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Critical Analysis of Research Papers

Introduction

The critical analysis is referred to breakdown of information within a paper in parts to evaluate their significance and weakness. In this study, a total of ten papers are to be critically analysed by using the CASP tool and out of them a single paper is to be studied in in-depth for critical analysis.

Research Question

What is the association between upper airway obstruction and bedwetting in children and the effectiveness of adenoidectomy and tonsillectomy surgeries in the resolution of urinary incontinence in children aged 5-18 years old?

Critical Appraisal using CASP Tool

The each of the ten articles presented in the CASP tool analysis was found to address a focused issue. This is evident as the study by Kaya et al. (2018) informs that it is going to address the significant impact of adenotonsillectomy on managing nocturnal enuresis as health issue among children who have adenotonsillar hypertrophy. This is the similar issue to be focused by Kaya et al. (2018), Ding et al. (2017), Weissbach et al. (2016), Parker et al. (2016), Kovacevic et al. (2015), Kovacevic et al. (2014), Ozler and Ozler (2014), Kovacevic et al. (2012), Thottam et al. (2013) and Waleed et al. (2013). In addition, the study by Ding et al. (2017) is also going to focus on the issue of changes in the value of salivary alpha-amylase among children with sleep apnea and adenotonsillar hypertrophy who have accessed or not accessed surgery. Moreover, the study by Kovacevic et al. (2014) tries to identify the clinical, demographic, laboratory as well as polysomnography parameters among the responders and non-responders of adenotonsillectomy. The Ozler and Ozler (2014) also focus on to address the issue of upper airway obstruction as well as primary nocturnal enuresis along with secondary enuresis in children. The study by Weissbach et al. (2016), Parker et al. (2016) and Kovacevic et al. (2014) further explore bedwetting in children associated with airway obstruction.

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The cohort for each of the study is recruited in acceptable manner by following proper selection biases. This is evident as neither of the ten studies recruited children below the age of 5 years because children lower than 5 years may have nocturnal enuresis due to physiological reason and not as a result of sleep apnea. Only the study of Kovacevic et al. (2015) included a control group apart from the experimental group. This is effective approach as presence of control and study group within single study allows effective comparison of findings to resolve and nullify alternative findings that are not right and raises confusion. The study of Parker et al. (2016), Kovacevic et al. (2015), Ding et al. (2017), Kovacevic et al. (2014), Kaya et al. (2018), Ozler and Ozler (2014) and Thottam et al. (2013) used prospective study. The strength of using prospective study design for the articles is that it allowed them to collect results at proper time intervals to develop follow-up results that can be effectively evaluated to develop more complete data and minimised error in the study (Ungureanu et al. 2018). The study by Kovacevic et al. (2012) used pilot study. The advantage of using pilot study is that it allowed effective establishment of validity of the study however increased time consumption is the limitation to be faced by the study (van der Meij et al. 2018). The Weissbach et al. (2016) used retrospective review. The advantage of using this study is that it allows use of sample size in executing research but it creates limitation of the research to develop biases in data collection (Wibowo et al. 2016).

The exposure in each of the study was effectively measured for lowering biases in the research. This is evident as studies by Kaya et al. (2018), Ding et al. (2017), Weissbach et al. (2016), Parker et al. (2016), Kovacevic et al. (2015), Kovacevic et al. (2014), Ozler and Ozler (2014), Kovacevic et al. (2012), Thottam et al. (2013) and Waleed et al. (2013) classified subjects or participants in exposure group within the study using similar procedure of considering age above 5 years and within 18 years along with the participants having health issue of sleep apnea or sleep-disordered breathing. In each of the study, the statistical analysis is done by using SPSS as the common method to develop the outcome with minimum bias. This is because SPSS software allows the researcher to have effective control in allocation of variables and provides use of proper statistical methods to develop quicker and accurately analysed data (Kumari et al. 2017).

In addition, in each of the ten studies used t-test and Chi-square test to analyse the collected data. The t-test is effective tool to be used for data analysis as it helped researcher in each of the studies to test their hypothesis by developing difference and comparison between two or more groups regarding whether or not bedwetting and nocturnal enuresis are resolved through adenotonsillectomy surgery. The follow-up of the participants to derive results for each of the studies was nearly complete enough in all the articles. The long follow-up of 12 months of the participants to derive results to understand the effectiveness of adenotonsillectomy on managing nocturnal enuresis among children was seen in studies by Ding et al. (2017), Weissbach et al. (2016), Ozler and Ozler (2014), Waleed et al. (2013) and Kovacevic et al. (2012). However, in the rest of the studies, follow-up was made between 1 to 3 months only to derive results regarding the impact of adenotonsillectomy on managing nocturnal enuresis.

