Nurses' perspectives on supporting children during needle-related medical procedures

Children state that among their worst fears during hospitalization are those related to various nursing procedures and to injections and needles. Nurses thus have a responsibility to help children cope with needle-related medical procedures (NRMP) and the potentially negative effects of these. The aim of the study is to describe the lived experience of supporting children during NRMP, from the perspective of nurses. Fourteen nurses took part in the study, six of whom participated on two occasions thus resulting in 20 interviews. A reflective lifeworld research approach was used, and phenomenological analysis was applied. The result shows that supporting children during NRMP is characterized by a desire to meet the child in his/her own world and by an effort to reach the child's horizon of understanding regarding these actions, based on the given conditions. The essential meaning of the phenomenon is founded on the following constituents: developing relationships through conversation, being sensitive to embodied responses, balancing between tact and use of restraint, being the child's advocate, adjusting time, and maintaining belief. The discussion focuses on how nurses can support children through various types of conversation and by receiving help from the parents' ability to be supportive, and on whether restraint can be supportive or not for children during NRMP. Our conclusion is that nurses have to see each individual child, meet him/her in their own world, and decide on supportive actions while at the same time balancing their responsibility for the completion of the NRMP. This work can be described as "balancing on a tightrope" in an unpredictable situation.

Mn-induced modifications of Ga 3d photoemission from (Ga, Mn)As: evidence for long range effects

Using synchrotron based photoemission, we have investigated the Mn-induced changes in Ga 3d core level spectra from as-grown Ga(1-x)Mn(x)As. Although Mn is located in Ga substitutional sites, and therefore does not have any Ga nearest neighbors, the impact of Mn on the Ga core level spectra is pronounced even at Mn concentrations in the region of 0.5%. The analysis shows that each Mn atom affects a volume corresponding to a sphere with around 1.4 nm diameter.

Thermal diffusion of Mn through GaAs overlayers on (Ga, Mn)As

Thermally stimulated diffusion of Mn through thin layers of GaAs has been studied by x-ray photoemission. (Ga, Mn)As samples with 5 at% Mn were capped with 4, 6 and 8 monolayer (ML) GaAs, and Mn diffusing through the GaAs was trapped on the surface by means of amorphous As. It was found that the out-diffusion is completely suppressed for an 8 ML thick GaAs film. The short diffusion length is attributed to an electrostatic barrier formed at the (Ga, Mn)As/GaAs interface.

Fluctuation-induced drift in a gravitationally tilted optical lattice

Experimental and theoretical studies are made of Brownian particles trapped in a periodic potential, which is very slightly tilted due to gravity. In the presence of fluctuations, these will trigger a measurable average drift along the direction of the tilt. The magnitude of the drift varies with the ratio between the bias force and the trapping potential. This can be closely compared to a theoretical model system, based on a Fokker-Planck-equation formalism. We show that the level of control and measurement precision we have in our system, which is based on cold atoms trapped in a three-dimensional dissipative optical lattice, makes the experimental setup suitable as a testbed for fundamental statistical physics. We simulate the system with a very simplified and general classical model, as well as with an elaborate semiclassical Monte Carlo simulation. In both cases, we achieve good qualitative agreement with experimental data.

Early insulin response in latent gestational diabetes

The intravenous glucose tolerance and glucose-stimulated early insulin response (EIR) were studied in late pregnancy and post partum in a reference (R) group of 9 women and in 18 women with latent gestational diabetes (LD), defined as a k-value of < 0.66/h and a normal fasting blood glucose concentration. During pregnancy, the LD group showed a lower EIR than the R group. However, the response ranged between normal and non-detectable. In the non-pregnant state, the EIR was the same in the two groups. The inability to increase the EIR during pregnancy wss most evident in women who even post partum had an abnormal glucose tolerance. In some women in the LD group, the EIR during pregnancy was even lower than in the non-pregnant state. The magnitude of the response in the non-pregnant state was not decisive of the capacity to increase the secretion during pregnancy. None of the women in the LD group developed manifest diabetes during pregnancy. They gave birth to children with normal birth weight, and no neonatal problems were registered except for one child with congenital heart malformation.

