Stories seldom told: paediatric nurses' experiences of caring for hospitalized children with special needs and their families

AIMS OF THE STUDY

This study explored paediatric nurses' experiences of caring for children with special needs and their families in an acute care setting. The aim of the study was to increase understanding of nurses' experiences of caring for these children and their families. The study was designed to reveal the caring practices embedded within these relationships through exploring nurses' stories.

STUDY DESIGN/METHODS

Gadamerian hermeneutic phenomenology and feminist research principles were the approaches used to guide the study. Interviews were held with experienced paediatric nurses and interpretation of interview transcripts using a Gadamerian hermeneutic phenomenological approach resulted in the identification of four themes.

FINDINGS

The four themes revealed were: Special Relationships; Multiple Dimensions of Who is Expert; Development of Trust Between Nurses and Families; and Feelings of Frustration and Guilt.

CONCLUSIONS

The study emphasized the context-specific nature of relationships between nurses and children and their families. The nurses spoke about the difficulties they encountered in their practice and some of the ways that they dealt with these problems. They discussed the things that they valued and those that made them feel guilty and frustrated. In doing so, they revealed their warmth, strength, humanity and caring.

A visuomotor reaction time task increases the irregularity and complexity of inspiratory airflow pattern in man

Previous studies have suggested that motor cortex may be involved in complex control of respiration in man. In this study, we estimated the influence of a simple visuomotor reaction time task (VMT) on the inspiratory airflow curve (IFC) by comparing measurements of standard deviation (SD), C(0) complexity and approximate entropy (ApEn) of the IFC at rest and during VMT conditions. It was found that both C(0) complexity and ApEn, but not SD of the IFC were significantly increased during the VMT challenge. The results suggest that visuomotor pathways may modulate respiratory motor pathways, because an increase in ApEn is suggestive of increased coupling or communication between (motor) systems.

Interaction of the E. coli DNA G:T-mismatch endonuclease (vsr protein) with oligonucleotides containing its target sequence

The Escherichia coli vsr endonuclease recognises G:T base-pair mismatches in double-stranded DNA and initiates a repair pathway by hydrolysing the phosphate group 5' to the incorrectly paired T. The enzyme shows a preference for G:T mismatches within a particular sequence context, derived from the recognition site of the E. coli dcm DNA-methyltransferase (CC[A/T]GG). Thus, the preferred substrate for the vsr protein is (CT[A/T]GG), where the underlined T is opposed by a dG base. This paper provides quantitative data for the interaction of the vsr protein with a number of oligonucleotides containing G:T mismatches. Evaluation of specificity constant (k(st)/K(D); k(st)=rate constant for single turnover, K(D)=equilibrium dissociation constant) confirms vsr's preference for a G:T mismatch within a hemi-methylated dcm sequence, i.e. the best substrate is a duplex (both strands written in the 5'-3' orientation) composed of CT[A/T]GG and C(5Me)C[T/A]GG. Conversion of the mispaired T (underlined) to dU or the d(5Me)C to dC gave poorer substrates. No interaction was observed with oligonucleotides that lacked a G:T mismatch or did not possess a dcm sequence. An analysis of the fraction of active protein, by "reverse-titration" (i.e. adding increasing amounts of DNA to a fixed amount of protein followed by gel-mobility shift analysis) showed that less than 1% of the vsr endonuclease was able to bind to the substrate. This was confirmed using "competitive titrations" (where competitor oligonucleotides are used to displace a (32)P-labelled nucleic acid from the vsr protein) and burst kinetic analysis. This result is discussed in the light of previous in vitro and in vivo data which indicate that the MutL protein may be needed for full vsr activity.

Changes in electromyogram during upper limb muscle contraction induced by resistive loaded breathing in humans

Expiratory only resistive loaded breathing (RL) reduces high energy electromyogram (EMG) power (EH) during an isometric contraction of a leg extensor muscle, but not an arm flexor. An interaction between afferent activity during expiratory RL and inspiratory non-loaded phases of breathing, which the contraction spanned, could have accounted for the reduced EH in these long contractions. Therefore this study tested the hypothesis that brief arm extensor muscle contractions (70% of maximal force), performed during a single phase of expiratory RL, would also exhibit reduced EH. Surprisingly, EH in triceps, but not biceps brachii was reduced significantly when the contraction was performed during inspiratory RL rather than expiratory RL. The results suggest that either (a) short and prolonged contractions or (b) motor drive to arm and leg extensors are affected differently by RL.

