine prolapse at stages 2 to 4, 374 subjects in total, were randomized in two ways: according to procedure type (186 undergoing SSLF and 188 undergoing ULS) and by receipt of either perioperative BPMT (186 patients) or usual care (188 patients). The follow-up rate was 84.5% at two years after surgery. Surgical success was defined as no descent of the vaginal apex more than a third of the way into the vaginal canal, no anterior or posterior vaginal wall drop beyond the hymen, no reported problems with vaginal bulging, 70

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and no need for retreatment. On these measures, the success rate with ULS was 59.2%, compared with 60.5% with SSLF. No significant differences in other outcomes, such as length of hospitalization, blood loss, surgical time, and postoperative treatment, were seen. Serious adverse events, most often intraoperative bladder perforation or vaginal-tissue granulation, occurred at nearly the same rate in the two groups (ULS, 16.5%; SSLF, 16.7%). Neurologic pain occurred more frequently with SSLF—12.4%, compared with 6.9% with ULS—and continued in 4.3% of the SSLF patients for at least four to six weeks. BPMT hadn’t delivered any significant improvements in perceived urinary symptoms at either the sixmonth mark or the two-year mark. These results suggest that pelvic floor–muscle training might not be helpful in this patient population. Barber MD, et al. JAMA 2014;311(10): 1023-34.

FATTY ACIDS AND CORONARY RISK According to this study: • • Cardiovascular guidelines that recommend eating foods with high levels of polyunsaturated fat and foods with low levels of saturated fat aren’t supported by study evidence.


ccording to a new analysis of existing research on fatty acids and heart risks, there is little evidence to support recommendations to consume more polyunsaturated fat and less saturated fat to reduce heart disease. The researchers conducted a systematic review and meta-analysis of studies available in medicaljournal databases through July 2013 that included the following: 32 prospective observational studies that concerned fatty acids from food intake; 17 prospective observational studies involving fatty acid biomarkers found in

blood; and 27 randomized controlled trials that investigated fatty acid supplements. All eligible studies evaluated these factors with respect to coronary events. The resulting data pool comprised more than 600,000 subjects globally and involved both healthy subjects and subjects with cardiac disease. In the 32 studies with subjects who reported their consumption of foods from fatty acids, the researchers compared the top third of subjects with the bottom third (in terms of fatty acid intake). They found insignificant associations between coronary events and the intake of long chain ω-3 and ω-6 polyunsaturated fatty acids, saturated fats, and monounsaturated fats. The 17 studies that examined blood biomarkers of fatty acids showed that two specific circulating saturated fatty acids, palmitic and stearic acids, had positive but not statistically significant associations with cardiovascular disease. Margaric acid (found in milk and dairy products), however, was significantly associated with a lower risk of coronary events. No other fatty acid biomarker had a statistically significant effect on coronary risk. The 27 randomized controlled trials analyzing the effect of fatty acid supplements on coronary risk involved more than 100,000 subjects; 5,726 had a coronary event. Of the subjects who had taken linolenic acid or ω-3 or ω-6 polyunsaturated fatty acid supplements, none had significant reductions in coronary risk, as compared with control subjects. The authors proposed that in light of the lack of significant correlations between polyunsaturated and saturated fats and coronary risk, current dietary guidelines may need to be reevaluated and revised to better reflect the research evidence. Chowdhury R, et al. Ann Intern Med 2014; 160(6):398-406. ▼

Surgical techniques for apical vaginal prolapse.

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