The nurse outcomes and patient outcomes following the High-Quality Care Project

BACKGROUND

There have been many single cross-sectional studies on nurse or patient outcomes. However, long-term evidence on improving nurse and patient outcomes is still limited. The High-Quality Care Project is a national project in China for improving nurse and patient outcomes by implementing primary nursing.

AIM

(1) To assess the long-term changes in nurse and patient outcomes in the context of the High-Quality Care Project. (2) To explore the potential influences of primary nursing on nurse and patient outcomes based on this study and broader existing evidence.

METHODS

The data of two cross-sectional studies were used for analysis. The two cross-sectional studies were conducted before (2009) and after (2016) the High-Quality Care Project. A total of 1376 nurses and 904 patients from 40 units of 10 tertiary hospitals were surveyed. Reliable and validated instruments were used to measure nurse and patient outcomes. Multilevel modelling was the main method for data analysis.

RESULTS

Nurses in 2016 were more satisfied than nurses in 2009 with most dimensions of nurse work environment and job satisfaction. However, they were not more satisfied with burnout, global job satisfaction or intention to leave their job. Nurses in 2016 also reported better quality of patient care and patient safety while their patients reported higher patient satisfaction.

CONCLUSION

The analysis of our results based on existing evidence indicates that primary nursing could be considered as a potentially effective way to improve nurse work environment and patient outcomes. More studies with rigorous study design from micro perspectives would be useful to further explore the direct effects of primary nursing on nurse or/and patient outcomes.

IMPLICATIONS FOR NURSING AND NURSING POLICY

Policymakers, healthcare service leaders and nurse managers should make efforts to provide multi-level supports to cultivate an encouraging environment for nurses to practice primary nursing, because the implementation of primary nursing may improve the nurse work environment and patient outcomes. Furthermore, improving nurse participation in hospital affairs and developing nursing discipline and education for increasing nursing staff resource and nurses' capacity - which all need policy and management supports - are crucial to further improve nurse and patient outcomes.

Two Separable Conformers of TATP and Analogues Exist at Room Temperature

[reaction: see text] TATP gives rise to two separable conformations because the barrier for interconversion between them is relatively high at room temperature. This kind of behavior is rare in cyclic organic systems and is the result of poor overlap in the "flip-flop" transition state. The crystal structure of the analogous tricyclohexanone triperoxide also indicates the presence of two conformers.

Reinventing patient-centered computing for the twenty-first century

Despite evidence over the past decade that patients like and will use patient-centered computing systems in managing their health, patients have remained forgotten stakeholders in advances in clinical computing systems. We present a framework for patient empowerment and the technical realization of that framework in an architecture called CareLink. In an evaluation of the initial deployment of CareLink in the support of neonatal intensive care, we have demonstrated a reduction in the length of stay for very-low birthweight infants, and an improvement in family satisfaction with care delivery. With the ubiquitous adoption of the Internet into the general culture, patient-centered computing provides the opportunity to mend broken health care relationships and reconnect patients to the care delivery process. CareLink itself provides functionality to support both clinical care and research, and provides a living laboratory for the further study of patient-centered computing.

Glutamine administration reduces Gram-negative bacteremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control

OBJECTIVE

To determine the effect of intravenous glutamine supplementation vs. an isonitrogenous control on infectious morbidity in severely burned patients. Previous clinical studies in seriously ill patients suggest a beneficial effect of glutamine on infectious morbidity, but no trials have examined possible clinical benefits in severely burned patients.

DESIGN

Prospective, double-blind, randomized trial.

SETTING

Burn intensive care unit of a university hospital.

PATIENTS

Twenty-six severe burn patients with total burn surface area of 25% to 90% and presence of full-thickness burns. Patients were evaluated for occurrence of bacteremia and antibiotic use during the first 30 days of their burn unit admission. Nutritional status and overall inflammation were also measured.

INTERVENTION

Either intravenous glutamine or an isonitrogenous control amino acid solution was administered as a continuous infusion during burn intensive care unit stay.

MEASUREMENTS AND MAIN RESULTS

The incidence of Gram-negative bacteremia was significantly reduced in the glutamine-supplemented group (8%) vs. control (43%; p <.04). No difference was seen in the incidence of Gram-positive bacteremia or fungemia. Average number of positive blood cultures, antibiotic usage, and mortality rates also were reduced but did not reach statistical significance. Significant improvements in serum transferrin and prealbumin were observed in glutamine-supplemented patients at 14 days after burn injury (p <.01 and.04, respectively). C-reactive protein was also significantly reduced at 14 days after burn injury in the glutamine group (p <.01).

