Experimental warming alters the community composition, diversity, and N2 fixation activity of peat moss (Sphagnum fallax) microbiomes.

Sphagnum-dominated peatlands comprise a globally important pool of soil carbon (C) and are vulnerable to climate change. While peat mosses of the genus Sphagnum are known to harbor diverse microbial communities that mediate C and nitrogen (N) cycling in peatlands, the effects of climate change on Sphagnum microbiome composition and functioning are largely unknown. We investigated the impacts of experimental whole-ecosystem warming on the Sphagnum moss microbiome, focusing on N2 fixing microorganisms (diazotrophs). To characterize the microbiome response to warming, we performed next-generation sequencing of small subunit (SSU) rRNA and nitrogenase (nifH) gene amplicons and quantified rates of N2 fixation activity in Sphagnum fallax individuals sampled from experimental enclosures over 2 years in a northern Minnesota, USA bog. The taxonomic diversity of overall microbial communities and diazotroph communities, as well as N2 fixation rates, decreased with warming (p < 0.05). Following warming, diazotrophs shifted from a mixed community of Nostocales (Cyanobacteria) and Rhizobiales (Alphaproteobacteria) to predominance of Nostocales. Microbiome community composition differed between years, with some diazotroph populations persisting while others declined in relative abundance in warmed plots in the second year. Our results demonstrate that warming substantially alters the community composition, diversity, and N2 fixation activity of peat moss microbiomes, which may ultimately impact host fitness, ecosystem productivity, and C storage potential in peatlands.

Novel Method for Noninvasive Sampling of the Distal Airspace in Acute Respiratory Distress Syndrome.

RATIONALE: A major barrier to a more complete understanding of acute respiratory distress syndrome (ARDS) pathophysiology is the inability to sample the distal airspace of patients with ARDS. The heat moisture exchanger (HME) filter is an inline bacteriostatic sponge that collects exhaled moisture from the lungs of mechanically ventilated patients. OBJECTIVES: To test the hypothesis that HME filter fluid (HMEF) represents the distal airspace fluid in patients with ARDS. METHODS: Samples of HMEF were collected from 37 patients with acute pulmonary edema (either from ARDS or hydrostatic causes [HYDRO; control subjects]). Concurrent undiluted pulmonary edema fluid (EF) and HMEF were collected from six patients. HMEF from 11 patients (8 ARDS and 3 HYDRO) were analyzed by liquid chromatography-coupled tandem mass spectometry. Total protein (bicinchoninic acid assay), MMP-9 (matrix metalloproteinase-9), and MPO (myeloperoxidase) (ELISA) were measured in 29 subjects with ARDS and 5 subjects with HYDRO. SP-D (surfactant protein-D), RAGE (receptor for advanced glycation end-products) (ELISA), and cytokines (IL-1ß, IL-6, IL-8, and tumor necrosis factor-α) (electrochemiluminescent assays) were measured in six concurrent HMEF and EF samples. MEASUREMENTS AND MAIN RESULTS: Liquid chromatography-coupled tandem mass spectrometry on concurrent EF and HMEF samples from four patients revealed similar base peak intensities and m/z values indicating similar protein composition. There were 21 significantly elevated proteins in HMEF from patients with ARDS versus HYDRO. Eight proteins measured in concurrent EF and HMEF from six patients were highly correlated. In HMEF, total protein and MMP-9 were significantly higher in ARDS than in HYDRO. CONCLUSIONS: These data suggest that HMEF is a novel, noninvasive method to accurately sample the distal airspace in patients with ARDS.

Can mentorship improve laboratory quality? A case study from influenza diagnostic laboratories in Southeast Europe.