The BCL-2 promoter (-938C>A) polymorphism does not predict clinical outcome in chronic lymphocytic leukemia

The (-938C>A) polymorphism in the promoter region of the BCL-2 gene was recently associated with inferior time to treatment and overall survival in B-cell chronic lymphocytic leukemia (CLL) patients displaying the -938A/A genotype and may thus serve as an unfavorable genetic marker in CLL. Furthermore, the -938A/A genotype was associated with increased expression of Bcl-2. To investigate this further, we analyzed the -938 genotypes of the BCL-2 gene in 268 CLL patients and correlated data with treatment status, overall survival and known prognostic factors, for example, Binet stage, immunoglobulin heavy-chain variable (IGHV) mutational status and CD38 expression. In contrast to the recent report, the current cohort of CLL patients showed no differences either in time to treatment or overall survival in relation to usage of a particular genotype. In addition, no correlation was evident between the (-938C>A) genotypes and IGHV mutational status, Binet stage or CD38. Furthermore, the polymorphism did not appear to affect the Bcl-2 expression at the RNA level. Taken together, our data do not support the use of the (-938C>A) BCL-2 polymorphism as a prognostic marker in CLL and argue against its postulated role in modulating Bcl-2 levels.

The G(-248)A polymorphism in the promoter region of the Bax gene does not correlate with prognostic markers or overall survival in chronic lymphocytic leukemia

The G(-248)A polymorphism in the promoter region of the Bax gene was recently associated with low Bax expression, more advanced stage, treatment resistance and short overall survival in B-cell chronic lymphocytic leukemia (CLL), the latter particularly in treated patients. To investigate this further, we analyzed 463 CLL patients regarding the presence or absence of the G(-248)A polymorphism and correlated with overall survival, treatment status and known prognostic factors, for example, Binet stage, VH mutation status and genomic aberrations. In this material, similar allele and genotype frequencies of the Bax polymorphism were demonstrated in CLL patients and controls (n=207), where 19 and 21% carried this polymorphism, respectively, and no skewed distribution of the polymorphism was evident between different Binet stages and VH mutated and unmutated CLLs. Furthermore, no difference in overall survival was shown between patients displaying the G(-248)A polymorphism or not (median survival 85 and 102 months, respectively, P=0.21), and the polymorphism did not influence outcome specifically in treated CLL. Neither did the polymorphism affect outcome in prognostic subsets defined by VH mutation status or genomic aberrations. In conclusion, the pathogenic role and clinical impact of the Bax polymorphism is limited in CLL.

Attitude towards remission induction for elderly patients with acute myeloid leukemia influences survival

Combination chemotherapy may induce remission from acute myeloid leukemia (AML), but validated criteria for treatment of elderly are lacking. The remission intention (RI) rate for elderly patients, as reported to the Swedish Leukemia Registry, was known to be different when comparing the six health care regions, but the consequences of different management are unknown. The Leukemia Registry, containing 1672 AML patients diagnosed between 1997 and 2001, with 98% coverage and a median follow-up of 4 years, was completed with data from the compulsory cancer and population registries. Among 506 treated and untreated patients aged 70-79 years with AML (non-APL), there was a direct correlation between the RI rate in each health region (range 36-76%) and the two-year overall survival, with no censored observations (6-21%) (chi-squared for trend=11.3, P<0.001; r2=0.86, P<0.02, nonparametric). A 1-month landmark analysis showed significantly better survival in regions with higher RI rates (P=0.003). Differences could not be explained by demographics, and was found in both de novo and secondary leukemias. The 5-year survival of the overall population aged 70-79 years was similar between the regions. Survival of 70-79-year-old AML patients is better in regions where more elderly patients are judged eligible for remission induction.