CONCLUSIONS

Significantly fewer bacteremic episodes with Gram-negative organisms occurred in the glutamine-supplemented patients. Glutamine supplementation improved measures of nutrition and decreased measures of overall inflammation. In addition, a trend toward lower mortality rate, decreased overall bacteremia incidence, and antibiotic usage in the glutamine group was observed. Glutamine's beneficial effects may be a result of improved gut integrity or immune function, but the precise mechanism of glutamine's protection is unknown.

Male-produced sex attractant pheromone of the green stink bug, Acrosternum hilare (Say)

Sexually mature virgin adult males of the green stink bug, Acrosternum hilare attracted sexually mature virgin adult females in laboratory bioassays using a vertical Y-tube. There was no indication that males attracted other males, or that females attracted either sex. These results suggested that A. hilare males produce a sex pheromone. Extracts of odors collected from sexually mature males contained compounds that were not present in extracts from females or sexually immature males. (4S)-Cis-(Z)-bisabolene epoxide ((4S)-cis-Z-BAE) was the major sex-specific component of the extract. The crude extract was attractive to female A. hilare, but when separated into four fractions, only the portion containing (4S)-cis-Z-BAE and the minor component (4S)-trans-Z-BAE was attractive to females. This fraction was as attractive as the crude extract, suggesting that the former contained all the pheromone components. Neither synthetic (4S)-cis-Z-BAE nor (4S)-trans-Z-BAE alone was attractive to females, but a 95:5 cis:trans blend, mimicing the ratio naturally produced by males, was attractive to females in Y-tube bioassays. Bioassays in a field cage showed that significantly more A. hilare females were attracted to cotton string lures treated with 1 mg of a 95:5 blend of (4S)-cis-Z-BAE and (4S)-trans-Z-BAE placed inside a bouquet of alfalfa than to an alfalfa bouquet containing a pentane-treated control. In field cage studies, attraction of females was greatest during the late afternoon and evening hours, and female A. hilare approached the synthetic pheromone source almost exclusively by walking.

[Cerebrovascular accident and its impact on clients, their partners, the couple's relationship]

The purpose of this study was to examine how stroke in one partner affects the personal well-being of the other partner and the couple's relationship. Six couples were followed throughout the rehabilitation period in the rehabilitation center and community setting. Study findings revealed that following the stroke, both patients and their spouses needed to redefine who they were and then redefine their couple relationship. The patients had to adapt to changes in their body and it's functioning. For the spouses, the need to redefine who they were was related to changes in their roles and responsibilities. For the couple, the need to redefine the relationship was related to the changes in both partners. The results of this study suggest that nurses consider the effects of stroke on the patient, the spouse, and the couple relationship and focus nursing interventions that facilitate the need to redefine themselves within the context of change.

Fixation of spent Saccharomyces cerevisiae biomass for lead sorption

Spent Saccharomyces cerevisiae cells from a beer fermentation process were evaluated for lead cation sorption. The crude biomass was washed with water and acetone prior to any other treatment. Although the washed biomass showed substantial lead ion sorption it was susceptible to microbial spoilage. Different aldehydes were tested as chemical fixation agents; however, most of them caused drastic lowering of the metal uptake capacity. However, benzaldehyde was not only an excellent fixation agent, but the biomass treated with it also retained its original lead sorption capacity. A mechanism for the fixation process is suggested.

An algorithm for early aggressive treatment of frostbite with limb salvage directed by triple-phase scanning

Frostbite injuries have traditionally been treated with expectant observation. With the exception of early blister aspiration tissues are allowed to demarcate before definitive debridement is accomplished. Triple-phase bone scanning has been used to define the extent of fatally damaged tissues in an attempt to allow for early debridement and wound closure. We suggest extending this technology to assess injury and direct debridement in patients for whom early aggressive salvage attempts are indicated. We present two cases in which triple-phase scanning was used to direct early debridement for aggressive limb salvage with flap reconstruction. Bone, ligament, tendon, and nerve were preserved and covered with vascularized tissue before the onset of frank necrosis. Postoperative scans reveal revascularization of these tissues. An algorithm incorporating triple-phase scanning for the evaluation and treatment of frostbite is presented.