The results of the study by Kaya et al. (2018) inform that there is a correlation between obstructive sleep apnea and bedwetting by children. The adenotonsillectomy surgery is effective in this case to resolve bedwetting by the children as it resolves the obstruction of upper airways causing sleep apnea. This is the similar results mentioned by the study of Ding et al. (2017), Weissbach et al. (2016), Parker et al. (2016), Kovacevic et al. (2014), Ozler and Ozler (2014), Kovacevic et al. (2012) and Waleed et al. (2013). Out of these studies, Kovacevic et al. (2014) and Thottam et al. (2013) mentioned that they have seen only half of their population who undergone adenotonsillectomy during the research to show resolving of bedwetting or nocturnal enuresis. However, the result by the study of Kovacevic et al. (2015) informs that adenotonsillectomy is effective to improve health-quality of life of children with sleep-disordered breathing irrespective of nocturnal enuresis outcome. Thus, this study does not support the fact that surgery of opening obstruction of upper airways is effective to resolve bedwetting in children. The results presented in each of the studies are precise and are valid as proper statistical data are provided to prove the reliability of the findings. The results derived from the articles can be applied to the general population as the findings are developed from different areas and countries. The results of each of the article fit with other journals used which is evident as in all the studies similar findings are developed with rare differences in opinions and perspectives of the researcher.

The implication of information developed from each of the ten studies is huge as the findings can be used as evidential information to be referred by the nurses and health professionals to determine the way to plan their practice to resolve bedwetting issues among children. Thus, the findings support evidence-based practice to be established in the healthcare field. Moreover, the studies can be used as a reference to inform parents by the health professionals regarding the approach they are to take to help the children get resolved of sleep apnea along with nocturnal enuresis.

In-depth critical appraisal

The article “Why does Andenotonsillectomy not correct enuresis in all children with sleep disorder breathing?” developed by Kovacevic et al. is original as previously no such detailed study based on the impact of Adenotonsillectomy in correcting enuresis among children is performed. In order to perform the study, the multidisciplinary prospective study approach is used (Kovacevic et al. 2014). The advantage of using multidisciplinary research is that it helps the researcher to develop broader perspective on the identified issues and develop conclusion for the study that shows minimum resistance to real condition. In addition, the multidisciplinary prospective study design helps the researcher in collecting highly valid data and gathers proper proof to support findings (Hilbrand et al. 2017). However, the limitation to be faced in this study by using multidisciplinary prospective study design is that it leads the researchers to develop lack of in-depth information related to certain matter as it is quite time consuming and expensive process (Geevasinga et al. 2016).

In this study, the participants selected are children from 5-18 years who are diagnosed with snoring and obstructive sleep apnea syndrome (OSAS) along with upper airway obstruction was chosen. However, the children below the age of 5 and not having enuresis were excluded for the study (Kovacevic et al. 2014). This ensured the study to be performed in valid nature because it excluded the inclusion of children below 5 years who have nocturnal enuresis which may be present among them due to physiological reasons and not as a result of sleep apnea. Moreover, it allowed exclusion of children with nonmonosymptomatic enuresis indicates those have secondary cause of enuresis other than sleep apnea. The mentioned study is performed in a realistic environment as participants are selected randomly from the paediatric urology department in the hospitals on the basis of their age and disease nature. The consideration of realistic environment act as strength for the study as it helped the research to develop practical utilitarian information which is significant for developing effective scientific knowledge (Mitrano and Nowack, 2017).

In this study, the blood samples are collected from participants for detecting the level of ADH and BNP secretion before and after Andenotonsillectomy (Kovacevic et al. 2014). The study by Szymanik-Grzelak et al. (2019) informs that Anti-diuretic Hormone (ADH) and Brain Natriuretic Peptide (BNP) are responsible to induce diuresis and natriuresis in patients with sleep-disordered breathing and nocturnal enuresis. Thus, the detection is strength for the study developed as the impact of Adenotonsillectomy in controlling enuresis can be properly detected through examination of hormonal control. In this study, the chi-square analysis and T-test are used to compare clinical characteristics as well as demographic variables in dry and wet groups. The strength of using chi-square analysis for the study is that it allows robustness and flexibility in comparing data between two or more groups (Thaseen et al. 2019). However, the limitation to be experienced by using Chi-square test is that it is sensitive to large sample size which leads to develop insignificant results (Kokudo et al. 2016). In the study, the sample size is 46 children which are quite small and therefore insignificant result gathering through chi-square test does not act as weakness for the research. The strength of using T-test for the study is that it allows easy calculation of data and simple interpretation of results along with allows executing the study within less time (Hossain et al. 2018).

