Transgender and nonbinary young adults' depression and suicidality is associated with sibling and parental acceptance-rejection

INTRODUCTION

Transgender and nonbinary young adults (TNB YA) report high rates of depression and more suicidality than their cisgender counterparts. Parental rejection is a known predictor of worse mental health among TNB YA; however, less is known about TNB YA experiences of sibling acceptance-rejection. The purpose of this study was to determine how TNB YA perception of sibling and parental acceptance-rejection are related to TNB YA depression and suicidality.

DESIGN

Cross-sectional.

METHODS

TNB YA (ages 18-25) who had disclosed their gender identity to an adult sibling were recruited to take part in an online study and completed measures of sibling and parent acceptance-rejection, depression, as well as lifetime and past year suicidality. Stepwise regressions were conducted to evaluate associations between acceptance-rejection and TNB YA depression and suicidality.

RESULTS

The sample consisted of 286 TNB YA (Mage  = 21.5, SD = 2.2) who were predominantly White (80.6%) and assigned female sex at birth (92.7%). Each family member's acceptance-rejection was associated with increased TNB YA depression scores when considered independently and combined. Independently, high rejection from each family member was associated with greater odds of reporting most suicidality outcomes. When all family members were considered together, only high rejection from a male parent was associated with four times greater odds of reporting lifetime suicidality. High rejection from both parents was associated with greater odds of reporting past year suicide attempt (OR: 3.26 female parent; 2.75 male parent).

CONCLUSION

Rejection from family members is associated with worse depression and suicidality, and rejection from male parents may be particularly damaging. Sibling acceptance uniquely contributes to TNB YA's depression symptoms alone and in the context of parental support.

Intersectionality in nursing research: A scoping review

Background

An intersectional approach to health research provides an analytical foundation to explain the multidimensionality of health status, resource accessibility, privilege, oppression, and current and historical context. The use of intersectionality in health research has known limitations. Its use in health-related fields too often focuses on outcomes, such as health disparities, rather than processes, such as power structures and social determinants.

Objective

This scoping review serves to examine how intersectionality has been implemented by nurses in the peer-reviewed literature. We offer insight into how it may be incorporated to inform future nursing research and healthcare provision.

Design & Methods

Systematic searches of PubMed (n = 257), SCOPUS (n = 807), EMBASE (n = 396), CINAHL (n = 224), and Health Source: Nursing and Academics (n = 491), published since the seminal publication on intersectionality (1989 - 2023), identified 131 research articles that met inclusion and exclusion criteria. Data extraction and synthesis were used to describe the breadth and depth of the literature specific to the application of intersectionality in nursing research.

Results

The included studies used intersectionality to examine the intersections of numerous identities, such as race, gender, and immigration status. However, most studies were descriptive/observational in nature, underreported their methods, and conducted deficit-based research instead of strength-based inquiries. Of note, the vast majority of included articles were published within the last five years.

Conclusions

Future researchers using intersectionality as a framework can improve their approach by reporting clear definitions and operationalization of intersectionality. Observational science dominated the included studies; future research should focus on intervention development and evaluation using an intersectional lens. Lastly, caution should be placed on research that focuses solely on deficits among marginalized communities, which places scientists at risk of perpetuating stereotypes or enhancing already-existing stigmas.

Societal stigma and mistreatment in healthcare among gender minority people: a cross-sectional study

BACKGROUND

Gender minority (GM; individuals whose gender is not aligned with that traditionally associated with the sex that was assigned to them at birth) people have widely reported mistreatment in healthcare settings. Mistreatment is enacted by individuals within society who hold stigmatizing beliefs. However, the relationship between healthcare mistreatment and societal stigma (i.e., the degree to which society disapproves of GM people) is unclear and not measured consistently.

METHODS

We analyzed data from 2,031 GM participants in The Population Research in Identity and Disparities for Equality (PRIDE) Study's 2019 Annual Questionnaire to determine whether societal stigma was associated with participants' past-year reports of mistreatment (defined as denial of healthcare services and/or lower quality care) in medical or mental healthcare settings. We created a proxy measure of societal stigma by incorporating variables validated in existing literature. Participants reported whether they had experienced mistreatment in medical and mental health settings independently.

RESULTS

Healthcare denial and/or lower quality care during the past year was reported by 18.8% of our sample for medical settings and 12.5% for mental health settings. We found no associations between the societal stigma variables and past-year reports of healthcare denial and/or lower quality care in medical or mental healthcare settings.

CONCLUSIONS

Although a high proportion of GM people reported past-year healthcare mistreatment in both medical and mental health settings, mistreatment had no relationship with societal stigma. Factors other than societal stigma may be more important predictors of healthcare mistreatment, such as healthcare workers' knowledge of and attitudes toward GM people. However, other measures of societal stigma, or different types of mistreatment, may show stronger associations. Identifying key factors that contribute to mistreatment can serve as targets for intervention in communities and healthcare settings.

Seeking safety intervention for comorbid post-traumatic stress and substance use disorder: A meta-analysis

PROBLEM STATEMENT

Seeking Safety (SS) is a widely implemented cognitive-behavioral therapy for comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD). It is a present-focused coping skills model that is highly flexible, with varied methods of delivery, to maximize acceptability and client access. The purpose of this meta-analysis is to examine the effect of SS on comorbid PTSD and SUD across randomized control trials (RCTs). In addition, ours is the first meta-analysis to examine the dose-response of SS by comparing delivery of all 25 SS topics versus fewer.

