Burn care and rehabilitation in Australia: health professionals’ perspectives

Objective: To understand health professionals’ perspectives of burn care and rehabilitation.

Design: Qualitative and semi-structured interviews.

Setting: Australian burn and rehabilitation units.

Participants: Twenty-two clinicians working in burns units across disciplines and healthcare settings.

Results: The data portrayed the health professionals’ perspectives of burn care and rehabilitation in Australia. Three themes were identified: (1) interprofessional collaboration; (2) integrated community care, and (3) empowering patients to self-care.

Conclusion: Burn care and rehabilitation remains a complex and a challenging area of care with limited access to burn services especially in rural and remote areas. Interprofessional training and education of health professionals involved with the complex care of burn injury remains a key element to support and sustain the long-term rehabilitation requirements for patients and their families. Empowering patients to develop independence early in their rehabilitation is fundamental to their ongoing recovery. A burns model of care that embraces a multidisciplinary collaboration and integrated care across the continuum has the potential to positively impact recovery and improve health outcomes.

• Implications for rehabilitation

• Burn care and rehabilitation remains a complex and challenging area of care.

• Managing the rehabilitation phase after burn injury can be as complex as managing the acute phase.

• Interprofessional collaboration, integrated community care, and empowering patients to self-care are key elements for sustaining the rehabilitation of adults with burn injuries.

     

Clinical teachers as caring mothers from the perspectives of Jordanian nursing students

The purpose of this transcultural qualitative study was to discover, describe and explain the meaning of a caring student-teacher encounter within the context of clinical education. Clinical teachers are registered nurses who have completed a university undergraduate nursing degree program and at least 1 year of post-registration clinical experience. They are employed as full-time staff of the faculty of nursing. Among the 19 Jordanian undergraduate nursing students interviewed, "clinical nurse teachers as caring mothers," emerged as an important theme. This paper describes the clinical teachers in their mothering roles, such as supporting, negotiating, reinforcing, transforming and releasing nursing students throughout their clinical practice. Understanding students' cultural beliefs and values provides possible predictors that could facilitate positive student-teacher relationships that could be used to plan the clinical education for nursing students. There is also a need to develop workshops in clinical teaching that would incorporate cultural awareness, especially in a multicultural student-teacher groups.     

Expression of activated MEK1 in differentiating epidermal cells is sufficient to generate hyperproliferative and inflammatory skin lesions

Epidermal activation of Erk MAPK is observed in human psoriatic lesions and in a mouse model of psoriasis in which beta1 integrins are expressed in the suprabasal epidermal layers. Constitutive activation of the upstream kinase MEK1 causes hyperproliferation and perturbed differentiation of human keratinocytes in culture. It is not known, however, whether Erk activation in differentiating keratinocytes is sufficient to trigger hyperproliferation of basal keratinocytes and a skin inflammatory infiltrate. To investigate this, we expressed constitutively active MEK1 in the suprabasal epidermal layers of transgenic mice. Proliferation in the epidermal basal layer was stimulated and epidermal terminal differentiation was perturbed. Some older mice also developed papillomas. There was a large increase in T lymphocytes, dendritic cells, and neutrophils in the skin. The effects of suprabasal MEK1 on basal keratinocytes and leukocytes, cells that were transgene negative, suggested that MEK1 activity might stimulate cytokine release. Transgenic keratinocytes expressed elevated IL-1alpha and crossing the mice with mice overexpressing the IL-1 receptor in the epidermal basal layer led to exacerbated hyperproliferation and inflammation. These data suggest that activation of MEK1 downstream of beta1 integrins plays an important role in epidermal hyperproliferation and skin inflammation.     

HIV and carotid atherosclerosis: a mediational model

ABSTRACT

Cardiovascular disease (CVD) is the leading cause of death in the US and is a significant contributor to morbidity and mortality for people living with HIV (PLWH). This study examined the association between HIV infection, cocaine usage, and inflammatory markers, and their combined association with carotid atherosclerosis among young and middle-aged adults with HIV. Participants (N?=?494) were enrolled based on HIV status and cocaine use. Blood pressure, body mass index (BMI), and cocaine use were assessed. Cytokines and growth factors, IL-1a, IL-6, TNFα and VEGF, and immune activation markers, sCD14 and sCD163 were measured. Participant age was 36.2 years (SD?=?9.5); 50% were male, 49% female and 1% transgender; 39% were HIV-positive, 50% were current or past smokers, and 39% endorsed cocaine use. A path analysis showed an indirect effect of HIV serostatus on the presence of carotid atherosclerotic plaques (Indirect Effect?=?0.048, SE?=?0.024, p?=?.043), when controlling age, BMI, smoking, and cocaine use. This effect was mediated by inflammatory markers and changes in blood pressure. Findings point to putative underlying mechanisms leading to atherosclerosis among PLWH.     