In this study, the Mann-Whitney U test is used for comparing sleep study parameters between wet and dry groups (Kovacevic et al. 2014). The strength of using the test for the study is that it allows the researcher to determine if the difference identified between two groups is significant or result of chance (MacFarland and Yates, 2016). However, the limitation to be experienced by using the Mann-Whitney U test is that the data collected through the process is prone to error and lack explanation regarding the reason of differences between the data (MacFarland and Yates, 2016). Thus, the weakness to be faced by the study with the use of the Mann-Whitney U test for comparing between two groups is that proper explanation may not provide for the cause of difference identified. The SPSS is used in the study for the analysis of the collected data. The strength of using SPSS for the study is that it allowed accurate data analysis to be executed in the quicker manner, in turn, avoiding development of unnecessary human error when analysis is done manually (La Vignera et al. 2016). The data collection in the study is done through determination of demographic, laboratory and clinical characteristics of children rather than gathering data through survey questionnaires that are filled by parents in other studies (Kovacevic et al. 2014). This acts as strength for the study to gather medically and scientifically approved data, in turn, avoiding errors that may be raised while collecting data through survey.

The study by Bascom et al. (2018) informs that children having enuresis shows decreased ADH level in their blood and increased level of BNP compared to healthy children. In addition, when these children having enuresis have sleep-disordered breathing (SDB) then the level of BNP is further increased in their blood. Thus, BNP increased can be correlated with SDB which the study by Lehmann et al. (2018) informs that are resolved after adenotonsillectomy. The BNP among children with obstructive sleep apnea syndrome is found to be higher level (Balaban et al. 2016). The ADH has the function to control the amount of water in the body and increased level of the hormone increases the osmolarity of the urine as well as decreases plasma osmolarity (Bascom et al. 2018). However, the results revealed that in contrast to the expectation in the current study the changes in nocturnal enuresis resolution cannot be explained through changes in ADH and BNP. This is because Anti-Diuretic Hormone (ADH) level in the blood was increased and brain natriuretic peptide (BNP) level was reduced among both wet and dry group of children after the adenotonsillectomy. Thus, indicating that adenotonsillectomy was not able to resolve enuresis among all children as many of them were still wetting beds.

The results also revealed that children who are prone to have fragmented sleep due to sleep apnea showed that release of the obstruction in the upper airways contributes in resolving nocturnal enuresis (Kovacevic et al. 2014). The fact is supported by the study of Bascom et al. (2018) where the researchers mentioned that children who have greater respiratory disruption during sleep faced increased nocturnal enuresis. Thus, the results developed the study is evident that control of sleep apnea would contribute to resolve nocturnal enuresis. The results in the study revealed that the adenotonsillectomy was able to control nocturnal enuresis among the 43% participants used in the study who had sleep-disordered breathing (Kovacevic et al. 2014). This reveals that the adenotonsillectomy is effective in nearly half of the children to resolve nocturnal enuresis faced as a result of sleep-disordered breathing. The results also revealed that children who were dry after the adenotonsillectomy showed fewer awakenings but increased sleep apnea and arousals compared to the children who were wet even after the surgery. Thus, it informs that controlling nocturnal enuresis among children is effective to lower sleep awakenings.

The limitation of the study was that the use of smaller sample size may have result the researcher to develop unpowered analysis due to which they have failed to determine the correlation of hormonal control with nocturnal enuresis resolution among children. The other limitation of the study is that it failed to use control group for comparing the results. The control group in the study is significant as it allows the researcher to nullify alternative explanations regarding the results of the experiments (Kovacevic et al. 2014). Thus, the lack of control group leads the researcher to assess the alternative effect of the intervention that is adenotonsillectomy for resolving nocturnal enuresis. The study lacked information regarding the participants who dropped from the research.