METHODS AND DESIGN

Articles published before January 2, 2023 (CINAHL n = 16, PsycINFO n = 31, MEDLINE n = 27, Cochrane n = 38, and Scopus n = 618) were searched. Seven studies were included for meta-analysis and dose-response analysis.

RESULTS

Based on effect sizes (ES), meta-analysis revealed that SS has a medium group, time (p = .04), and time by group effect on substance use per the Addiction Severity Index at 3 months and a small effect on Clinician-Administered PTSD Scale scores by group, a large effect by time, and a medium time by group (p = .002) effect at 6 months. Based on the pooled ES examining various measures across multiple timepoints, SS had small to medium effects on substance use by time, group, or time by group and medium to large effects on PTSD symptoms by time, group, or time by group (except for the group effect at 3-month follow-up). Significant effects were found for substance use by time at 3 and 6 months and for PTSD postintervention, at 6 months and 9 months by group, time, and time by group while only by time at 3 months. Meta-regression revealed that partial dose versions of SS generally function as well as the full dose version of SS when observing long-term effects (greater than 3 months).

DISCUSSION

Findings suggest SS has merit in treating PTSD symptoms and SUD. Based on the summarized effect sizes, SS appears more effective in reducing PTSD than substance use, which converges with the larger treatment outcome literature that consistently finds this. We explore reasons that treatment of SUD is more challenging than treating PTSD and offer suggestions for practitioners. We emphasize the need for future studies to utilize common measures and provide full details of treatment delivery for optimal comparison across studies.

Stressors in health care and their association to symptoms experienced by gender diverse people

OBJECTIVES

Many individuals whose gender does not align with the sex they were assigned at birth (gender diverse [GD] people) report stressful health care encounters. We examined the relationship of these stressors to symptoms of emotional distress and impaired physical functioning among GD people.

STUDY DESIGN

This study was conducted using a cross-sectional design with data from the 2015 United States Transgender Survey.

METHODS

Composite metrics of health care stressors and physical impairments were developed, and the Kessler Psychological Distress Scale (K-6) provided a measure of emotional distress. Linear and logistic regression were used to analyze the aims.

RESULTS

A total of 22,705 participants from diverse gender identity subgroups were included. Participants who experienced at least one stressor in health care during the past 12 months had more symptoms of emotional distress (β = 0.14, P < .001) and 85% greater odds of having a physical impairment (odds ratio = 1.85, P < .001). Transgender men exposed to stressors were more likely than transgender women to experience emotional distress and have a physical impairment, with other gender identity subgroups reporting less distress. Black participants exposed to stressful encounters reported more symptoms of emotional distress than White participants.

CONCLUSIONS

The results suggest that stressful encounters in health care are associated with symptoms of emotional distress and greater odds of physical impairment for GD people, with transgender men and Black individuals being at greatest risk of emotional distress. The findings indicate the need for assessment of factors that contribute to discriminatory or biased health care for GD people, education of health care workers, and support for GD people to reduce their risk of stressor-related symptoms.

Potential paths to suicidal ideation and suicide attempts among high-risk women

Although men are more likely to die by suicide, women experience a greater and more rapidly increasing rate of suicidal ideation (SI) and are 3 times more likely to attempt suicide than men. Despite this increased risk, little is known about factors that contribute to SI or suicide attempts (SA) among women. We examined factors associated with SI and SA among women and identified mood-related symptoms that differentiate women who reported attempting suicide from those who did not. Women at elevated risk for depression from across the U.S. (N = 3372; age 18 to 90) completed a survey regarding depression, anxiety, sociodemographic and reproductive status, behavioral/mental health history, and exposure to adversity. Structural equation modeling and logistic regression were used to analyze the data. Variables with the most significant relationships to SI were severity of depression (OR = 5.2, p = 0.000) and perceived stress (OR = 1.18, p = 0.000) while frequency of suicidal thoughts (OR = 3.3, p = 0.000), family history of a depression diagnosis (OR = 1.6, p = 0.000) and exposure to violence (OR = 1.9, p = 0.000) had the strongest association with SA. Childhood abuse/trauma was associated with SA (OR = 1.13, p = 0.000) but not SI. 'Feeling bad about themselves, a failure, or having let themselves or their family down' was the symptom that most clearly differentiated women who attempted suicide from women who reported suicidal ideation but no SA. The salience of childhood abuse and domestic/community violence to women's risk for a suicide attempt reinforces previous findings that these adversities may differentiate suicide risk for women versus men. Continued research is essential to understand varied paths that may lead to suicidal behavior among women, some which appear unrelated to the frequency or intensity of their suicidal thoughts.

State-Level Policy Environments, Discrimination, and Victimization among Sexual and Gender Minority People

Legislation has been passed in some states to reduce discrimination and victimization toward sexual and gender minority people (SGM; people who are not solely heterosexual and/or whose gender identity is not equal to what is socially associated with sex assigned at birth). The purpose of these analyses is to test whether state-level policy environments are associated with past-year discrimination and victimization among SGM people. Cross-sectional data from The Population Research in Identity and Disparities for Equality (PRIDE) Study annual questionnaire (collected 2018−2019), a national study of the health of SGM adults in the USA, were used for these analyses. Measures included related to discrimination, victimization, and demographic characteristics. State-level policy environments were measured using data from the Movement Advancement Project. Logistic regression analyses evaluated state-level policy environment scores and past-year discrimination and victimization among gender identity categories. In this sample, 7044 people (gender minority n = 2530) were included. Cisgender sexual minority (odds ratio [OR] = 1.007, p = 0.041) and the gender expansive subgroup of gender minority people (OR = 1.010, p = 0.047) in states with more protective policy environments had greater odds of discrimination. The gender expansive subgroup was found to have greater odds of victimization in states with more protective policy environments (OR = 1.003, p < 0.05). There was no relationship between state-level policy environments and victimization among any other study groups. SGM people may experience increased risk for discrimination and victimization despite legislative protections, posing continued risks for poor health outcomes and marginalization. Evaluation of factors (e.g., implementation strategies, systems of accountability) that influence the effectiveness of state-level polices on the reported experiences of discrimination and victimization among SGM people is needed.