Methodological issues in the development of the Canadian Cancer Incidence Atlas

The Canadian Cancer Incidence Atlas is among recent national atlases using incidence rather than mortality data. Methods used to assess the significance and spatial correlation of the age-standardized rates (ASIRs) for the 290 census divisions are described. The expected number of cases by area was used to determine cancer sites with sufficient cases to be mapped. ASIR significance was assessed using a simulation based on a Poisson distribution. The consistency of the observed case distributions with the Poisson distribution was examined. The bootstrap confidence interval (CI) for the ASIR developed by Swift was used in the atlas. Spatial correlation was assessed with Moran's I/I(max) and the significance determined by a simulation in order to allow for area population variation. Data quality indicators typically used for cancer registries were presented, supplemented by a registry questionnaire.

Auto-transporter A protein of Neisseria meningitidis: a potent CD4+ T-cell and B-cell stimulating antigen detected by expression cloning

A meningococcal genomic expression library was screened for potent CD4+ T-cell antigens, using patients' peripheral blood lymphocytes (PBLs). One of the most promising positive clones was fully characterized. The recombinant meningococcal DNA contained a single, incomplete, open reading frame (ORF), which was fully reconstructed with reference to available genomic sequence data. The gene was designated autA (auto-transporter A) as its peptide sequence shares molecular characteristics of the auto-transporter family of proteins. Only a single copy of this gene was detected in the meningococcal, and none in the gonococcal, genomic sequence databases. The complete autA gene, when cloned into an expression vector, expressed a protein of approximately 68 kDa. Purified rAutA recalled strong secondary T-cell responses in PBLs of patients and some healthy donors, and induced strong primary T-cell responses in healthy donors. The human B-cell immunogenicity and cross-reactivity of AutA, purified under native conditions, was confirmed in dot immunoblot experiments. Immunoblots with rabbit polyclonal antibodies to rAutA demonstrated the conserved nature, antigenicity and cross-reactivity of AutA amongst meningococci of different serogroups and strains representing different hypervirulent lineages. AutA showed homology with another meningococcal and gonococcal ORF (designated AutB). AutB was cloned and expressed and used to raise an autB-specific antiserum. Immunoblot experiments indicated that AutB is not expressed in meningococci and does not cross-react with AutA. Thus, AutA, being a potent CD4+ T-cell and B-cell-stimulating antigen, which is highly conserved, deserves further investigation as a potential vaccine candidate.

Allele frequencies of polymorphisms of the tumour necrosis factor-alpha, interleukin-10, interferon-gamma and interleukin-2 genes in a North European Caucasoid group from the UK

Cytokine gene polymorphisms affecting cytokine production may influence rejection and graft-versus-host disease following solid organ and haemopoietic stem cell (HSC) transplantation, respectively. Polymorphisms in the regulatory regions of several cytokine genes have been described; for example, tumour necrosis factor-alpha (TNF-alpha) has a G/A substitution at position -308, interleukin-2 (IL-2) has a T/G substitution at position -330 and interleukin-10 (IL-10) has substitutions at positions -1082(G/A), -819(C/T) and -592(C/A). Microsatellites associated with cytokine production have been detected in the first intron of the IFN-gamma gene and flanking the TNF-alpha gene. In this study, we have genotyped a single panel of healthy Northern European Caucasoids living in the south-east of England for the above-mentioned polymorphisms and compared the results to those published for other populations. A PCR method using sequence-specific primers (SSP) was developed for genotyping the IL-2 polymorphism, and the ABI PRISMtrade mark 310 genetic analyser was used to detect the TNF-alpha and IFN-gamma microsatellites. The allele frequencies of all the studied polymorphisms were consistent with those reported for other UK Caucasoid populations, but differences were observed when compared to other Oriental, African and Caucasoid groups. If these cytokine polymorphisms prove to have functional consequences, then any differences across population groups may have significant clinical relevance in disease and in the outcome of solid organ and HSC transplantation.

Effect of pulmonary rehabilitation on quality of life in patients with COPD: the use of SF-36 summary scores as outcomes measures

PURPOSE

Pulmonary rehabilitation (PR) is an accepted therapy for patients with chronic obstructive pulmonary disease (COPD), improving both exercise capacity and quality of life (QOL). Generic measures of QOL have been criticized as being insensitive to detecting the improvement in QOL after PR in contrast to disease-specific instruments. The authors looked at the Medical Outcomes Survey Short Form 36-item questionnaire (SF-36), a generic QOL measure, to detect changes in QOL in COPD patients after completion of PR.

METHODS

Patients with COPD who participated in a PR program completed the QOL questionnaire before and after completion of PR. Exercise tolerance was assessed by the 6-minute walking test. Quality of life was assessed by the SF-36; the authors calculated its eight dimensions as well as mental (MCS) and physical (PCS) component summary scores.