Factors associated with anger and anger expression in caregivers of elderly relatives

Objectives: Anger is a common feeling among family caregivers of elderly dependents. However, this feeling has received less attention than other emotional effects of caring. This study measures anger in caregivers and analyzes its predictors.

Method: Trait anger and anger expression (expression-in, expression-out and expression index), caregiver and care recipient features, stressors (e.g. care demands and support), appraisal (e.g. burden) and resources (e.g. coping, self-efficacy) were assessed in 111 caregivers of elderly dependent relatives. Staged stepwise multiple linear regression analyses were carried out for each of the four anger scores.

Results: Caregivers presented mild anger levels and showed expression-in rather than expression-out of anger. Stepwise multiple linear regression analyses showed that a bad relationship between caregiver and care recipient, the presence of disruptive behaviors and caregivers’ low efficacy to handle them, and mostly the use of emotion-focused coping were the significant predictors of trait anger, anger expression index and anger expression-out. Explained variance for each of these regression models was 38%, 33% and 27%, respectively. Burden was the only significant predictor for internal anger expression (8% explained variance).

Conclusion: Results highlight that interventions aimed to improve caregivers’ strategies to address memory and behavior problems and to promote the use of effective coping strategies could be helpful to prevent anger and expression-out of anger. Reducing burden in caregivers might result in reductions of anger expression-in. Data underscore the need to consider anger feeling and both in-expression and out-expression of anger separately in order to understand anger experience in caregivers.     

Hierarchical tumor heterogeneity mediated by cell contact between distinct genetic subclones

Intratumor heterogeneity is an important mediator of poor outcomes in many cancers, including breast cancer. Genetic subclones frequently contribute to this heterogeneity; however, their growth dynamics and interactions remain poorly understood. PIK3CA and HER2 alterations are known to coexist in breast and other cancers. Herein, we present data that describe the ability of oncogenic PIK3CA mutant cells to induce the proliferation of quiescent HER2 mutant cells through a cell contact–mediated mechanism. Interestingly, the HER2 cells proliferated to become the major subclone over PIK3CA counterparts both in vitro and in vivo. Furthermore, this phenotype was observed in both hormone receptor–positive and –negative cell lines, and was dependent on the expression of fibronectin from mutant PIK3CA cells. Analysis of human tumors demonstrated similar HER2:PIK3CA clonal dynamics and fibronectin expression. Our study provides insight into nonrandom subclonal architecture of heterogenous tumors, which may aid the understanding of tumor evolution and inform future strategies for personalized medicine.     

Repeated cross-fostering affects maternal behavior and olfactory preferences in rat pups

Disturbances in early mother–infant relationships are strongly associated with changes in the development of a number of physiological and behavioral systems in the neonate that can create a complex change in patterns of vulnerability throughout life. Institutionalized children, despite receiving adequate care, display important behavioral changes in adult life, and such changes are strongly associated with a lack of selective and consistent attachment to the maternal figure in early life. It is not yet clear how human adoption processes alter the mother–infant relationship early in life. Here, to mimic the situation of human adoption and explore the impact on the formation of attachment between the infant and a caregiver, we use a repeated cross-fostering (RCF) model in rodents in two postnatal periods, postnatal days (PND) 1 to 3 (early RCF) and 9 to 11 (late RCF). Early exposure but not late exposure to RCF reduces the pups' preference for the odor of the mother figure. Moreover, early exposure and slightly later exposure to RCF reduce maternal care and motivation in collecting the pups and bringing them to the nest. The RCF protocol creates an unstable environment for mother–pup interaction, but it seems to affect learned attachment to the mother only when it occurs during the corresponding sensitive period of development.     

Factors influencing Hong Kong Chinese patients' decision-making in seeking early treatment for acute myocardial infarction

The purpose of this study was to identify, through in-depth interview, factors that influenced 27 Hong Kong Chinese patients' decision-making in seeking early treatment for acute myocardial infarction (AMI). The median delay time from the onset of symptoms to arrival at the hospital was 15.6 hours for men and 53.7 hours for women. Three major categories emerged from the data: (a) becoming aware of the threat, (b) maintaining a sense of normality, and (c) struggling to mobilize resources. A variety of decisions were made by patients from the onset of chest pain to seeking help. These decisions were heavily influenced by healthcare factors (access to emergency medical service (EMS) and treatment), personal factors (cognitive interpretations of symptoms), sociocultural factors (family situation, cultural beliefs, and practices), and coping strategies.     

