Infection rislks associated with urinary catheters

Urinary catheterisation can kill. It is one of the most common healthcare interventions but carries the risk of 'significant danger' to patients from infection (Pratt et al 2001). While essential for some patients, this invasive procedure is sometimes unjustified and even forgotten once in place (Saint et al 2005). Accountability for the safe management of urinary catheters by using evidence-based guidelines is emphasised. New ways of examining practice and planning for improvement (Department of Health 2005), and new technology (Tambyah 2004) will contribute to better outcomes for those patients for whom the procedure is essential.     

Long-term effect of introducing an early warning score on respiratory rate charting on general wards

The respiratory rate is an early indicator of disease, yet many clinicians underestimate its importance and hospitals report a poor level of respiratory rate recording. We studied the short- and long-term effects of introducing a new patient vital signs chart and the modified early warning score (MEWS), which incorporates respiratory rate on the prevalence of respiratory rate recording in six general wards of our hospital. Prior to the commencement of the study, the average percentage of occupied beds where at least one respiratory rate recording had been made in a single 24-h period was 29.5+/-13.5%. After the introduction of the new vital signs chart to all six wards, and the introduction of MEWS to three wards, this rose to 68.9+/-20.9%. When all six wards had been using both the new chart and the MEWS system for almost 1 year, the figure had reached 91.2+/-5.6%. During the pre-introduction period, there was no difference in the prevalence of respiratory rate recording between the specialties (orthopaedic, 26.9%; surgery, 32.9%; medicine, 29.8%; p=0.118). During the second two audit periods, the prevalence of respiratory rate monitoring was consistently higher on medical wards than on surgical and orthopaedic wards (p<0.001). The study confirms the long-term beneficial effect of introducing the MEWS system on respiratory rate recording into the general wards of our hospital. As respiratory rate abnormalities are early markers of disease, it is hoped that improved monitoring will have an impact on the nature and timeliness of the response to critical illness. This may have an impact on the future incidence of potentially avoidable cardiac arrest, deaths and unanticipated intensive care unit admission.     

Individual and group cognitive-behavioral therapy for psychotic disorders: a pilot investigation

The present study is an uncontrolled pilot investigation of individual and group cognitive-behavioral therapy (CBT) for patients with positive symptoms of psychosis (n = 6). While previous studies have utilized either individual or group CBT for schizophrenia, the present investigation is the first to include both components for patients in the chronic phase of a psychotic illness. The results of this pilot study suggest that this approach may be useful for both positive and negative symptoms of psychosis. In addition, depression, anxiety, and hopelessness scores all decreased dramatically. The majority of the gains made during treatment were maintained over an 11-month follow-up period. A combined CBT treatment program may offer benefits in terms of delusional thinking, depression, and anxiety when used as an adjunctive treatment to medication. While the present study demonstrated positive effects from treatment, results are limited by the small sample size.     

Preparing children for day case nuclear medicine procedures

OBJECTIVES: To audit standards developed for children undergoing nuclear medicine procedures involving day case attendance on the renal unit. METHODS: A prospective audit was undertaken of 210 children (113 males) undergoing day case nuclear medicine procedures in a teaching hospital department catering for adult and paediatric patients. An audit sheet was completed by both ward and nuclear medicine staff at the time of the procedure over an 18-month period. RESULTS: The majority of families were given relevant information about the procedures and adequate notice before the scan date. Most patients were offered surface analgesia for the venepuncture and play preparation before the procedure. Fifty-eight per cent of patients were successfully cannulated at the first attempt and 88% after three attempts. Only 4% of children were sedated. The median delay between the scheduled and actual scan time was 15 min, with 71% of children being scanned within the standard of a 0-20-min delay. Most delays were due to logistic problems within the department (43%). Cannulation problems (35%) and patient-related factors (22%) accounted for further delays. CONCLUSIONS: The audit of these locally agreed standards has resulted in changes in practice, including nurse training for cannulation and better scheduling within the nuclear medicine department. We believe that play preparation is an essential component for all potentially painful procedures, with few patients requiring sedation. The standards could be used for comparative audits between units.     

Segmental arterial mediolysis: angioplasty of bilateral renal artery stenoses with 2-year imaging follow-up

Segmental arterial mediolysis (SAM) is a rare condition caused by loss of muscular elements in the walls of medium-sized, usually visceral, arteries. This causes dissection, occlusion, aneurysm formation, and rupture. The clinical presentation is usually catastrophic as a result of vascular occlusion or rupture. Herein an unusual case of renovascular hypertension resulting from SAM is reported, which was successfully treated with balloon angioplasty.     

Comparison of sequential versus simultaneous methods of adrenal venous sampling

PURPOSE: To compare two methods of adrenal venous sampling (AVS) in preoperative localization of adrenal lesions in primary hyperaldosteronism. MATERIALS AND METHODS: Twenty-one patients (13 men, eight women) underwent selective adrenal venous sampling between July 2001 and May 2003. One of the 21 patients underwent repeat AVS, for a total of 22 procedures. In half the procedures (n = 11), simultaneous bilateral adrenal venous catheterization and sampling was performed before and after intraprocedural adrenocorticotropic hormone (ACTH) administration; in the remaining half (n = 11), sequential catheterization of the left and right adrenal veins was performed during continuous ACTH infusion 1 hour before and throughout AVS. Chart review provided procedural data, including sampling intervals and aldosterone/cortisol ratios. Patient records provided clinical data, including blood pressure, serum aldosterone levels, and computed tomography and magnetic resonance imaging findings. Surgical pathology reports confirmed unilateral disease but were not applicable to bilateral disease. RESULTS: Selective AVS was completed successfully in 21 of 22 procedures (95%); the unsuccessful sampling was repeated successfully. Disease lateralized in 13 of 22 cases. Simultaneous bilateral AVS localized unilateral disease in seven of eight cases (88%) and was nondiagnostic in one case (13%), with cases confirmed by surgical pathology reports. Sequential bilateral AVS localized unilateral disease in four of four cases (100%) confirmed by surgical pathology reports, with one lost to follow-up. Bilateral disease was diagnosed in six of 22 cases: two of 11 by simultaneous AVS and four of 11 by sequential AVS. Three of 22 cases demonstrated borderline hormone levels that failed to meet the diagnostic threshold for recommended adrenalectomy. Mean elapsed time between acquisition of right and left samples did not differ between simultaneous and sequential AVS (P = .09). Baseline (prestimulation) sampling did not contribute unique diagnostic information in any case and provided contradictory or confounding information in three of 11 simultaneous AVS procedures (27%). CONCLUSIONS: Sequential bilateral catheterization does not compromise the reliability of time-sensitive AVS. Both simultaneous and sequential AVS are adequate studies; however, obtaining baseline prestimulation samples during simultaneous AVS is unnecessary and increases the cost of the procedure.     

Uncovering value in the Medicare+Choice marketplace

Medicare managed care plans, now known as Medicare+Choice plans, have long been seen as a solution to Medicare's fiscal problems, including serving as a model for overall Medicare reform. Despite the challenges faced today, the M+C program provides a clear opportunity for the federal government to seek private innovation and experience in evolving Medicare to a more sustainable economic model, and for the private sector to tap into the vast product opportunities of serving a growing Medicare population.