RESULTS

The patients realized a significant improvement in exercise tolerance; 6-minute walking test distance increased from 470 +/- 104 m (mean +/- standard deviation) to 536 +/- 133 m (P = 0.0006) after PR. Quality of life also improved in nearly all dimensions and in both summary scores; PCS improved from 26.1 +/- 8.0 before PR to 30.5 +/- 9.0 after PR (P = 0.008) and MCS improved from 27.9 +/- 7.0 before PR to 34.1 +/- 5.0 after PR (P = 0.0002).

CONCLUSION

The SF-36 and its summary scores are sensitive instruments to detect improvement in QOL in COPD patients after PR.

Structure and coding content of CST (BART) family RNAs of Epstein-Barr virus

CST (BART BARF0) family viral RNAs are expressed in several types of Epstein-Barr virus (EBV) infection, including EBV-associated cancers. Many different spliced forms of these RNAs have been described; here we have clarified the structures of some of the more abundant splicing patterns. We report the first cDNAs representing a full-length CST mRNA from a clone library and further characterize the transcription start. The relative abundance of splicing patterns and genomic analysis of the open reading frames (ORFs) suggest that, in addition to the much studied BARF0 ORF, there may be important products made from some of the upstream ORFs in the CST RNAs. Potential biological functions are identified for two of these. The product of the RPMS1 ORF is shown to be a nuclear protein that can bind to the CBF1 component of Notch signal transduction. RPMS1 can inhibit the transcription activation induced through CBF1 by NotchIC or EBNA-2. The protein product of another CST ORF, A73, is shown to be a cytoplasmic protein which can interact with the cell RACK1 protein. Since RACK1 modulates signaling from protein kinase C and Src tyrosine kinases, the results suggest a possible role for CST products in growth control, perhaps consistent with the abundant transcription of CST RNAs in cancers such as nasopharyngeal carcinoma.

Early intervention to remove mesiodens and avoid orthodontic therapy

Recognition of dental anomalies is essential in determining appropriate treatment for each patient. Diagnosis and assessment of mesiodens are critical in avoiding complications such as blocking the eruption of the maxillary central incisors, cyst formation, and dilaceration of the permanent incisors. Collecting data for diagnostic criteria, utilizing diagnostic radiographs, and determining when to refer to a specialist are important steps in the treatment of mesiodens. Early diagnosis and timely intervention could reduce or eliminate the need for orthodontic treatment and prevent serious complications.

Microcomputer education for nursing: an approach to microcomputer education in a large tertiary care center

Communication skills needed for the healthcare environment are changing. In the past, poor reading and writing skills made it difficult to use a paper chart. Current computer technology provides many new opportunities for communicating in the clinical setting. Computer literacy has become a necessary skill for efficient use of clinical computer systems. At this large tertiary care setting, a survey was developed and distributed to staff to assess learner needs. Nursing staff identified educational needs for basic computer knowledge, the ability to move between computer functions, and the skills to navigate through specific applications. Based on survey analysis, three educational classes were constructed that addressed the department's specific needs.

Mycobacterium marinum hand infection: case reports and review of literature

Three patients with Mycobacterium marinum infection are described. Key elements in the diagnosis of this infection are a high index of suspicion, taking a history with an emphasis on exposure to tropical fish or other potential sources of M. marinum infection, and tissue biopsy for culture and histology. The microbiologist should be informed about the suspicion of M. marinum infection so that appropriate cultures can be performed. As M. marinum does not grow under routine culture conditions, the diagnosis is easily missed resulting in delayed treatment. The treatment is essentially antimicrobial therapy for the superficial lesions supplemented by an appropriate surgical debridement especially when deep structures are involved.

Surgical correction of lumbar kyphotic deformity: posterior reduction "eggshell" osteotomy

OBJECT

Progressive kyphotic deformity of the lumbar or thoracolumbar spine may lead to back pain, cosmetic deformity, and risk of neurological compromise. The authors describe a series of patients in whom they performed a single-stage, posterior reduction ("eggshell") osteotomy procedure to improve sagittal contour by creating lordosis within a single vertebral body.

METHODS

From 1995 to 1997 the authors performed 12 osteotomy procedures in 11 patients with thoracolumbar or lumbar kyphosis. Seven patients presented with iatrogenic deformity, three with deformity secondary to traumatic injury, and one patient with ankylosing spondylitis. Their mean age at time of surgery was 46.6 years (range 23-78 years). All patients suffered from back pain and were unable to stand upright, but in only one patient were neurological findings demonstrated. The mean preoperative deformity was -26 degrees (range -90 to 0 degrees). At 6-month follow-up examination the mean sagittal contour measured 17.5 degrees (range - 17 to 44 degrees), indicating that the mean surgical correction was 40.1 degrees (range 25 to 58 degrees). All patients reported decreased back pain at follow up, and none required narcotic analgesic medication. Complications included a dense paresis that developed immediately postoperatively in a patient who was found to have residual dural compression, which was corrected by emergency decompressive surgery. One elderly patient suffered a perioperative cerebrovascular accident, and three patients suffered neurapraxia with transient muscle weakness of the quadriceps. There was one case of a dural tear. There were no deaths, and prolonged intensive care stays were not required.