BACKGROUND: Strengthening the quality of laboratory diagnostics is a key part of building global health capacity. In 2015, the Centers for Disease Control and Prevention (CDC), the Southeast European Center for Surveillance and Control of Infectious Diseases (SECID), WHO European Regional Office (WHO EURO) and American Public Health Laboratories (APHL) collaborated to address laboratory quality training needs in Southeast Europe. Together, they developed a quality assurance (QA) mentorship program for six national laboratories (Laboratories A-E) in five countries utilizing APHL international consultants. The primary goal of the mentorship program was to help laboratories become recognized by WHO as National Influenza Centers (NICs). The program aimed to do this by strengthening influenza laboratory capacity by implementing quality management systems (QMS) action steps. After 1 year, we evaluated participants' progress by the proportion of QMS action steps they had successfully implemented, as well as the value of mentorship as perceived by laboratory mentees, mentors, and primary program stakeholders from SECID and WHO EURO. METHODS: To understand perceived value we used the qualitative method of semi-structured interviews, applying grounded theory to the thematic analysis. RESULTS: Mentees showed clear progress, having completed 32 to 68% [median: 62%] of planned QMS action steps in their laboratories. In regards to the perceived value of the program, we found strong evidence that laboratory mentorship enhances laboratory quality improvement by promoting accountability to QMS implementation, raising awareness of the importance of QMS, and fostering collaborative problem solving. CONCLUSION: In conclusion, we found that significant accomplishments can be achieved when QA programs provide dedicated technical mentorship for QMS implementation. Since the start of the mentoring, Laboratory "B" has achieved NIC recognition by WHO, while two other labs made substantial progress and are scheduled for recognition in 2018. In the future, we recommend that mentorship is more inclusive of laboratory directors, and that programs evaluate the amount of staff time needed for mentorship activities, including lab-based assessments and mentoring.

Severity scoring of lung oedema on the chest radiograph is associated with clinical outcomes in ARDS.

BACKGROUND: There is no accurate, non-invasive measurement to estimate the degree of pulmonary oedema in acute respiratory distress syndrome (ARDS). We developed the Radiographic Assessment of Lung Oedema (RALE) score to evaluate the extent and density of alveolar opacities on chest radiographs. After first comparing the RALE score to gravimetric assessment of pulmonary oedema in organ donors, we then evaluated the RALE score in patients with ARDS for its relationship to oxygenation and clinical outcomes. METHODS: We compared radiographs with excised lung weights from 72 organ donors (derivation cohort) and radiographs with clinical data from 174 patients with ARDS in the ARDSNet Fluid and Catheter Treatment Trial (validation cohort). To calculate RALE, each radiographic quadrant was scored for extent of consolidation (0-4) and density of opacification (1-3). The product of the consolidation and density scores for each of the four quadrants was summed (maximum score=48). RESULTS: Agreement between two independent reviewers for RALE score was excellent (intraclass correlation coefficient=0.93, 95% CI 0.91 to 0.95). In donors, pre-procurement RALE score correlated with height-adjusted total lung weight (ρ=0.59, p<0.001). In patients with ARDS, higher RALE scores were independently associated with lower PaO2/fractional inspired oxygen and worse survival. Conservative fluid management significantly decreased RALE score over 3 days compared with liberal fluid management. CONCLUSIONS: The RALE score can be used to assess both the extent of pulmonary oedema and the severity of ARDS, by utilising information that is already obtained routinely, safely and inexpensively in every patient with ARDS. This novel non-invasive measure should be useful for assessing ARDS severity and monitoring response to therapy.

Molybdenum-Based Diazotrophy in a Sphagnum Peatland in Northern Minnesota.

Microbial N2 fixation (diazotrophy) represents an important nitrogen source to oligotrophic peatland ecosystems, which are important sinks for atmospheric CO2 and are susceptible to the changing climate. The objectives of this study were (i) to determine the active microbial group and type of nitrogenase mediating diazotrophy in an ombrotrophic Sphagnum-dominated peat bog (the S1 peat bog, Marcell Experimental Forest, Minnesota, USA); and (ii) to determine the effect of environmental parameters (light, O2, CO2, and CH4) on potential rates of diazotrophy measured by acetylene (C2H2) reduction and 15N2 incorporation. A molecular analysis of metabolically active microbial communities suggested that diazotrophy in surface peat was primarily mediated by Alphaproteobacteria (Bradyrhizobiaceae and Beijerinckiaceae). Despite higher concentrations of dissolved vanadium ([V] 11 nM) than molybdenum ([Mo] 3 nM) in surface peat, a combination of metagenomic, amplicon sequencing, and activity measurements indicated that Mo-containing nitrogenases dominate over the V-containing form. Acetylene reduction was only detected in surface peat exposed to light, with the highest rates observed in peat collected from hollows with the highest water contents. Incorporation of 15N2 was suppressed 90% by O2 and 55% by C2H2 and was unaffected by CH4 and CO2 amendments. These results suggest that peatland diazotrophy is mediated by a combination of C2H2-sensitive and C2H2-insensitive microbes that are more active at low concentrations of O2 and show similar activity at high and low concentrations of CH4 IMPORTANCE Previous studies indicate that diazotrophy provides an important nitrogen source and is linked to methanotrophy in Sphagnum-dominated peatlands. However, the environmental controls and enzymatic pathways of peatland diazotrophy, as well as the metabolically active microbial populations that catalyze this process, remain in question. Our findings indicate that oxygen levels and photosynthetic activity override low nutrient availability in limiting diazotrophy and that members of the Alphaproteobacteria (Rhizobiales) catalyze this process at the bog surface using the molybdenum-based form of the nitrogenase enzyme.

Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill.

RATIONALE: Hypoxemia is common during endotracheal intubation of critically ill patients and may predispose to cardiac arrest and death. Administration of supplemental oxygen during laryngoscopy (apneic oxygenation) may prevent hypoxemia. OBJECTIVES: To determine if apneic oxygenation increases the lowest arterial oxygen saturation experienced by patients undergoing endotracheal intubation in the intensive care unit. METHODS: This was a randomized, open-label, pragmatic trial in which 150 adults undergoing endotracheal intubation in a medical intensive care unit were randomized to receive 15 L/min of 100% oxygen via high-flow nasal cannula during laryngoscopy (apneic oxygenation) or no supplemental oxygen during laryngoscopy (usual care). The primary outcome was lowest arterial oxygen saturation between induction and 2 minutes after completion of endotracheal intubation. MEASUREMENTS AND MAIN RESULTS: Median lowest arterial oxygen saturation was 92% with apneic oxygenation versus 90% with usual care (95% confidence interval for the difference, -1.6 to 7.4%; P = 0.16). There was no difference between apneic oxygenation and usual care in incidence of oxygen saturation less than 90% (44.7 vs. 47.2%; P = 0.87), oxygen saturation less than 80% (15.8 vs. 25.0%; P = 0.22), or decrease in oxygen saturation greater than 3% (53.9 vs. 55.6%; P = 0.87). Duration of mechanical ventilation, intensive care unit length of stay, and in-hospital mortality were similar between study groups. CONCLUSIONS: Apneic oxygenation does not seem to increase lowest arterial oxygen saturation during endotracheal intubation of critically ill patients compared with usual care. These findings do not support routine use of apneic oxygenation during endotracheal intubation of critically ill adults. Clinical trial registered with www.clinicaltrials.gov (NCT 02051816).

Randomized, placebo-controlled trial of acetaminophen for the reduction of oxidative injury in severe sepsis: the Acetaminophen for the Reduction of Oxidative Injury in Severe Sepsis trial.

OBJECTIVES: This trial evaluated the efficacy of acetaminophen in reducing oxidative injury, as measured by plasma F2-isoprostanes, in adult patients with severe sepsis and detectable plasma cell-free hemoglobin. DESIGN: Single-center, randomized, double-blind, placebo-controlled phase II trial. SETTING: Medical ICU in a tertiary, academic medical center. PATIENTS: Critically ill patients 18 years old or older with severe sepsis and detectable plasma cell-free hemoglobin. INTERVENTIONS: Patients were randomized 1:1 to enteral acetaminophen 1 g every 6 hours for 3 days (n = 18) or placebo (n = 22) with the same dosing schedule and duration. MEASUREMENTS AND MAIN RESULTS: F2-Isoprostanes on study day 3, the primary outcome, did not differ between acetaminophen (30 pg/mL; interquartile range, 24-41) and placebo (36 pg/mL; interquartile range, 25-80; p = 0.35). However, F2-isoprostanes were significantly reduced on study day 2 in the acetaminophen group (24 pg/mL; interquartile range, 19-36) when compared with placebo (36 pg/mL; interquartile range, 23-55; p = 0.047). Creatinine on study day 3, a secondary outcome, was significantly lower in the acetaminophen group (1.0 mg/dL; interquartile range, 0.6-1.4) when compared with that in the placebo (1.3 mg/dL; interquartile range, 0.83-2.0; p = 0.039). There was no statistically significant difference in hospital mortality (acetaminophen 5.6% vs placebo 18.2%; p = 0.355) or adverse events (aspartate aminotransferase or alanine aminotransferase > 400; acetaminophen 9.5% vs placebo 4.3%; p = 0.599). CONCLUSIONS: In adults with severe sepsis and detectable plasma cell-free hemoglobin, treatment with acetaminophen within 24 hours of ICU admission may reduce oxidative injury and improve renal function. Additional study is needed to confirm these findings and determine the effect of acetaminophen on patient-centered outcomes.