Health Insurance Prevalence Among Gender Minority People: A Systematic Review and Meta-Analysis

Purpose

Gender minority (GM) (people whose gender does not align with the sex assigned at birth) people have historically been insured at lower rates than the general population. The purpose of this review is to (1) assess the prevalence of health insurance among GM adults in the United States, (2) examine prevalence by gender, and (3) examine trends in prevalence before and after implementation of the Affordable Care Act.

Methods

Published articles from PubMed, EMBASE, and Web of Science databases before April 26th, 2019, were included. This review is registered on PROSPERO (CRD42019133627). Analysis was guided by a random-effects model to obtain a meta-prevalence estimate for all GM people and stratified by gender subgroup. Heterogeneity was assessed using a Q-test and I ² measure.

Results

Of 55 included articles, a random pooled estimate showed that 75% GM people were insured (95% confidence interval [CI]: 0.71-0.79; p<0.001). Subgroup analysis by gender determined 70% of transgender women (95% CI: 0.64-0.76; p<0.001; I ²=97.16%) and 80% of transgender men (95% CI: 0.77-0.83; p=0.01; I ²=54.51%) were insured. Too few studies provided health insurance prevalence data for gender-expansive participants (GM people who do not identify as solely man or woman) to conduct analysis.

Conclusion

The pooled prevalence of health insurance among GM people found in this review is considerably lower than the general population. Standardized collection of gender across research and health care will improve identification of vulnerable individuals who experience this barrier to preventative and acute care services.

Barriers to accessing and engaging in healthcare as potential modifiers in the association between polyvictimization and mental health among Black transgender women

BACKGROUND

Black transgender women endure pervasive polyvictimization (experiencing multiple forms of violence throughout the lifespan). Polyvictimization is associated with poor mental health. Black transgender women also face barriers in access to healthcare, but the extent that such barriers modify the association between polyvictimization and poor mental health has not been described using convergent mixed-methods analysis.

METHODS

This convergent mixed-methods secondary analysis employs an intersectional lens and integrates two inter-related datasets to describe barriers to healthcare and the extent that such barriers modify the association between polyvictimization and mental health among Black transgender women. Investigators used survey data (n = 151 participants) and qualitative interview data (n = 19 participants) collected from Black transgender women (age 18 years and older) in Baltimore, MD and Washington, DC between 2016 and 2018. Analyses include thematic content analysis, bivariate analysis, joint display, and multivariate linear regression analysis examining mediation and moderation.

RESULTS

Joint display illuminated three domains to describe how barriers to healthcare present among Black transgender women-Affordability, Accessibility, and Rapport and Continuity. Independent t-tests revealed significantly higher polyvictimization, Post Traumatic Stress Disorder (PTSD), and depression scores among participants who reported at least one barrier to healthcare (BHI) compared to those who reported no barriers. BHI significantly moderated and partially mediated the association between polyvictimization and PTSD symptom severity and BHI fully mediated the association between polyvictimization and depressive symptom severity-when accounting for age and location.

DISCUSSION

Findings highlight the importance of access to healthcare in modifying the association between polyvictimization and PTSD and depression symptom severity among Black transgender women. Findings call for immediate interventions aimed at reducing barriers to healthcare and improved training for clinical providers serving Black transgender women.

COVID-19 News and Its Association with the Mental Health of Sexual and Gender Minority Adults: A Cross-Sectional Study

Background

Sexual and gender minority (SGM; people whose sexual orientation is not heterosexual or whose gender identity varies from what is traditionally associated with the sex assigned to them at birth) people experience high rates of trauma and substantial disparities in anxiety and posttraumatic stress disorder (PTSD). Exposure to traumatic stressors such as news related to COVID-19 may be associated with symptoms of anxiety and PTSD.

Objective

This study aims to evaluate the relationship of COVID-19 news exposure with anxiety and PTSD symptoms in a sample of SGM adults in the United States.

Methods

Data were collected between March 23 and August 2, 2020, from The PRIDE Study, a national longitudinal cohort study of SGM people. Regression analyses were used to analyze the relationship between self-reported news exposure and symptoms of anxiety using the Generalized Anxiety Disorder-7 and symptoms of COVID-19–related PTSD using the Impact of Events Scale-Revised.

Results

Our sample included a total of 3079 SGM participants. Each unit increase in COVID-19–related news exposure was associated with greater anxiety symptoms (odds ratio 1.77, 95% CI 1.63-1.93; P<.001) and 1.93 greater odds of PTSD (95% CI 1.74-2.14; P<.001).

Conclusions

Our study found that COVID-19 news exposure was positively associated with greater symptoms of anxiety and PTSD among SGM people. This supports previous literature in other populations where greater news exposure was associated with poorer mental health. Further research is needed to determine the direction of this relationship and to evaluate for differences among SGM subgroups with multiple marginalized identities.