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Conclusion

The data collected through the critical appraisal of the articles inform that the findings can be used to support evidence-based practice to resolve bedwetting issues among children. The results from the articles inform that there is direct correlation between upper airway obstruction and bedwetting issues in children and the use of adenoidectomy and tonsillectomy surgeries is effective to resolve the urinary incontinence among children from 5 to 18 years of age. In future, additional research is required to develop understand regarding the reason behind adenoidectomy and tonsillectomy surgeries are not effective in some children to control their urinary incontinence. Moreover, the way control of Anti-Diuretic Hormone and Brain natriuretic peptide to be maintained to effectively resolved nocturnal enuresis among all children. In addition, qualitative data collection method is to be applied to understand the extent of impact adenoidectomy and tonsillectomy surgeries are creating on children in real lie to manage their urinary incontinence.

References

Balaban, M., Aktas, A., Sevinc, C. and Yucetas, U., 2016. The relationship of enuresis nocturna and adenoid hypertrophy. Archivio Italiano di Urologia e Andrologia, 88(2), pp.111-114.

Bascom, A., McMaster, M.A., Alexander, R.T. and MacLean, J.E., 2018. Nocturnal enuresis in children is associated with differences in autonomic control. Sleep, 42(3), p.zsy239.

Ding, H., Wang, M., Hu, K., Kang, J., Tang, S., Lu, W. and Xu, L., 2017. Adenotonsillectomy can decrease enuresis and sympathetic nervous activity in children with obstructive sleep apnea syndrome. Journal of pediatric urology, 13(1), pp.41-e1.

Ezzat, W.F., Fawaz, S.A. and Farid, S.M., 2011. Impact of sleep-disordered breathing and its treatment on children with primary nocturnal enuresis. Swiss medical weekly, 141(2526).pp.34-56.

Geevasinga, N., Menon, P., Scherman, D.B., Simon, N., Yiannikas, C., Henderson, R.D., Kiernan, M.C. and Vucic, S., 2016. Diagnostic criteria in amyotrophic lateral sclerosis: a multicenter prospective study. Neurology, 87(7), pp.684-690.

Gökçe, A., Aslan, S., Yalçinkaya, F.R., Davarci, M., Kaya, Y.S., Savaş, N., GÖRÜR, S., Dağli, Ş., Kiper, A.N. and Balbay, M.D., 2012. Improvement of monosymptomatic enuresis after adenotonsillectomy in children with obstructive sleep apnea syndrome. Turkish Journal of Medical Sciences, 42(5), pp.757-761.

Heba, H.A., Lobna, M.E., Ahmed, E.M., Wael, S. and Ashraf, K.A., 2013. Effect of adenotonsillectomy on nocturnal enuresis in children with OSA. Egyptian Journal of Chest Diseases and Tuberculosis, 62(2), pp.275-280.

Hilbrand, S., Coall, D.A., Gerstorf, D. and Hertwig, R., 2017. Caregiving within and beyond the family is associated with lower mortality for the caregiver: A prospective study. Evolution and Human Behavior, 38(3), pp.397-403.

Hossain, M.A., Hossain, K.M.A., Hossain, M., Rahaman, I. and Taoheed, F., 2018. Effectiveness of gait training supported by overhead harness in patients with spinal cord injury (SCI) at rehabilitation centre in Bangladesh. Int J Neurorehabilitation, 5(332), pp.2376-0281.

Kaya, K.S., Türk, B., Erol, Z.N., Akova, P. and Coşkun, B.U., 2018. Pre-and post-operative evaluation of the frequency of nocturnal enuresis and Modified Pediatric Epworth Scale in pediatric obstructive sleep apnea patients. International journal of pediatric otorhinolaryngology, 105, pp.36-39.

Kokudo, T., Hasegawa, K., Matsuyama, Y., Takayama, T., Izumi, N., Kadoya, M., Kudo, M., Ku, Y., Sakamoto, M., Nakashima, O. and Kaneko, S., 2016. Survival benefit of liver resection for hepatocellular carcinoma associated with portal vein invasion. Journal of hepatology, 65(5), pp.938-943.

Kovacevic, L., Jurewicz, M., Dabaja, A., Thomas, R., Diaz, M., Madgy, D.N. and Lakshmanan, Y., 2013. Enuretic children with obstructive sleep apnea syndrome: should they see otolaryngology first?. Journal of pediatric urology, 9(2), pp.145-150.