Novel gentamicin resistance genes in Campylobacter isolated from humans and retail meats in the USA.

OBJECTIVES: To understand the molecular epidemiology of gentamicin-resistant Campylobacter and investigate aminoglycoside resistance mechanisms. METHODS: One-hundred-and-fifty-one gentamicin-resistant Campylobacter isolates from humans (n = 38 Campylobacter jejuni; n = 41, Campylobacter coli) and retail chickens (n = 72 C. coli), were screened for the presence of gentamicin resistance genes by PCR and subtyped using PFGE. A subset of the isolates (n = 41) was analysed using WGS. RESULTS: Nine variants of gentamicin resistance genes were identified: aph(2″)-Ib, Ic, Ig, If, If1, If3, Ih, aac(6')-Ie/aph(2″)-Ia and aac(6')-Ie/aph(2″)-If2. The aph(2″)-Ib, Ic, If1, If3, Ih and aac(6')-Ie/aph(2″)-If2 variants were identified for the first time in Campylobacter. Human isolates showed more diverse aminoglycoside resistance genes than did retail chicken isolates, in which only aph(2″)-Ic and -Ig were identified. The aph(2″)-Ig gene was only gene shared by C. coli isolates from human (n = 27) and retail chicken (n = 69). These isolates displayed the same resistance profile and similar PFGE patterns, suggesting that contaminated retail chicken was probably the source of human C. coli infections. Human isolates were genetically diverse and generally more resistant than the retail chicken isolates. The most frequent co-resistance was to tetracycline (78/79, 98.7%), followed by ciprofloxacin/nalidixic acid (46/79, 58.2%), erythromycin and azithromycin (36/79, 45.6%), telithromycin (32/79, 40.5%) and clindamycin (18/79, 22.8%). All human and retail meat isolates were susceptible to florfenicol. CONCLUSIONS: This study demonstrated that several new aminoglycoside resistance genes underlie the recent emergence of gentamicin-resistant Campylobacter, and that, in addition to contaminated retail chicken, other sources have also contributed to gentamicin-resistant Campylobacter infections in humans.

Electronic Patient Reported Outcome Measures for Optimal Remote Symptom Management in Advanced Breast Cancer: Embracing Digital Health Technology.

OBJECTIVE: To review the use of electronic patient outcome measures (ePROMs) in advanced breast cancer (ABC) and its effectiveness in supporting remote symptom monitoring. DATA SOURCES: An overview of published randomized controlled trials using electronic patient-reported outcome measures (ePROMs) in ABC care. CONCLUSION: The use of ePROMs in ABC care combined with oncology clinical nurse specialist (CNS) interventions has shown that patient-centered care through remote monitoring of disease and treatment symptoms can improve ABC patient outcomes and experience. IMPLICATIONS FOR NURSING PRACTICE: Oncology clinical nurse specialists (CNSs) have an important role in the effective implementation of ePROMs in ABC care. CNSs are considered most appropriate to lead on and respond to ePROMs, addressing complex symptom issues and maximizing the quality of life (QoL) for the ABC patient. CNSs are a crucial link between the patient, primary and secondary level care health professionals, and the ePROM portal for ABC care.

Making the unbearable, bearable: Qualitative examination of patient, family and nurses' perspectives on the role and value of specialist metastatic breast care nurses.

PURPOSE: To examine the role and value of specialist metastatic breast care nurses in Australia from the perspective of metastatic breast care nurses, patients, and family members. Metastatic breast cancer (mBC) is treatable yet incurable, with distinct supportive care needs, yet many of these needs are unmet. METHOD: Diverse sampling methods were used to recruit 10 people with mBC, 5 family members and 10 metastatic breast care nurses. Semi-structured interviews were conducted online or by telephone during August-December 2020, and analysed thematically. RESULTS: The role of the specialist nurse was strongly valued within and across participant groups, with close alignment regarding what was highly valued. Three themes were identified. First, nurses played a vital role in giving voice and visibility to patients with mBC in a healthcare system in which they often felt invisible. Second, nurses combined their clinical and psychosocial skills with a sense of authentic engagement to create a safe space for those with mBC to discuss their feelings, experiences, and topics, especially those that were unlikely to be discussed in their other social and clinical interactions. Finally, nurses supported patients in living as well as possible while managing symptoms, ongoing treatment, and attendant psychosocial impacts of an incurable and life-limiting condition. CONCLUSIONS: This study underscores the central importance of metastatic breast care nurses in enhancing patient well-being, bridging gaps in care, and offering much-needed support. By addressing patients' emotional, clinical, and social needs, these specialist nurses contribute to a more holistic and compassionate approach to managing mBC.