CONCLUSIONS

Single-level posterior reduction osteotomy provides excellent sagittal correction of kyphotic deformity in the lumbar region, with a risk of cauda equina and root and plexus compromise due to the extensive neural exposure.

Pneumococcal vaccine uptake in medical patients discharged from a district hospital

A survey of 400 patients discharged from medical wards found that 161 (40%) had risk factors for severe pneumococcal infection, but that only half of these had received pneumococcal vaccine. Improved vaccine uptake in high risk patients could be achieved by universal vaccination of people aged over 65 years.

Septic arthritis due to Streptococcus pneumoniae in Nottingham, United Kingdom, 1985-1998

Pneumonia and meningitis are the 2 most frequent manifestations of Streptococcus neumoniae infection. Pneumococcal septic arthritis is considered to be relatively uncommon. Between 1985 and 1998, 32 (8. 2%) of 389 cases of septic arthritis seen in the 2 hospitals in Nottingham, United Kingdom, were due to S. pneumoniae. Six of 7 children with pneumococcal septic arthritis were aged <2 years. Of the 25 adults, 20 (80%) were aged >60 years, 11 (44%) had concomitant pneumococcal infection elsewhere, and 23 (92%) had articular or nonarticular diseases and/or other risk factors. In the elderly, a lack of febrile response was striking. S. pneumoniae was isolated from blood and joint cultures in >70% of cases, and gram-positive diplococci were seen in the joint fluids of 90% of patients. The mean duration of antimicrobial therapy for adults was twice as long as that for children. Eight (32%) of the adults died.

Pulmonary adiaspiromycosis in a patient with acquired immunodeficiency syndrome

Adiaspiromycosis is a noninfectious, nonarthropod-transmitted fungal infection that occurs worldwide in lower vertebrates, especially rodents. However, humans may become accidental hosts. Reported here is a case of adiaspiromycosis of the lung in an HIV-positive, 40-year-old, bisexual man who first presented with cough and dyspnea. Cultures of a bronchoalveolar lavage and protected brush specimen revealed the presence of fungal elements that were identified as Emmonsia parva var. parva. The patient was successfully treated with amphotericin B and thereafter with fluconazole. This organism should be added to the list of pathogens that cause pulmonary infection in AIDS patients.

Interindividual variation in mitotic recombination

Mitotic recombination (MR) between homologous chromosomes is a mutational event that results in loss of heterozygosity in half of the segregants at mitosis. Loss of heterozygosity may have important biological consequences. The purpose of this study was to describe human variation in the spontaneous frequency of MR. Using an immunoselection technique for isolating the somatic mutations that result in loss of expression of one of the codominant alleles at the HLA-A locus, we have measured the frequency and molecular basis of somatic mutations in lymphocytes from a population of young adults. Mutations were classified as being the result of intragenic changes, major deletions, or MR. Here we show that the MR mutation frequency in females was significantly greater than that in males but that intragenic mutation frequency showed no association with sex. Individual variation in MR frequency ranged over more than two orders of magnitude and was not normally distributed. Furthermore, the observed number of individuals from whom no mutants resulting from MR were obtained was significantly greater than was expected. The endogenous level of MR may be under genetic control. Given the association of loss of heterozygosity with cancer initiation and progression, low endogenous MR may confer a reduced lifetime risk of cancer, and the converse may apply.

Delivering prevention: the role of public programs in delivering care to high-risk populations

A successful program of prevention or early detection should have a high level of population coverage and should ensure that high-risk populations are targeted. In practice, relatively little attention has been paid to the tendency toward greater use of preventive care by populations at lower risk, in other words, for higher use by the wealthy than by the poor. Current delivery patterns of preventive care raise questions as to how to organize these services more effectively. Physician-based delivery of preventive care in a fee-for-service system seems to result in Canadian patterns of use that are fairly similar to those found in the United States. Universal free insurance alone does not appear to be enough to counteract the failure to target preventive care toward the least-healthy groups. Appropriately-run Canadian provincial programs may be able both to expand coverage and to target high-risk populations. The population coverage for three measures directed toward prevention or early detection--childhood immunization (which in Manitoba has been offered through a long-standing provincial program), screening mammography (a new provincial program), and cervical cancer screening (no provincial program)-are compared using longitudinal administrative data from Manitoba. The discussion emphasizes the role of provincial programs and the possibilities for using population-based data to help provide cost-effective care to high-risk populations.