Subcutaneous alemtuzumab vs ATG in adjusted conditioning for allogeneic transplantation: influence of Campath dose on lymphoid recovery, mixed chimerism and survival

Sixty-nine consecutive patients (median age 54 years) were prospectively enrolled in a single-institution protocol for allogeneic transplantation with adjusted non-myeloablative fludarabine-melfalan-based conditioning including cyclosporin A and MMF, and one of three modes of serotherapy. Thirty-one donors (45%) were unrelated. The first cohort of 29 had ATG (Thymoglobulin 2 mg/kg x 3 days), the subsequent 26 had Campath 30 mg x 3 days subcutaneously, and the final cohort of 14 had 30 mg Campath once. The groups were similar as regards age, diagnosis and risk factors. Campath-patients had no acute toxicity, fewer days with fever and antibiotics, and required fewer transfusions than ATG-treated patients. 3-d-Campath patients showed lower lymphocyte counts from day +4, and CD4+, CD8+, CD19+ and NK cells recovered slower than in ATG-treated patients. More Campath patients developed mixed chimerism that required DLI. 3-d-Campath induced more serious and opportunistic infections than ATG, which resulted in a greater non-relapse mortality and an impaired overall survival despite a low tumor-related mortality. The change of the Campath dosing schedule to one dose abrogated the deleterious effect of 3-d-Campath on immune recovery, severe infections and survival. Subcutaneous Campath is simple and provides strong immune suppression with no early toxicity, but dose limitation to 30 mg once is recommended.

Heterogeneity of nodularin bioaccumulation in northern Baltic Sea flounders in 2002

The cyanobacterial hepatotoxin nodularin is abundantly produced by the cyanobacterium Nodularia spumigena in the Baltic Sea during July-August. Nodularin is a potent hepatotoxin and a tumour promoter, distributed in various Baltic Sea environmental compartments, especially food webs involving mussels. Flounders receive nodularin through consumption of blue mussels. In this study nodularin concentrations in individual flounders (liver) were examined between July and September 2002 (six sample sets, four to 10 samples/set), providing information about contribution of sampling on estimates of bioaccumulation intensity. Toxin was determined using liquid chromatography/mass spectrometry (LC/MS) and enzyme-linked immunosorbent assay (ELISA). Additionally, liver histopathology was examined. Observed toxin concentrations were ND-390 microg kg(-1) dw (LC/MS) and 20-2230 microg kg(-1) dw (ELISA), with maximum concentrations in September (ELISA). The ELISA protocol generally resulted in higher, up to approximately 10-fold, toxin concentrations than LC/MS, with increasing difference toward September. This difference may have originated from different extraction solvents in LC/MS and ELISA, ion suppression in LC/MS, and temporal increase in nodularin metabolites detectable with ELISA. The differences in toxin concentrations between individual liver samples were considerable with relative standard deviation values of 20-154% (LC/MS) and 28-106% (ELISA). Since the precision of the ELISA method employed was <25% and that of LC/MS <10%, it can be concluded that the largest source of error in bioaccumulation estimates may be an inadequate number of samples. Although there were tissue lesions in several liver samples, occurrence of lesions was not related to toxin concentrations.

Autologous and allogeneic stem cell transplantation in adult ALL: the Swedish Adult ALL Group experience

Adult patients with acute lymphoblastic leukaemia (ALL) have been treated according to national protocols in Sweden since 1986. Stem cell transplantation (SCT) has been recommended in first remission for patients with risk factors for relapse, and for standard risk patients only after relapse. In this retrospective study, the results of autologous and allogeneic SCT in these populations were evaluated. In total, 187 patients with a median age of 34 years (17-66 years) underwent SCT. The 5-year disease-free survival (DFS), for all patients, was 26% (Confidence intervals (CI) 20-32%). The 5-year DFS was higher for patients transplanted in first remission 32% (CI 24-40%) compared to 14% (CI 5-23%; P<0.0001) in patients transplanted beyond first remission. No significant differences in DFS (P=0.06) were determined between autologous, related donor and unrelated donor SCT in the whole cohort. A lower relapse rate was counterbalanced by higher treatment-related mortality in patients undergoing allogeneic SCT. In Philadelphia-positive ALL, allogeneic SCT was superior to autologous SCT, with a 5-year DFS of 30% (CI 12-47%) vs 0% (P=0.04). Limited chronic graft-versus-host-disease (GVHD) was associated with an improved DFS of 53% (CI 38-69%) compared to no chronic GVHD of 22% (CI 10-36%; P=0.0008), indicating a clinically important graft-versus-leukaemia effect.

