A model for examining predictors of outcomes of telephone nursing advice

Although telephone advice nursing is the fastest-growing nursing specialty, useful information to guide managers' decisions about how best to structure and support advice services to achieve desired outcomes is unavailable. We identified issues and variables relevant to outcomes of telephone advice from the perspectives of callers, nurses, and the system. Subsequently, we derived a model for studying factors affecting nursing advice outcomes that will help managers identify modifiable factors to improve outcomes of care.     

Tracking the daily availability of burn beds for national emergencies

Medical planning for Operation Iraqi Freedom included predictive models of expected number of burn casualties. In all but the best-case scenario, casualty estimates exceeded the capacity of the only Department of Defense burn center. Examination of existing federal-civilian disaster plans for military hospital augmentation revealed that bed availability data were neither timely nor accurate. Recognizing the need for accurate knowledge of burn bed availability, the Department of Defense requested assistance from the American Burn Association (ABA). Directors of burn centers in the United States were queried for interest in participation in a mass casualty plan to provide overflow burn bed capacity. A list of 70 participating burn centers was devised based upon proximity to planned military embarkation points. A computer tracking program was developed. Daily automated e-mail messages requesting bed status were sent to burn center directors at 6 am Central time with responses requested before 11 am. The collated list of national overflow burn bed capacity was e-mailed each day to the ABA Central Office and to federal and military agencies involved with burn patient triage and transportation. Once automated, this task required only 1-2 hours a day. Available burn-bed lists were generated daily between March 17 and May 2, 2003 and then every other day until May 9, 2003. A total of 2151 responses were received (mean, 43 burn centers per day). A system to track daily nationwide burn bed availability was successfully implemented. Although intended for military conflict, this system is equally applicable to civilian mass casualty situations. We advocate adoption of this or a similar bed tracking system by the ABA for use during burn mass casualty incidents.     

Changes observed in urine microbiology following replacement of long-term urinary catheters: need to modify UTI guidelines in the UK?

Aims

Bacteria adherent to long-term urinary catheters (LTUC) may give misleading urine culture results. Guidelines in the USA recommend changing LTUC before urine collection to diagnose UTI and before commencing appropriate antimicrobial treatment. However, in the UK there is no such guidance. In this study, we evaluated differences in urine cultures before and after changing LTUC.

Methods

In a prospective study in a UK urology department, we made a quantitative and qualitative comparison between paired urines collected before and after catheter change in patients with LTUC. We measured culture growth on a four-point ordinal scale as nil, scanty (< 10⁷ cfu/L), moderate (10⁷–10⁸ cfu/L) or heavy (> 10⁸ cfu/L) and recorded the range of bacterial species isolated. Statistical analysis was by Wilcoxon matched-pairs test.

Results

Sixty-six patients (55 males, 11 females) took part in the study. Urines with no growth increased from 7/66 (11%) before change of catheter to 21/66(32%) after change of catheter. Cultures reported as heavy growth (> 10⁸ cfu/L) reduced from 48/66 (73%) to 25/66 (38%) after catheter change (p < 0.001). Except for Pseudomonas spp., other organisms were isolated less frequently after catheter change. No Proteus spp. was isolated after catheter change.

Conclusions

This study confirms that failure to change long-term catheters before collecting urine for culture may give misleading results. In the interest of accurate diagnosis and antimicrobial stewardship, UK guidelines should recommend changing long-term urinary catheters before collection of urine for culture.

     

Predictors for a further local in-brain progression after re-craniotomy of locally recurrent cerebral metastases

Treatment of recurrent cerebral metastases is an emerging challenge due to the high local failure rate after surgery or radiosurgery and the improved prognosis of patients with malignancies. A total of 36 patients with 37 metastases who underwent surgery for a local in-brain progression of a cerebral metastasis after previous metastasectomy were retrospectively analyzed. Degree of surgical resection on an early postoperative MRI within 72 h after surgery was correlated with the local in-brain progression rate and overall survival. Complete surgical resection of locally recurrent cerebral metastases as confirmed by early postoperative MRI could only be achieved in 37.8%. Detection of residual tumor tissue on an early MRI following recurrent metastasis surgery correlated with further local in-brain progression when defining a significance level of p?=?0.05 but not after ?idák or Bonferroni significance level correction for multiple testing: However, definite local tumor control could finally be achieved in 91.9% after adjuvant therapy. Overall survival after recurrent metastasectomy was significantly higher as predicted by diagnosis-specific graded prognostic assessment (12.9?±?2.3 vs. 8.4?±?0.7 months; p?<?0.0001). However, our series involved a limited number of heterogeneous patients. A larger, prospective, and controlled study is required. Considering the adequate local tumor control achieved in the vast majority of patients, surgery of recurrent metastases may represent one option in a multi-modal treatment approach of patients suffering from locally recurrent cerebral metastases.     

Oxytocin Induces Mammary Epithelium Disruption and Could Stimulate Epithelial Cell Exfoliation

Mammary epithelial cells (MEC) are exfoliated from the epithelium into milk, influencing the number of MEC present in the udder. This process is associated with epithelium integrity. The release of oxytocin (OT) induced by milking causes myoepithelial cell contraction, which, in turn, may stimulate MEC exfoliation through mechanical forces. To investigate the role of OT in MEC exfoliation, we inhibited or induced myoepithelial cell contraction by injecting the OT receptor antagonist atosiban (Ato) or a supraphysiological dose of OT, respectively. Eight cows were assigned to 2 treatments during 2 milkings according to a crossover experimental design: Control+OT (cows were first milked to collect standard milk and then received 5 IU of OT to collect residual milk through a second milking) and Ato?+?OT (cows were injected with Ato (50 μg/kg of body weight) and milked to collect cisternal milk, then received 5 IU of OT to collect alveolar milk through a second milking). Milk MEC were purified to determine their concentration and number in milk. Mammary epithelium integrity was assessed by measuring the kinetics of plasma lactose concentration. Inhibiting myoepithelial cell contraction by Ato injection decreased the number of exfoliated MEC in milk. In contrast, OT injection increased the concentration of MEC in the residual milk and the number of MEC in the alveolar milk. Ato injection reduced plasma lactose concentration, whereas, in both treatments, OT injections increased it. Our results suggested that myoepithelial cell contraction caused by OT could stimulate MEC exfoliation into milk and was associated with epithelium disruption.