Pre-diagnostic routes to colorectal cancer in Central New Zealand: factors that lead to emergency presentation and longer diagnostic intervals at primary and secondary level care.

Introduction Although international large-scale studies have investigated routes to diagnosis for colorectal cancer, there is limited information on how New Zealanders seek help for bowel symptoms across different pre-diagnostic routes. Aim To better understand pre-diagnostic routes for colorectal cancer, including the characteristics of patients and key events associated with each route. Methods This study was a retrospective audit of hospital administrative and medical records for 120 patients with a confirmed diagnosis of colorectal cancer between 2016 and 2017. All patients were receiving care at one of two hospitals in central New Zealand; one urban and one rural. Extracted data were used to: categorise pre-diagnostic routes for colorectal cancer; describe the characteristics of people who presented by each route; and compare key events in the diagnostic and treatment intervals for people who presented by each route. Results Six routes to the diagnosis of colorectal cancer were identified. The three main routes included: routine general practitioner (GP) referral (28%, 95% CI: 21-37%), emergency presentation (27%, 95% CI: 20-35%), and other outpatient services (26%, 95% CI: 19-34%). Patients diagnosed by routine GP referral had the longest time to diagnosis, impacting on timeliness of treatment. Discussion This study has generated detailed insights about pre-diagnostic routes for colorectal cancer in New Zealand and shown consistency with findings from previously published international research. The granular findings can now inform areas for person- and system-level interventions that, in turn, could be tested in future studies to minimise emergency department and late presentations for colorectal cancer treatment in New Zealand.

Accuracy of the Radiographic Assessment of Lung Edema Score for the Diagnosis of ARDS.

Background: Bilateral opacities on chest radiographs are part of the Berlin Definition for Acute Respiratory Distress Syndrome (ARDS) but have poor interobserver reliability. The "Radiographic Assessment of Lung Edema" (RALE) score was recently proposed for evaluation of the extent and density of alveolar opacities on chest radiographs of ARDS patients. The current study determined the accuracy of the RALE score for the diagnosis and the prognosis of ARDS. Methods: Post-hoc analysis of a cohort of invasively ventilated intensive care unit (ICU) patients expected to need invasive ventilation for >24 h. The Berlin Definition was used as the gold standard. The RALE score was calculated for the first available chest radiograph after start of ventilation in the ICU. The primary endpoint was the diagnostic accuracy for ARDS of the RALE score. Secondary endpoints included the prognostic value of the RALE score for ICU and hospital mortality, and the association with ARDS severity, and the PaO2/FiO2. Receiver operating characteristic (ROC) curves were constructed, and the optimal cutoff was used to determine sensitivity, specificity and the negative and positive predictive value of the RALE score for ARDS. Results: The study included 131 patients, of whom 30 had ARDS (11 mild, 15 moderate, and 4 severe ARDS). The first available chest radiograph was obtained median 0 [0 to 1] days after start of invasive ventilation in ICU. Compared to patients without ARDS, a higher RALE score was found in patients with ARDS (24 [interquartile range (IQR) 16-30] vs. 6 [IQR 3-11]; P < 0.001), with RALE scores of 20 [IQR 14-24], 26 [IQR 16-32], and 32 [IQR 19-36] for mild, moderate and severe ARDS, respectively, (P = 0.166). The area under the ROC for ARDS was excellent (0.91 [0.86-0.96]). The best cutoff for ARDS diagnosis was 10 with 100% sensitivity, 71% specificity, 51% positive predictive value and 100% negative predictive value. The RALE score was not associated with ICU or hospital mortality, and weakly correlated with the PaO2/FiO2. Conclusion: In this cohort of invasively ventilated ICU patients, the RALE score had excellent diagnostic accuracy for ARDS.

Rapidly fatal pneumonitis from immunotherapy and concurrent SARS-CoV-2 infection in a patient with newly diagnosed lung cancer.