Mortality During the First 24 Months After Delivery in Relation to CD4 T-Lymphocyte Levels and Viral Load in a Cohort of Breast-Feeding HIV-1-Infected Women in Dar es Salaam, Tanzania

The objective of this study was to analyze the mortality during the first 24 months after delivery in relation to CD4 T-lymphocyte levels and viral load at enrollment (36 weeks of gestation) in a cohort of HIV-1-seropositive breast-feeding women at the Dar es Salaam site of the multicenter Petra trial (a mother-to-child HIV-1 transmission intervention trial using antiretroviral therapy). Antiretroviral treatment was not available in this setting apart from the short treatment given within the trial around delivery to prevent mother-to-child transmission of HIV. T-lymphocyte subsets were determined by flow cytometry. Plasma HIV-1 RNA was quantified by the Amplicor HIV-1 RNA Monitor v 1.5 assay. Mortality after delivery was analyzed using the life-table technique and Cox regression. The analysis included 266 mothers. The CD4 cell counts at enrollment were <200 cells/mm in 14.5% of the mothers. The viral load at enrollment was >100,000 RNA copies/mL in 33.6% of the mothers. The mortality 24 months after delivery was 6.7% (95% CI = 3.1-10.1%). The mortality 24 months after delivery was 29.9% (95% CI = 13.1-46.9%) for mothers with <200 CD4 cells/mm at enrollment, 3.3% (95% CI = 0-6.6%) for mothers with 200-499 CD4 cells/mm, 2.9% (95% CI = 0-7.1%) for mothers with >500 CD4 cells/mm (P = 0.0000), 15.0% (95% CI = 6.6-23.4%) for mothers with viral load >100,000 copies/mL at enrollment, and 2.8% (95% CI = 0-5.6%) for mothers with viral load <100,000 copies/mL (P = 0.0000). In the multivariate analysis CD4 cell counts and viral load were both independent risk factors for mortality (P < 0.001 and P = 0.004, respectively). In conclusion, the mortality was high among women with severe immunosuppression or high viral load at enrollment, but not in the rest of the women. CD4 lymphocyte count in late pregnancy was a better predictor of death within 2 years than was viral load. The results support the World Health Organization recommendation to initiate antiretroviral treatment in resource-limited settings in HIV-1-infected adults with CD4 cell counts <200/mm and show that this is appropriate also among perinatal women.

Early diagnosis of HIV-1 infection in infants in Dar es Salaam, Tanzania

OBJECTIVES

To evaluate two simple methods, an immune complex dissociation (ICD) p24 antigen assay and an HIV-1-specific IgA antibody assay, for the early demonstration of HIV-1 infection in infants, using the polymerase chain reaction (PCR) as the reference method.

DESIGN AND SETTING

Group A: 143 HIV-1-seropositive and 134 -seronegative mothers and their infants were recruited at delivery at the main hospital in Dar es Salaam, Tanzania. Group B: 26 HIV-PCR-positive hospitalized children in Dar es Salaam, 3-15 months old and suspected of having an HIV-related illness.

METHODS

Blood samples were taken from mothers and infants in group A at intervals during the children's first 24 months and once from each of the children in group B. Peripheral blood mononuclear cells were tested by nested PCR for viral DNA. Plasma samples were tested by the Coulter p24 antigen (ag) enzyme-linked immunosorbent assay (ELISA) after acid dissociation of p24 antigen-antibody complexes. All p24-ag-positive reactions were confirmed by neutralization. Viral specific IgA antibodies were demonstrated in plasma by a modified ELISA.

RESULTS

One hundred and sixty-three of 174 samples from seropositive mothers were PCR-positive (sensitivity 93.7%) and 612 of 614 samples from seronegative mothers and children of seronegative mothers were PCR-negative (specificity 99.7%). Twenty-nine of 145 (20.0%) children born to seropositive mothers were positive by PCR when tested during the first year of life. By use of both the p24 ag ELISA and the IgA antibody ELISA in combination, HIV-1 infection was detected in 9 of 17 (53%) PCR-positive children 1-8 weeks old, in 15 of 18 (83%) PCR-positive children 9-26 weeks old and in 23 of 24 (96%) PCR-positive children 27-52 weeks old. The specificities of the p24 ag ELISA and the IgA ELISA were 100%.

CONCLUSIONS

The p24 ag assay and the IgA antibody ELISA, when used in combination, had a high sensitivity and specificity for detection of HIV-1 infection in infants, especially in those above the age of 6 months.