Integrating LGBTQ+ health into medical education

BACKGROUND

LGBTQ+ people experience significant barriers in accessing health care including inadequate provider knowledge and stigma in health care settings. Undergraduate medical education programs have increased efforts to integrate LGBTQ+ health topics, such as comprehensive sexual history taking and gender-affirming practices, into their curriculums to provide clinically inclusive care for LGBTQ+ patients.

APPROACH

A Topic Steward was appointed to oversee the integration of LGBTQ+ health topics throughout the existing undergraduate medical curriculum. The aim was to expand the LGBTQ+ health curriculum for undergraduate medical students through teaching comprehensive sexual history taking; offering specialty-specific LGBTQ+ health education through clerkships; describing the difference between sex assigned at birth, gender identity, and gender expression; describing the difference between sexual orientation and sexual behaviour; identifying health care disparities that LGBTQ+ people experience; and developing an inclusive approach to providing medical care for LGBTQ+ patients.

EVALUATION

The program started in July 2017 with UCSFSOM students in their first, second, or third years (~150 medical students per year) participating in the integrated curriculum that included didactic lectures, small group discussions, and LGBTQ+ clerkship opportunities. The hours of LGBTQ+ health curriculum at the UCSFSOM increased from 4.5 hours to 15-20 hours in approximately 2 years under the Topic Steward approach.

IMPLICATIONS

The next step is to develop standardised tools for assessing LGBTQ+ health competencies for medical students. This involves integrating more questions regarding LGBTQ+ health topics in traditional exams at UCSFSOM and developing specialty-specific assessment instruments that other medical schools could administer to test core competencies in LGBTQ+ health.

Healthcare Mistreatment, State-Level Policy Protections, and Healthcare Avoidance Among Gender Minority People

INTRODUCTION

This study examined whether past experiences of mistreatment in healthcare were associated with greater healthcare avoidance due to anticipated mistreatment among gender minority (GM) people. We evaluated whether state-level healthcare policy protections moderated this relationship.

METHODS

Data from the 2018 Annual Questionnaire of The PRIDE Study, a national longitudinal study on sexual and gender minority people's health, were used in these analyses. Logistic regression modeling tested relationships between lifetime healthcare mistreatment due to gender identity or expression and past-year healthcare avoidance due to anticipated mistreatment among GM participants. Interactions between lifetime healthcare mistreatment and state-level healthcare policy protections and their relationship with past-year healthcare avoidance were tested.

RESULTS

Participants reporting any lifetime healthcare mistreatment had greater odds of past-year healthcare avoidance due to anticipated mistreatment among gender expansive people (n = 1290, OR = 4.71 [CI]: 3.57-6.20), transfeminine people (n = 263, OR = 10.32 [CI]: 4.72-22.59), and transmasculine people (n = 471, OR = 3.90 [CI]: 2.50-6.13). Presence of state-level healthcare policy protections did not moderate this relationship in any study groups.

CONCLUSIONS

For GM people, reporting lifetime healthcare mistreatment was associated with healthcare avoidance due to anticipated mistreatment. State-level healthcare policy protections were not a moderating factor in this relationship. Efforts to evaluate the implementation and enforcement of state-level policies are needed. Continued efforts to understand instances of and to diminish healthcare mistreatment of GM people are recommended.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13178-022-00748-1.

Implementing Trauma-Informed Education Practices in Undergraduate Mental Health Nursing Education

BACKGROUND

Nursing students may have risk factors for trauma reactivation through learning activities conducted as part of their education and training. Trauma-informed education practices (TIEP) could help reduce this risk.

METHOD

Course policies, content, procedures, and support structures consistent with the tenets of TIEP were implemented in undergraduate mental health courses with traditional third-year nursing students at two universities.

RESULTS

Students responded positively to the implementation of TIEP. Most (92%) qualitative feedback students provided in formal evaluations was directly related to at least one principle of TIEP, most commonly "promoting social, emotional, and academic safety." Some students (39.3%) interpreted TIEP as demonstrations of "genuine" caring for the students as individuals and their own mental health.

CONCLUSION

Integrating TIEP into an undergraduate nursing mental health course is feasible and beneficial and allows faculty to role model skills and values central to nursing practice. [J Nurs Educ. 2021;60(12):707-711.].

Minority Stress, Structural Stigma, and Physical Health Among Sexual and Gender Minority Individuals: Examining the Relative Strength of the Relationships

Background

Sexual and gender minority (SGM; i.e., non-heterosexual and transgender or gender-expansive, respectively) people experience physical health disparities attributed to greater exposure to minority stress (experiences of discrimination or victimization, anticipation of discrimination or victimization, concealment of SGM status, and internalization of stigma) and structural stigma.

Purpose

To examine which components of minority stress and structural stigma have the strongest relationships with physical health among SGM people.

Methods

Participants (5,299 SGM people, 1,902 gender minority individuals) were from The Population Research in Identity and Disparities for Equality (PRIDE) Study. Dominance analyses estimated effect sizes showing how important each component of minority stress and structural stigma was to physical health outcomes.

Results

Among cisgender sexual minority women, transmasculine individuals, American Indian or Alaskan Native SGM individuals, Asian SGM individuals, and White SGM individuals a safe current environment for SGM people had the strongest relationship with physical health. For gender-expansive individuals and Black, African American, or African SGM individuals, the safety of the environment for SGM people in which they were raised had the strongest relationship with physical health. Among transfeminine individuals, victimization experiences had the strongest relationship with physical health. Among Hispanic, Latino, or Spanish individuals, accepting current environments had the strongest relationship with physical health. Among cisgender sexual minority men prejudice/discrimination experiences had the strongest relationship with physical health.