Does severe acute pain provoke lasting changes in attentional and emotional mechanisms of pain-related processing? A longitudinal study

Pain experiences, learning, and genetic factors have been proposed to shape attentional and emotional processes related to pain. We aimed at investigating whether a singular major pain experience also changes cognitive-emotional processing. The influence of acute postoperative pain after cosmetic surgery of the thorax was tested in 80 preoperatively pain-free male individuals. Acute pain was measured as independent variable during the first week postsurgery by pain intensity ratings and the requested analgesic boluses (Patient-Controlled Epidural Analgesia (PCEA)). Pain catastrophizing (Pain Catastrophizing Scale (PCS)), pain anxiety (Pain Anxiety and Symptom Scale (PASS)), pain hypervigilance (Pain Vigilance and Awareness Questionnaire (PVAQ)), and attentional biases to emotionally loaded stimuli (including pain) in a dot-probe task were assessed 1 week, 3 months, and 6 months postsurgery as dependent variables. Hierarchical regression analyses were performed to test whether the 2 acute pain parameters can predict these cognitive-emotional variables. As a rigorous test, significant prediction was required in addition to the prediction of the dependent variables by themselves with lag-1. Acute pain (mainly the pain ratings) appeared to be a significant predictor for PCS, PASS, and PVAQ 1 week after surgery (deltaR² = [8.7% to 11.3%]). In contrast, the attentional biases in the dot-probe task could not be predicted by the pain ratings. The levels of pain catastrophizing and pain hypervigilance increased in the acute phase after surgery when influenced by acute pain and declined, along with pain anxiety, during the next 3 months. In conclusion, a one-time intense pain experience, such as acute postoperative pain, appeared to produce at least short-lived changes in the attentional and emotional processing of pain.     

Primary Graft Function, Metabolic Control, and Graft Survival After Islet Transplantation

OBJECTIVE

To investigate the influence of primary graft function (PGF) on graft survival and metabolic control after islet transplantation with the Edmonton protocol.

RESEARCH DESIGN AND METHODS

A total of 14 consecutive patients with brittle type 1 diabetes were enrolled in this phase 2 study and received median 12,479 islet equivalents per kilogram of body weight (interquartile range 11,072–15,755) in two or three sequential infusions within 67 days (44–95). PGF was estimated 1 month after the last infusion by the β-score, a previously validated index (range 0–8) based on insulin or oral treatment requirements, plasma C-peptide, blood glucose, and A1C. Primary outcome was graft survival, defined as insulin independence with A1C ≤6.5%.

RESULTS

All patients gained insulin independence within 12 days (6–23) after the last infusion. PGF was optimal (β-score ≥7) in nine patients and suboptimal (β-score ≤6) in five. At last follow-up, 3.3 years (2.8–4.0) after islet transplantation, eight patients (57%) remained insulin independent with A1C ≤6.5%, including seven patients with optimal PGF (78%) and one with suboptimal PGF (20%) (P = 0.01, log-rank test). Graft survival was not significantly influenced by HLA mismatches or by preexisting islet autoantibodies. A1C, mean glucose, glucose variability (assessed with continuous glucose monitoring system), and glucose tolerance (using an oral glucose tolerance test) were markedly improved when compared with baseline values and were significantly lower in patients with optimal PGF than in those with suboptimal PGF.

CONCLUSIONS

Optimal PGF was associated with prolonged graft survival and better metabolic control after islet transplantation. This early outcome may represent a valuable end point in future clinical trials.The short-term effectiveness of islet transplantation for alleviating hypoglycemia and controlling glucose homeostasis while limiting or even avoiding the need for exogenous insulin has been established (1). Despite protocol modifications in donor selection, islet preparation, or recipient treatment, insulin independence with adequate metabolic control was, however, rarely prolonged beyond 2 years (1–5). The most frequently proposed explanations include chronic allogenic rejection, recurrence of autoimmunity, and β-cell toxicity from administered immunosuppressive drugs (6). It is, however, unclear why similar drawbacks do not preclude the more durable results of pancreas transplantation (7). Alternatively, a slightly impaired glucose control associated with suboptimal graft function, even in patients with apparently successful islet transplantation, could contribute to progressive islet exhaustion and precipitate graft decline (6). In this prospective longitudinal study, we explored this hypothesis by analyzing the influence of primary graft function (PGF) on graft survival and metabolic control in a consecutive cohort of 14 patients followed up for 2 years and beyond after islet transplantation with the Edmonton protocol.