Roentgen stereophotogrammetric analysis using computer-based image-analysis

The two-dimensional position of markers in radiographs for Roentgen Stereophotogrammetric Analysis (RSA) is usually determined using a measuring table. The purpose of this study was to evaluate the reproducibility and the accuracy of a new RSA system using digitized radiographs and image-processing algorithms to determine the marker position in the radiographs. Four double-RSA examinations of a phantom and 18 RSA examinations from six patients included in different RSA-studies of knee prostheses were used to test the reproducibility and the accuracy of the system. The radiographs were scanned at 600 dpi resolution and 256 gray levels. The center of each of the tantalum-markers in the radiographs was calculated by the computer program from the contour of the marker with the use of an edge-detection software algorithm after the marker was identified on a PC monitor. The study showed that computer-based image analysis can be used in RSA-examinations. The advantages of using image-processing software in RSA are that the marker positions are determined in an objective manner, and that there is no need for a systematic manual identification of all the markers on the radiograph before the actual measurement.

Characterization of acetone-washed yeast biomass functional groups involved in lead biosorption

The mechanism of lead cation biosorption by acetone-washed biomass of Saccharomyces uvarum was investigated by chemical modifications and spectroscopic monitoring of the cell components. Reacting the carboxyl groups with propylamine, which neutralizes these anions, considerably decreased the metallic ion uptake, indicating that negatively charged carboxyl groups play an important role in lead bisorption due to electrostatic attraction. After lead biosorption the photoacoustic Fourier transform infrared spectroscopy showed a change in the symmetrical stretch of the carboxylate groups of the acetone-washed yeast biomass, and the X-ray photoelectron spectroscopy oxygen peak was also found to be shifted. These findings support the hypothesis that lead uptake occurs mainly through binding to the carboxyl group. In X-ray photoelectron spectroscopy the nitrogen peak decreased after the biosorption of lead, suggesting that nitrogen-containing groups are also involved in the biosorption process. Acylation of amino groups was shown to increase the lead biosorption capacity. The acylation reaction converts the positively charged amino group to an amide capable of coordination to lead cations. Deproteination by boiling the biosorbent with NaOH increased the lead uptake. The acetone-washed biomass uptake of lead from an aqueous solution at ph 5.5 was 48.9 mg/g dry weight. Pure chitin adsorbed 48.8 mg lead/g dry weight. Mannan isolated from S. uvarum did not adsorb lead at all. Electrostatic attraction of the carboxyl groups and other anions present in the acetone-washed biomass, and complexation with nitrogen atoms, especially in chitin, appear to be the main mechanisms involved in lead cation biosorption.

An alternative strategy for studying adverse events in medical care

BACKGROUND

Data about the frequency of adverse events related to inappropriate care in hospitals come from studies of medical records as if they represented a true record of adverse events. In a prospective, observational design we analysed discussion of adverse events during the care of all patients admitted to three units of a large, urban teaching hospital affiliated to a university medical school. Discussion took place during routine clinical meetings. We undertook the study to enhance understanding of the incidence and scope of adverse events as a basis for preventing them.

METHODS

Ethnographers trained in qualitative observational research attended day-shift, weekday, regularly scheduled attending rounds, residents' work rounds, nursing shift changes, case conferences, and other scheduled meetings in three study units as well as various departmental and section meetings. They recorded all adverse events during patient care discussed at these meetings and developed a classification scheme to code the data. Data were collected about health-care providers' own assessments about the appropriateness of the care that patients received to assess the nature and impact of adverse events and how health-care providers and patients responded to the adverse events.

FINDINGS

Of the 1047 patients in the study, 185 (17.7%) were said to have had at least one serious adverse event; having an initial event was linked to the seriousness of the patient's underlying illness. Patients with long stays in hospital had more adverse events than those with short stays. The likelihood of experiencing an adverse event increased about 6% for each day of hospital stay, 37.8% of adverse events were caused by an individual, 15.6% had interactive causes, and 9.8% were due to administrative decisions. Although 17.7% of patients experienced serious events that led to longer hospital stays and increased costs to the patients, only 1.2% (13) of the 1047 patients made claims for compensation.

INTERPRETATION

This study shows that there is a wide range of potential causes of adverse events that should be considered, and that careful attention must be paid to errors with interactive or administrative causes. Healthcare providers' own discussions of adverse events can be a good source of data for proactive error prevention.