Conclusion

Safe community environments had the strongest relationships with physical health among most groups of SGM people. Increasing safety and buffering the effects of unsafe communities are important for SGM health.

A Review of the State of HIV Nursing Science With Sexual Orientation, Gender Identity/Expression Peoples

ABSTRACT

Throughout the HIV pandemic, nurses have contributed to or led approaches to understanding the effects of HIV disease at individual and societal levels. Nurses have advocated for socially just care for more than a century, and our efforts have created a foundation on which to further build the state of HIV nursing science with sexual orientation and gender identity/expression (SOGI) Peoples. Nurses have also participated in the development of approaches to manage HIV disease for and in collaboration with populations directly affected by the disease. Our inclusive approach was guided by an international human rights legal framework to review the state of nursing science in HIV with SOGI Peoples. We identified articles that provide practice guidance (n = 44) and interventions (n = 26) to address the health concerns of SOGI Peoples and our communities. Practice guidance articles were categorized by SOGI group: SOGI People collectively, bisexual, transgender, cisgender lesbian, women who have sex with women, cisgender gay men, and men who have sex with men. Interventions were categorized by societal level (i.e., individual, family, and structural). Our review revealed opportunities for future HIV nursing science and practices that are inclusive of SOGI Peoples. Through integrated collaborative efforts, nurses can help SOGI communities achieve optimal health outcomes that are based on dignity and respect for human rights.

Transgender and gender diverse health education for future nurses: Students' knowledge and attitudes

BACKGROUND

Compared to cisgender peers, transgender and gender diverse (TGD) people experience significant health disparities associated with discrimination and limited access to appropriate care in healthcare settings. Nurses represent the largest segment of the United States (US) healthcare workforce; however, US nursing programs only dedicate approximately 2.12 h to Lesbian, Gay, Bisexual, and TGD (LGBT)-related content.

OBJECTIVES/DESIGN/SETTING/PARTICIPANTS

To fill the gap in TGD-related nursing education, the Transgender Curriculum Integration Project (TCIP) developed and integrated an evidence-based curriculum specific to TGD health into the pre-licensure accelerated Bachelor's in Nursing Science (BSN) program at Johns Hopkins School of Nursing. The purpose of this study was to assess the preliminary efficacy and feasibility (i.e., attrition, engagement, acceptability) of the TCIP in improving the TGD-related health knowledge and attitudes among a sample of pre-licensure nursing students.

METHODS

TCIP utilized a self-administered online survey to assess students' knowledge and attitudes about TGD health prior to (time point 1) and following (time points 2 and 3) the integration of TGD-specific content into five nursing pre-licensure courses. Rank-based nonparametric testing using Kruskal-Wallis H and Mann-Whitney U were conducted to determine if there were statistically significant differences in responses between the three time points. Thematic content analysis was used to determine themes present among short answers.

RESULTS

Findings indicate TGD-specific content improved student's gender sensitivity overtime, with improvements in self-reported skills in providing care for TGD people and knowledge of additional TGD-specific resources. However, gender sensitivity remains low among student's and students requested more TGD content suggesting room for further improvement.

CONCLUSIONS

Findings support the efficacy of TCIP and highlight complexities of curricular change that can guide future curricular integration and evaluation in nursing programs nation-wide.

Early Recognition of Pediatric Sepsis Simulation Checklist - An Exploratory Study

PURPOSE

To report on the modification and exploration of a 21-item Early Detection of Pediatric Sepsis Assessment Checklist aimed at improving nursing students' recognition of key factors that contribute to early detection of sepsis in pediatric patients through clinical simulation.

DESIGN AND METHODS

One hundred and thirty-one undergraduate, pre-licensure nursing students were evaluated using the adapted 21-item Early Detection of Pediatric Sepsis Assessment Checklist in simulation using high-fidelity manikins. Categorical Principle Component Analysis was used to evaluate for factor structure, with items accounting for <0.20 of the variance were dropped from the loadings.

RESULTS

Two factors emerged from the analysis: assessment and deterioration, accounting for 68% of the variance. Factor one, assessment, contained nine items (α = 0.77; λ = 3.36). Factor two, deterioration, contained seven items (α = 0.72; λ = 2.85). Five items did not load and were dropped from the factor structure, resulting in a 16-item checklist.

CONCLUSIONS

Two factors emerged from the analysis which is key to improving the early detection of pediatric sepsis. Assessment, factor one, accounted for the nursing students' central skills of recognizing baseline vital signs and timely medication administration. Deterioration, factor two, contained items reflecting the recognition of changes from baseline that require action. Conceptually, these factors reflect the most central points in the early detection of signs in pediatric patients at risk for sepsis.

PRACTICE IMPLICATIONS

This checklist forms a valuable tool to assess the knowledge of pre-licensure students and may possibly be extended as a tool to assess the clinical readiness and performance of new graduates through the safety and supervision allotted by simulation.

