Ultrasound measurement of median and ulnar nerve cross-sectional area in acromegaly

CONTEXT: Acromegalic patients may complain of sensory disturbances in their hands. OBJECTIVE: Our objective was to examine median (MN) and ulnar nerves (UN) of acromegalic patients with ultrasound (US) and to determine whether nerve abnormalities correlate with clinical parameters and nerve conduction studies (NCS). PATIENTS: We prospectively examined the MN and UN in 34 nondiabetic, acromegalic patients (18 females and 16 males; age range 18-79 yr) and 34 sex-, age-, and body mass index-matched controls with 17-5 MHz US. INTERVENTION: The MN was examined at the carpal tunnel (MN-Ct) and at mid-forearm (MN-f) levels; the UN at the mid-forearm (UN-f) and distal arm (UN-a). A total of 272 nerve cross-sectional areas (CSA) were recorded from both patients and controls. In addition, 22 patients underwent NCS. RESULTS: Nerves of acromegalic patients (MN-Ct=16.5+/-4.4 mm2; MN-f=10.5+/-2.4 mm2; UN-f=9.5+/-3.0 mm2; UN-a=13.1+/-3.7 mm2) had significantly (P<0.0001) greater CSA compared with controls (MN-Ct=7.4+/-1.7 mm2; MN-f=5.5+/-1.4 mm2; UN-f=5.3+/-1.4 mm2; UN-a=6.6+/-1.7 mm2). NCS displayed at least one abnormality in 59% of patients. Acromegalic patients, grouped according to disease activity (14 controlled, 8 partially controlled, 12 uncontrolled), had significantly (P<0.0001) greater CSA compared with controls. Nerve CSA were significantly greater in uncontrolled patients compared to controlled, both at MN-Ct and at UN-f levels (P<0.01). Abnormal NCS were observed in five of seven uncontrolled patients and four of nine controlled patients. IGF-I levels, but not GH levels, were correlated with CSA (r=0.34), whereas disease duration correlated with both nerve CSA and NCS (r=0.33 and r=0.31). CONCLUSION: US identified a significantly increased volume of MN and UN in acromegalic patients. Peripheral nerve enlargement in acromegaly seems to be an intrinsic feature of the disease related to clinical control, disease duration, and IGF-I levels.     

Nursing practice environment,quality of care,and morale of hospital nurses in Japan

The purpose of this study was to describe Japanese hospital nurses' perceptions of the nursing practice environment and examine its association with nurse‐reported ability to provide quality nursing care, quality of patient care, and ward morale. A cross‐sectional survey design was used including 223 nurses working in 12 acute inpatient wards in a large Japanese teaching hospital. Nurses rated their work environment favorably overall using the Japanese version of the Practice Environment Scale of the Nursing Work Index. Subscale scores indicated high perceptions of physician relations and quality of nursing management, but lower scores for staffing and resources. Ward nurse managers generally rated the practice environment more positively than staff nurses except for staffing and resources. Regression analyses found the practice environment was a significant predictor of quality of patient care and ward morale, whereas perceived ability to provide quality nursing care was most strongly associated with years of clinical experience. These findings support interventions to improve the nursing practice environment, particularly staffing and resource adequacy, to enhance quality of care and ward morale in Japan.     

Nursing prioritization of the patient need for care: A tacit knowledge embedded in the clinical decision-making literature

Every day in clinical settings, nurses practise in complex and dynamic situations. Nurses work to achieve emergent order in these situations through nursing prioritization of the patient need for care. As direct research on nursing prioritization had not been reported, a study, using critical realism as method, was designed to discern the profession's embedded understanding from within the clinical decision-making literature. The research synthesizes a tacit knowledge on nursing prioritization of the patient need for care from key international literature (from 1966 to 2003). Nursing prioritization was discerned in both education and practice literatures; interrelationships between these and theoretical approaches were also identified. Nursing prioritization of the patient need for care was revealed both as a non-sequential decision-making process throughout unfolding patient situations and as an advanced skill of nursing practice. Increasing confidence with this skill is the hallmark of developing expertise.     

Family presence during resuscitation and invasive procedures

The practice of allowing family to be present during patient resuscitation or invasive procedures (Family Presence) is gaining acceptance in North America and the United Kingdom in controlled circumstances. Research into Family Presence has demonstrated multiple benefits for the patient, family and health care team. These advantages include helping the family to understand the severity of the illness/trauma and to see that appropriate attempts were undertaken to save their loved one. Family Presence can also facilitate improved communication between the health care team and family. In spite of evidence supporting Family Presence as a useful practice for patient, family and health care team, the use of Family Presence is uncommon within Australian emergency departments and hospitals. Clear expectations at organisational, governmental and professional levels are essential to effectively implement this approach. To be supported in the clinical area, the success of a Family Presence program requires an inclusive approach to program development. A critical component of a successful Family Presence program is a family facilitator who is adequately prepared for the role and committed to supporting the family during resuscitation or invasive procedures. Research exploring Family Presence in Australia is lacking and highlights the need for context specific research in this area.