Hyperbaric oxygenation upregulates rat lung Na,K-ATPase

Exposure of rats to hyperoxia is associated with increased active Na+ transport in rat lungs and increased Na,K-adenosine triphosphate (ATPase) expression in alveolar epithelial cells. Hyperbaric oxygenation (HBO) has been reported to act as an accelerated model of hyperoxic cell damage. Sublethal and intermittent exposure to HBO, however, has been suggested to upregulate endogenous protective mechanisms. In the present study, we tested whether short-term HBO, prior to inducing lung injury, would upregulate lung Na,K-ATPase. The results show that HBO, either intermittent or single 2.5 h exposure, increased lung Na,K-ATPase alpha-1 and beta-1 messenger ribonucleic acid (mRNA) transcript levels up to fourfold. Na,K-ATPase activity in lungs of rats exposed to HBO increased twofold during the first 2 h following removal from the hyperbaric chamber, and remained elevated for up to 6 h following HBO. Conceivably, the increase in Na,K-ATPase activity following HBO is due to an increase in activity from a basal to a higher rate, or possibly due to recruitment/translocation of Na,K-ATPases from inner membranes to the plasma membrane.

Retroperitoneal placement of an ICD generator: a solution for a difficult problem

A woman experienced multiple episodes of pocket erosion after placement of an implantable cardioverter defibrillator culminating in a pocket infection. The device was placed in a retroperitoneal location, and the patient has not developed further episodes of pocket erosion or infection. Interrogation of the device in this position and its subsequent replacement have been straightforward.

A randomized trial of a nursing intervention to promote the adjustment of children with chronic physical disorders

OBJECTIVE

This study was conducted to determine whether a specialized form of nursing could help prevent or reduce psychosocial maladjustment among children, aged 4 to 16 years, with chronic physical disorders. In contrast to other studies, nurses were chosen to provide the intervention based on their central role in health care and the appropriateness of their training for this task.

METHODOLOGY

A clinical trial was conducted in which 332 children and their families were randomly assigned either to receive this specialized nursing for a 1-year period, or to remain in the control condition. The children were all active outpatients in nine clinics at the Montreal Children's Hospital. Three measures of psychosocial functioning administered before and after the intervention were the basis for assessing its efficacy. The measures included the behavior problems profile of the Achenbach Child Behavior Checklist, the Personal Adjustment and Role Skills, completed by the parents, and two versions of the Self-Perception Profile (Harter) for children aged 4 to 7 years and 8 to 16 years.

RESULTS

Differences between groups were examined both categorically and quantitatively. In the former, the percent of children with clinical scores (those above or below a cut-off indicative of maladjustment) at baseline and postintervention were compared. In the latter, the mean scores at the end of the trial were analyzed using analysis of covariance with the baseline scores as covariates. Statistically significant positive differences were found in the domain of anxiety/depression on the Personal Adjustment and Role Skills, and in the areas of scholastic competence, behavior, and global self-worth on the Harter.

CONCLUSION

The results indicate that this intervention helps children with chronic disorders by preventing or reducing maladjustment. Most university-prepared nurses already have the basic skills required to achieve these results; only a modest investment in reorientation may be needed. Thus, other pediatric centers should be able to replicate these findings and thereby take a major step toward improving the lives of children with chronic disorders.

Mechanical comparison of 10 suture materials before and after in vivo incubation

The material properties of ten 2-O suture materials were evaluated tensiometrically at time = 0 and again after 6 weeks incubation in rats. All suture material was incubated and tested without knots. Specialized machinery was used with a custom securing apparatus to pull suture material apart at constant speed. Stress-strain curves were derived, and from these strength, toughness, strain at rupture, and elastic modulus were determined. Sutures tested included Vicryl [poly(glycolide-lactide)], Dexon (polyglycolic acid), Ethibond (polyester), silk, plain gut, chromic gut, Maxon (polyglyconate), PDS (polydioxanone), nylon, and Prolene (polypropylene). Elastic modulus was greatest for braided, least for monofilament, and intermediate for gut sutures, regardless of chemical composition (ANOVA, P = 0.0001). Strength, strain, and toughness decreased in all of the sutures over time in vivo with the exception of braided polyester (Ethibond), which remained stable. Silk demonstrated the least strength and toughness while PDS and Maxon were the strongest and toughest at time = 0. Vicryl, Dexon, and gut sutures were absorbed to the point that they could not be tested after 6 weeks in vivo. Performance tables are provided for all sutures.