Trans* Community Connection, Health, and Wellbeing: A Systematic Review

Purpose: Transgender and nonbinary (trans*) people are affected disproportionately by discrimination and violence, contributing to gender minority stress and negative health effects. Transgender community connection (TCC), defined as (i) emotional connectedness (internal sense of belonging) to the trans* community and/or (ii) behavioral participation in the trans* community (observable interaction with other trans* people, in person, online, or through media) may moderate these negative effects on health. This systematic review synthesizes research on links between TCC and health and wellbeing for trans* people. Methods: Twenty research articles (3 quantitative, 3 mixed methods, and 14 qualitative) linking TCC to health and wellbeing were identified from systematic searches of PubMed, CINAHL, and PsycINFO. Data regarding TCC were extracted, synthesized, and grouped by (i) gender transitioning, (ii) mental health, (iii) sexual health, and (iv) access to care to illustrate the findings. Results: TCC was linked to several positive outcomes, including improved mental health, increased connection to care, supported exploration of sexual and gender identities, and informed gender transition. For transgender women, especially, TCC was also linked to increased engagement in sex work (as a worker, not a client) and, in some cases, deterred them from getting sexual health testing and treatment due to fear of being observed at specialized clinics and subsequent loss of confidentiality among peers. Conclusion: These findings highlight the overall protective nature of TCC and a need to consider best practices to ensure confidentiality for community members. The findings can be used to inform the development and adaptation of health care interventions aimed at decreasing the harmful effects of gender minority stress for trans* people.

Translating Research into Agile Development (TRIAD): Development of Electronic Health Record Tools for Primary Care Settings

OBJECTIVES

This article describes a method for developing electronic health record (EHR) tools for use in primary care settings.

METHODS

The "Translating Research into Agile Development" (TRIAD) method relies on the close collaboration of researchers, end users, and development teams. This five-step method for designing a tailored EHR tool includes (1) assessment, observation, and documentation; (2) structured engagement for collaboration and iterative data collection; (3) data distillation; (4) developmental feedback from clinical team members on high-priority EHR needs and input on design prototypes and EHR functionality; and (5) agile scrum sprint cycles for prototype development.

RESULTS

The TRIAD method was used to modify an existing EHR for behavioral health clinicians (BHCs) embedded with primary care teams, called the BH e-Suite. The structured engagement processes stimulated discussions on how best to automate BHC screening tools and provide goal tracking functionality over time. Data distillation procedures rendered technical documents, with information on workflow steps, tasks, and associated challenges. In the developmental feedback phase, BHCs gave input on screening assessments, scoring needs, and other functionality to inform prototype feature development. Six 2-week sprint cycles were conducted to address three domains of prototype development: assessment and documentation needs, information retrieval, and monitoring and tracking. The BH e-Suite tool resulted with eight new EHR features to accommodate BHCs' needs.

CONCLUSION

The TRIAD method can be used to develop EHR functionality to address the evolving needs of health professionals in primary care and other settings. The BH e-Suite was developed through TRIAD and was found to be acceptable, easy to use, and improved care delivery during pilot testing. The BH e-Suite was later adopted by OCHIN Inc., which provided the tool to its 640 community health centers. This suggests that the TRIAD method is a promising research and development approach.

Toric intraocular lens outcomes with a new protocol for IOL selection and implantation

INTRODUCTION

The published literature on toric intraocular lenses (IOL) reports postoperative refractive cylinder less than or equal to 0.5 D in anywhere from 25% to 100% of implantations with both the Acrysof^® Toric and Tecnis^® Toric IOL, depending upon the article. However, the majority of articles tend to cite rates between 70% and 80%.

PURPOSE

The purpose was to evaluate my personal outcomes for both models of toric IOL, in terms of one-month postoperative refractive cylinder, after implementation of new methods of IOL selection, calculation and implantation.

MATERIALS AND METHODS

The new protocol included measurement of centroid surgically induced astigmatism by vector analysis; calculations using only the Barrett toric calculator, for which the keratometry values were obtained by optical biometry, while the keratometric axes were chosen by visual inspection of the axial topographic map; preoperative marking with the toriCAM cell phone appliance; and corneal incisions performed either manually or with a femtosecond laser. A prospective, observational study was conducted of all consecutive monofocal toric IOL implantations from September 2016 through April 2017. One-month postoperative refractive cylinder was recorded for each eye.

RESULTS

Seventy eyes were implanted with monofocal toric IOL, 31 Acrysof^® Toric and 39 Tecnis^® Toric. Mean postoperative refractive cylinder was 0.48 D (0.00-1.50) for the Acrysof^® Toric group and 0.46 D (0.00-1.00) for the Tecnis^® Toric group. There were no statistically significant differences in postoperative refractive cylinder between IOL models or methods of incision. The percentage of eyes achieving postoperative refractive cylinder ≤0.50 D ("success") was 77% for the Acrysof^® Toric group (82% for laser-assisted and 75% for manual) and 72% for the Tecnis^® Toric group (80% for laser-assisted and 69% for manual).

CONCLUSION

The implementation of the new protocol resulted in an overall surgical success rate of 77% for Acrysof^® Toric IOL and 72% for Tecnis^® Toric IOL (P=0.7702). Femtosecond laser-assisted surgery resulted in higher success rates than manual surgery (82% vs. 75% for Acrysof^® Toric and 80% vs. 69% for Tecnis^® Toric), but these differences were not statistically significant (Acrysof^® Toric P=0.7336; Tecnis^® Toric P=0.8862).

A computer-based interactive multimedia program to reduce HIV transmission for women with intellectual disability

BACKGROUND

Despite recent recognition of the need for preventive sexual health materials for people with intellectual disability (ID), there have been remarkably few health-based interventions designed for people with mild to moderate ID. The purpose of this study was to evaluate the effects of a computer-based interactive multimedia (CBIM) program to teach HIV/AIDS knowledge, skills and decision making.