Kovacevic, L., Wolfe-Christensen, C., Lu, H., Lulgjuraj, M., Abdulhamid, I., Thottam, P.J., Madgy, D.N. and Lakshmanan, Y., 2015. Adenotonsillectomy improves quality of life in children with sleep-disordered breathing regardless of nocturnal enuresis outcome. Journal of pediatric urology, 11(5), pp.269-e1.

Kovacevic, L., Wolfe-Christensen, C., Lu, H., Toton, M., Mirkovic, J., Thottam, P.J., Abdulhamid, I., Madgy, D. and Lakshmanan, Y., 2014. Why does adenotonsillectomy not correct enuresis in all children with sleep disordered breathing?. The Journal of urology, 191(5S), pp.1592-1596.

Kumari, A., Saini, V., Jain, P.K. and Gupta, M., 2017. Prediction of delivery in women with threatening preterm labour using phosphorylated insulin-like growth factor binding protein-1 and cervical length using transvaginal ultrasound. Journal of clinical and diagnostic research: JCDR, 11(9), p.QC01.

La Vignera, S., Condorelli, R.A., Cimino, L., Russo, G.I., Morgia, G. and Calogero, A.E., 2016. Late-onset hypogonadism: the advantages of treatment with human chorionic gonadotropin rather than testosterone. The Aging Male, 19(1), pp.34-39.

Lehmann, K.J., Nelson, R., MacLellan, D., Anderson, P. and Romao, R.L., 2018. The role of adenotonsillectomy in the treatment of primary nocturnal enuresis in children: A systematic review. Journal of pediatric urology, 14(1), pp.53-e1.

MacFarland, T.W. and Yates, J.M., 2016. Mann–whitney u test. In Introduction to nonparametric statistics for the biological sciences using R (pp. 103-132). Springer, Cham.

Mitrano, D.M. and Nowack, B., 2017. The need for a life-cycle based aging paradigm for nanomaterials: importance of real-world test systems to identify realistic particle transformations. Nanotechnology, 28(7), p.072001.

Park, S., Lee, J.M., Sim, C.S., Kim, J.G., Nam, J.G., Lee, T.H., Han, M.W., Kwon, J.K. and Lee, J.C., 2016. Impact of adenotonsillectomy on nocturnal enuresis in children with sleep‐disordered breathing: A prospective study. The Laryngoscope, 126(5), pp.1241-1245.

Soylu Özler, G. and Özler, S., 2014. Coexistence of upper airway obstruction and primary and secondary enuresis nocturna in children and the effect of surgical treatment for the resolution of enuresis nocturna. Advances in medicine, 2014. pp.23-45.

Szymanik-Grzelak, H., Daniel, M.U., Skrzypczyk, P., Kotuła, I. and Pańczyk-Tomaszewska, M., 2019. Is copeptin a reliable biomarker of primary monosymptomatic nocturnal enuresis?. Central-European journal of immunology, 44(1), p.38.

Thaseen, I.S., Kumar, C.A. and Ahmad, A., 2019. Integrated Intrusion Detection Model Using Chi-Square Feature Selection and Ensemble of Classifiers. Arabian Journal for Science and Engineering, 44(4), pp.3357-3368.

Thottam, P.J., Kovacevic, L., Madgy, D.N. and Abdulhamid, I., 2013. Sleep Architecture Parameters Predicting Postoperative Nocturnal Enuresis Resolution in Children With Obstructive Sleep Apnea. Journal of pediatric urology, 13(1), pp.21-67.

Ungureanu, B.S., Pătrașcu, Ș., Drăgoescu, A., Nicolau, C., Copăescu, C., Șurlin, V. and Săftoiu, A., 2018. Comparative study of NOTES versus endoscopic ultrasound gastrojejunostomy in pigs: a prospective study. Surgical innovation, 25(1), pp.16-21.

van der Meij, E., Anema, J.R., Huirne, J.A. and Terwee, C.B., 2018. Using PROMIS for measuring recovery after abdominal surgery: a pilot study. BMC health services research, 18(1), p.128.

Weissbach, A., Leiberman, A., Tarasiuk, A., Goldbart, A. and Tal, A., 2006. Adenotonsilectomy improves enuresis in children with obstructive sleep apnea syndrome. International journal of pediatric otorhinolaryngology, 70(8), pp.1351-1356.

Wibowo, S., Grandhi, S., Chugh, R. and Sawir, E., 2016. A pilot study of an electronic exam system at an Australian University. Journal of Educational Technology Systems, 45(1), pp.5-33.


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