The effect of a distal site of compression on neural regeneration

The effect of a distal site of nerve compression on neural regeneration after a nerve repair was investigated in the rat model. After chronic compression had been established by placement of a Silastic band about a distal site of the posterior tibial nerve, the proximal posterior tibial nerve was divided, and then immediately repaired. Beginning 6 months after nerve repair, neural regeneration, assayed by walking track analysis, demonstrated significantly impaired function in the group of rats with a distal site of compression, compared with the repair group without a distal site of compression (p < .05). Followed for 3 additional months, neural function further significantly (p < .001) deteriorated in the group with distal compression. Morphometric analysis demonstrated that both the nerve repair alone and repair-plus-compression groups had 1) significantly decreased axon and nerve-fiber diameters (p < .001), and 2) significantly increased myelinated nerve-fiber density (p < .001), compared with normal; these findings are consistent with neural regeneration. However, the repair-plus-compression group had significantly (p < .03) fewer regenerating fibers than did the repair-without-distal-compression group. This experimental study suggests that consideration be given to release of sites of known anatomic narrowing in close proximity to a nerve reconstruction.

Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup

BACKGROUND

The identification and removal of adenomatous polyps and post-polypectomy surveillance are considered to be important for the control of colorectal cancer. In current practice, the intervals between colonoscopies after polypectomy are variable, often a year long, and not based on data from randomized clinical trials. We sought to determine whether follow-up colonoscopy at three years would detect important colonic lesions as well as follow-up colonoscopy at both one and three years.

METHODS

Patients were eligible if they had one or more adenomas, no previous polypectomy, and a complete colonoscopy and all their polyps had been removed. They were randomly assigned to have follow-up colonoscopy at one and three years or at three years only. The two study end points were the detection of any adenoma, and the detection of adenomas with advanced pathological features (defined as those > 1 cm in diameter and those with high-grade dysplasia or invasive cancer).

RESULTS

Of 2632 eligible patients, 1418 were randomly assigned to the two follow-up groups, 699 to the two-examination group and 719 to the one-examination group. The percentage of patients with adenomas in the group examined at one and three years was 41.7 percent, as compared with 32.0 percent in the group examined at three years (P = 0.006). The percentage of patients with adenomas with advanced pathological features was the same in both groups (3.3 percent).

CONCLUSIONS

Colonoscopy performed three years after colonoscopic removal of adenomatous polyps detects important colonic lesions as effectively as follow-up colonoscopy after both one and three years. An interval of at least three years is recommended before follow-up colonoscopy after both one and three years. An interval of at least three years is recommended before follow-up examination after colonoscopic removal of newly diagnosed adenomatous polyps. Adoption of this recommendation nationally should reduce the cost of post-polypectomy surveillance and screening.

Impact of a clinical preventive medicine curriculum for primary care faculty: results of a dissemination model

BACKGROUND

This study was designed to test a dissemination model for providing clinical preventive medicine (CPM) training to general internal medicine faculty across the United States.

METHODS

The model incorporated direct instruction of a few faculty as seminar facilitators who, in turn, taught a CPM curriculum to their faculty colleagues, who then could teach it to housestaff and students. The CPM curriculum consisted of six seminars that focused primarily on the risk factors for chronic diseases and on behavior change methods for modifying smoking, diet, and exercise.

RESULTS

Faculty who participated in the seminars had significant pre- to post-test increase in knowledge and reported self-efficacy to implement CPM strategies with patients, as well as changes in CPM clinical practices. These faculty, in turn, successfully disseminated CPM information to their housestaff, who also had increases in self-efficacy and changed clinical practices regarding CPM topics.

CONCLUSIONS

The successful implementation of the dissemination model attests to its viability as a mechanism for disseminating CPM curricula and increasing the emphasis on CMP issues in both clinical teaching and clinical encounters with patients.

Biomechanical analysis of intrinsic tendon healing in vitro and the effects of vitamins A and E

This in vitro study was designed to test the hypothesis that flexor tendons have an intrinsic capability to heal as judged by rigorously defined biomechanical criteria. Rabbit forepaw flexor tendons (n = 114) were transected and repaired in zone II and cultured in standard media or media supplemented with vitamin A or E. Tenorrhaphies were disrupted at 0, 2, 8, and 12 weeks after repair by fixed-speed tensiometry. The following parameters were calculated: true stress, true strain, and normalized energy absorption. Statistical analysis was by Student's t test. Peak stress (strength) increased equally in all groups over time (p less than 0.05), while normalized energy absorption (toughness) was markedly higher in the vitamin E-treated group after 2 weeks' incubation (p less than 0.05). These data represent the first biomechanical evidence of intrinsic tendon healing in vitro. Biomechanical methodology and vitamin effects are discussed in detail.