METHODS

Twenty-five women with mild to moderate ID evaluated the program. The study used a quasi-experimental within-subjects design to assess the efficacy of the CBIM program. Research participants completed five qualitative and quantitative instruments that assessed HIV knowledge, and decision-making skills regarding HIV prevention practices and condom application skills (i.e. demonstration of skills opening a condom and putting it on a model penis). In addition, 18 service providers who work with women with ID reviewed the program and completed a demographics questionnaire and a professional customer satisfaction survey.

RESULTS

Women with ID showed statistically significant increases from pre-test to post-test in all knowledge and skill domains. Furthermore, the statistical gains were accompanied by medium to large effect sizes. Overall, service providers rated the program highly on several outcome measures (stimulation, relevance and usability).

CONCLUSIONS

The results of this study indicate the CBIM program was effective in increasing HIV/AIDS knowledge and skills among women with ID, who live both semi-independently and independently, in a single-session intervention. As the CBIM program is not dependent on staff for instructional delivery, it is a highly efficient teaching tool; and CBIM is an efficacious means to provide behavioural health content, compensating for the dearth of available health promotion materials for people with ID. As such, it has a potential for broad distribution and implementation by medical practitioners, and public health offices. People with ID are part of our society, yet continue to be overlooked, particularly in the area of health promotion. Special tools need to be developed in order to address the health disparities experienced by people with ID.

N-terminal residues of plasmatocyte-spreading peptide possess specific determinants required for biological activity

Plasmatocyte-spreading peptide (PSP) is a 23-amino acid cytokine that activates a class of insect immune cells called plasmatocytes. The tertiary structure of PSP consists of an unstructured N terminus (residues 1-6) and a well structured core (residues 7-23). A prior study indicated that deletion of the N terminus from PSP eliminated all biological activity. Alanine substitution of the first three residues (Glu(1)-Asn(2)-Phe(3)) further indicated that only replacement of Phe(3) resulted in a loss of activity equal to the N-terminal deletion mutant. Here, we characterized structural determinants of the N terminus. Adding a hydroxyl group to the aromatic ring of Phe(3) (making a Tyr) greatly reduced activity, whereas the addition of a fluorine (p-fluoro) did not. Substitutions that changed the chirality or replaced the aromatic ring of Phe(3) with a branched aliphatic chain (making a Val) also greatly decreased activity. The addition of a methylene group to Val (making a Leu) partially restored activity, whereas the removal of a methylene group from Phe (phenyl-Gly) eliminated all activity. These results indicated that a branched carbon chain with a methylene spacer at the third residue is the minimal structural motif required for activity. The deletion of Glu(1) also eliminated activity. Additional experiments identified the charged N-terminal amine and backbone of Glu(1) as key determinants for activity.

Patterns of lung disease in a "normal" smoking population: are emphysema and airflow obstruction found together?

STUDY OBJECTIVES

We determined whether emphysema demonstrated on high-resolution CT (HRCT) scanning in apparently well smokers is associated with airflow obstruction.

INTERVENTIONS

Lung function testing and limited HRCT scanning.

DESIGN

Lung function measurements and scans were analyzed independently of each other. We used analysis of covariance to compare FEV(1) and maximum expiratory flow at 50% of vital capacity (MEF(50)) values after suitable corrections, between subjects with and without parenchymal damage (emphysema and/or reduced carbon monoxide transfer coefficient [KCO]), and to compare indexes of parenchymal damage between subjects with and without airflow obstruction.

SETTING

Radiology and lung function departments of a district general hospital.

PARTICIPANTS

Eighty current cigarette smokers and 20 lifetime nonsmoking control subjects (aged 35 to 65 years) who volunteered following publicity in local media. In all subjects, FEV(1) was > 1.5 L; no subjects were known to have lung disease.

MEASUREMENTS AND RESULTS

FEV(1) and MEF(50) were measured spirometrically; static lung volumes were measured by helium dilution and body plethysmography; KCO was measured by a single-breath technique. HRCT scans were analyzed for emphysema by two radiologists. Of smokers, 25% had HRCT emphysema, generally mild; 16.3% and 25% had reduced FEV(1) and MEF(50), respectively; 12.5% had reduced KCO. Smokers with airflow obstruction were not more likely to have parenchymal damage. Smokers with parenchymal damage did not have reduced airway function. Nonsmokers generally had normal airways and parenchyma.

CONCLUSIONS

"Normal" smokers with lung damage had either airflow obstruction or parenchymal damage, but not generally both.

Structure and activity of the insect cytokine growth-blocking peptide. Essential regions for mitogenic and hemocyte-stimulating activities are separate

Growth-blocking peptide (GBP) is a 25-amino acid insect cytokine found in Lepidopteran insects that possesses diverse biological activities such as larval growth regulation, cell proliferation, and stimulation of immune cells (plasmatocytes). The tertiary structure of GBP consists of a structured core that contains a disulfide bridge and a short antiparallel beta-sheet (Tyr(11)-Arg(13) and Cys(19)-Pro(21)) and flexible N and C termini (Glu(1)-Gly(6) and Phe(23)-Gln(25)). In this study, deletion and point mutation analogs of GBP were synthesized to investigate the relationship between the structure of GBP and its mitogenic and plasmatocyte spreading activity. The results indicated that deletion of the N-terminal residue, Glu(1), eliminated all plasmatocyte spreading activity but did not reduce mitogenic activity. In contrast, deletion of Phe(23) along with the remainder of the C terminus destroyed all mitogenic activity but only slightly reduced plasmatocyte spreading activity. Therefore, the minimal structure of GBP containing mitogenic activity is 2-23 GBP, whereas that with plasmatocyte spreading activity is 1-22 GBP. NMR analysis indicated that these N- and C-terminal deletion mutants retained a similar core structure to wild-type GBP. Replacement of Asp(16) with either a Glu, Leu, or Asn residue similarly did not alter the core structure of GBP. However, these mutants had no mitogenic activity, although they retained about 50% of their plasmatocyte spreading activity. We conclude that specific residues in the unstructured and structured domains of GBP differentially affect the biological activities of GBP, which suggests the possibility that multifunctional properties of this peptide may be mediated by different forms of a GBP receptor.