Immune checkpoint inhibitors (ICIs) are used for the treatment of numerous cancers, but risks associated with ICI-therapy during the COVID-19 pandemic are poorly understood. We report a case of acute lung injury in a lung cancer patient initially treated for ICI-pneumonitis and later found to have concurrent SARS-CoV-2 infection. Post-mortem analyses revealed diffuse alveolar damage in both the acute and organizing phases, with a predominantly CD68+ inflammatory infiltrate. Serum was positive for anti-SARS-CoV-2 IgG, suggesting that viral infection predated administration of ICI-therapy and may have contributed to a more fulminant clinical presentation. These data suggest the need for routine SARS-CoV-2 testing in cancer patients, where clinical and radiographic evaluations may be non-specific.

Metastatic breast cancer recurrence: a literature review of themes and issues arising from diagnosis.

An understanding of the impact of recurrent metastatic breast cancer diagnosis is vital to palliative care nurses since the prognosis for such women is generally poor and many present with a complex range of physical and psychosocial problems. However, while many quantitative studies have focused on quality of life in patients receiving different treatments for their metastatic disease, researchers have paid very little attention to the personal impact of recurrent disease and few qualitative papers have been published on this phenomenon. This literature review, therefore, provides an overview of the main issues affecting breast cancer patients with recurrent metastases, and identifies the key differences between this group and those diagnosed with other forms of breast cancer. In total, the literature search identified 10 papers which attempt to describe women's reactions to a diagnosis of recurrent metastatic breast cancer, although many do not focus solely on the experiences of this group of patients. The review provides fresh insight into these experiences and explores common themes arising from the literature so that nurses may better understand the patient's experience and respond to their needs appropriately.

Determination of carotenoid as the purple pigment in Gorgonia ventalina sclerites using Raman microscopy.

The production of purple pigment in gorgonian sclerites in response to biotic insults has been used to determine the disease state of these organisms. The chemical nature of the pigment present in the sclerites has until now been unknown. Using Raman microscopy, it was determined that this pigment is a carotenoid with a polyene chain containing between 14 and 15 carbon double bonds.

Collaboration in developing a protocol for nurse-led seroma aspiration.

A seroma is a serous fluid collection which may develop in the space between the chest wall and skin flaps following breast cancer surgery with axillary lymph node dissection. Seroma formation following mastectomy is most common. This article aims to produce a protocol for nurse-led seroma aspiration in collaboration with the breast multidisciplinary team and describe the four main steps involved in the development. It was important to develop a protocol for nurse-led seroma aspiration to enable the breast cancer clinical nurse specialist (CNS) to practice confidently and safely in an extended area of practice. The protocol will assist the breast cancer CNS by providing clear and specific guidance. CNSs considering developing a protocol for seroma aspiration should involve all relevant members of the breast multidisciplinary team. Breast cancer CNSs must be trained in seroma aspiration and undergo clinical supervision. Only when deemed competent, should nurse specialists provide a seroma aspiration service independently. Patient satisfaction with the nurse-led seroma aspiration service should be evaluated by clinical audit at an early stage.

The complexity of non face-to-face work with patients affected by metastatic breast cancer and their carers. The 'hidden consultations' of the clinical nurse specialist.

INTRODUCTION: Survival rates in breast cancer have risen in the last 30 years. Almost one third of those diagnosed will go onto developing metastatic breast cancer which is becoming a long term condition in cancer care. In 2006 429,000 new cases of breast cancer were recorded across Europe. In recent years treatment for metastatic breast cancer in the UK has moved to the ambulatory setting meaning non face-to-face contact, for example through telephone consultation, has become a vital method of management. METHOD: A prospective study conducted over a 1-month period at a London Trust. Data was collected by two clinical nurse specialists on incoming calls using Excel and a bespoke interrelational structured query database. These data were then mined using standard data mining techniques. RESULTS: The study collected 28 days of data. 229 patient and carer telephone contacts were recorded across the Trust. Most calls were from patients (62.5%). Incoming calls resulted in the delivery of 1282 interventions, a mean of six interventions per call (range 1-8) and clustered into four areas: meeting information needs (29%), symptom management (26%), psychological/social issues (33%) and other issues (12%). The incoming telephone work accounted for 63 h which represented 30% of the total working time of the clinical nurse specialist. Calls primarily originated from patients who were in the follow-up phase (43% of calls), a group usually thought to prefer self management.