[Effect of hemodialysis on hemodynamic assessment and cardiac flows determined by Doppler echocardiography]

25 patients with end-stage renal failure were studied by different echocardiographic techniques before and immediately after hemodialysis using M-mode, 2-dimensional and Doppler echocardiography. Preload reduction after dialysis was manifested by a decrease in body weight, in left atrial diameter and in the left ventricular end-diastolic dimension. Doppler flow patterns immediately after dialysis showed reduction in early diastolic velocities across the atrioventricular valves and increase in the flow velocities across the semilunar valves and the peripheral A-V fistula. The flow velocity integral, calculated by Doppler echocardiography, was lower after dialysis. Significant improvement in left ventricular myocardial function after dialysis was correlated with reduction in afterload and increase in myocardial contractility.

The rectus abdominis muscle flap in a combined abdominovaginal repair of difficult vesicovaginal fistulae. A report of three cases

Conventional repairs had been tried on three patients suffering from vesicovaginal fistulas after abdominal hysterectomies. Separate vaginal and abdominal approaches had been tried and had resulted not only in failure but also in tissue loss and fibrosis. A final synchronous vaginoabdominal approach using a rectus abdominis muscle flap was used successfully in all three patients.

Unfavourable outcomes of drug therapy--subjective probability versus confidence intervals

To investigate how individual predictions compare with confidence intervals, we asked 50 medical residents and 28 graduate students with biostatistics training to estimate unfavourable outcomes of drug therapy (therapeutic failures and side-effects) in groups of 10 and 20 patients. The predictions made by physicians and graduate students were similar for both sample sizes and types of outcome. The majority (58%) of estimates were greater than the upper limit of the 95% confidence interval, a bias that may hamper the correct interpretation of therapeutic risks in medical decision-making.

Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room

In a prospective multicenter investigation of emergency room patients with acute chest pain, physicians admitted 96% of patients with acute myocardial infarction (AMI) and discharged 4%. Of 35 patients who were sent home with AMI, only 11 (31%) returned to the same hospital because of persistent symptoms. Compared with a control group of 105 randomly selected patients with AMI who were admitted from the emergency room, patients in whom AMI was missed were significantly younger, had less typical symptoms and were less likely to to have had prior AMI or angina or to have electrocardiographic evidence of ischemia or infarction not known to be old. Despite the less typical presentations of patients in whom AMI was missed, after controlling for age and sex, the short-term mortality rate was significantly higher among patients in whom AMI was missed but in whom it was detected through our follow-up procedures than in admitted AMI patients. As determined by independent reviewers, 49% of the missed AMIs could have been diagnosed through improved electrocardiographic reading skills or by admission of patients with recognized ischemic pain at rest or ischemic electrocardiographic changes not known to be old.

The McGill model of nursing: a practice-derived model

This article describes the salient features of the McGill model of nursing, (ie, health, family, collaboration, and learning), within the health, person, environment, and nursing paradigm. According to the model, the central goal of nursing is to maintain, strengthen, and develop the patient's health by actively engaging him or her in a learning process. Because health is a learned phenomenon and the family is considered the primary socializer in this learning, the family is the focus of nursing. The nurse strives to structure a learning environment that enables the patient to participate as fully as possible. The nurse and patient together set goals and, building on the patient's strengths and resources, devise means of achieving them.

Fulminant pulmonary infections in renal transplant recipients

Opportunistic pulmonary infections often appear in patients requiring immunosuppressive therapy following renal transplantation. Fungal protozoal, viral and bacterial infections demand an immediate definitive diagnosis, since the outcome is related to the rapidity in establishing a diagnosis and the institution of appropriate therapy. Of 200 consecutive renal transplants during a seven year period, severe pulmonary infections developed in 21 patients. In 17 patients, a specific infectious agent was identified, using the flexible fiberoptic bronchoscope. Pathogenic specimens were obtained by bronchial washing, brushing or transbronchoscopic biopsy of the lung through the inner channel of the flexible bronchoscope. Bronchoscopy for localized lesions of the lung was aided by fluoroscopic guidance; for diffuse lesions, a roentgenogram of the chest was used to obtain bronchoscopic specimens from areas of maximum infiltration. Specimens were immediately dispatched and processed by the pathology laboratory. Except for one patient, all the others with fungal, protozoal and viral infections survived with functioning kidneys. Three deaths resulted from bacterial infections. Antemortem diagnoses were confirmed in all four patients who died.