Alanine-scanning mutagenesis of plasmatocyte spreading peptide identifies critical residues for biological activity

Plasmatocyte spreading peptide (PSP) is a 23-amino acid cytokine that induces a class of insect immune cells called plasmatocytes to spread on foreign surfaces. The structure of PSP consists of a disordered N terminus (residues 1-6) and a well-defined core (residues 7-23) stabilized by a disulfide bridge between Cys(7) and Cys(19), hydrophobic interactions, and a short beta-hairpin. Structural comparisons also indicate that the core region of PSP adopts an epidermal growth factor (EGF)-like fold very similar to the C-terminal subdomain of EGF-like module 5 of thrombomodulin. To identify residues important for plasmatocyte spreading activity, we bioassayed PSP mutants in which amino acids were either replaced with alanine or deleted. Within the well-defined core of PSP, alanine replacement of Cys(7) and Cys(19) (C7.19A) eliminated all activity. Alanine replacement of Arg(13) reduced activity approximately 1000-fold in comparison to wild-type PSP, whereas replacement of the other charged residues (Asp(16), Arg(18), Lys(20)) surrounding Cys(19) diminished activity to a lesser degree. The point mutants Y11A, T14A, T22A, and F23A had activity identical or only slightly reduced to that of wild-type PSP. The mutant PSP-(7-23) lacked the entire unstructured domain of PSP and was found to have no plasmatocyte spreading activity. Surprisingly, E1A and N2A had higher activity than wild-type PSP, but F3A had almost no activity. We thus concluded that the lack of activity for PSP-(7-23) was largely due to the critical importance of Phe(3). To determine whether reductions in activity correlated with alterations in tertiary structure, we compared the C7.19A, R13A, R18A, and F3A mutants to wild-type PSP by NMR spectroscopy. As expected, the simultaneous replacement of Cys(7) and Cys(19) profoundly affected tertiary structure, but the R13A, R18A, and F3A mutants did not differ from wild-type PSP. Collectively, these results indicate that residues in both the unstructured and structured domains of PSP are required for plasmatocyte-spreading activity.

Plasmatocyte spreading peptide (PSP1) and growth blocking peptide (GBP) are multifunctional homologs

Recently, we identified Plasmatocyte spreading peptide (PSP1) from the moth Pseudoplusia includens and reported that it mediates adhesion of hemocytes to foreign surfaces. PSP1 is structurally very similar to three classes of peptides identified earlier from other species of Lepidoptera: growth blocking peptide (GBP) originally identified in Pseudaletia separata, and a series of related peptides from other species designated as paralytic (PP) or cardioactive (CAP) peptides. In this study, we conducted parallel experiments in P. includens and P. separata to determine whether PSP1 and GBP have distinct or multiple biological activities. Both peptides affected the adhesive state of hemocytes from each moth very similarly. PSP1 and GBP exhibited significant growth blocking and paralytic activity in P. separata. Both peptides also had growth blocking activity in P. includens although larvae had to be injected with higher doses of each peptide to reduce weight gain than was observed for P. separata. However, GBP and PSP1 had little paralytic activity in P. includens. Collectively, our results indicate that GBP and PSP1 are multifunctional, but that some interspecific variation also exists in their growth blocking and paralytic activities. We suggest that all PSP1, GBP, PP and CAP family members are homologs that likely have multiple biological activities. Based upon the unique consensus sequence of their N termini, we propose that these molecules be henceforth referred to as members of the "ENF" peptide family.

Plasmatocyte spreading peptide induces spreading of plasmatocytes but represses spreading of granulocytes

In most Lepidoptera, plasmatocytes and granulocytes are the two hemocyte classes capable of adhering to foreign targets. Previously, we identified plasmatocyte spreading peptide (PSP1) from the moth Pseudoplusia includens and reported that it induced plasmatocytes to rapidly spread on foreign surfaces. Here we examine whether the response of plasmatocytes to PSP1 was influenced by cell density or culture conditions, and whether PSP1 affected the adhesive state of granulocytes. Plasmatocyte spreading rates were clearly affected by cell density in the absence of PSP1 but spreading was density independent in the presence of PSP1. PSP1 also induced plasmatocytes in agarose-coated culture wells to form homotypic aggregations rather than spread on the surface of culture wells. In contrast, granulocytes rapidly spread in a density independent manner in the absence of PSP1, but were dose-dependently inhibited from spreading by the addition of peptide. An anti-PSP1 polyclonal antibody neutralized the spreading activity of synthetic PSP1. This antibody also neutralized the plasmatocyte spreading activity of granulocyte-conditioned medium, and significantly delayed plasmatocyte spreading when cells were cultured at a high density in unconditioned medium. These results suggested that the spreading activity derived from granulocytes is due in part to PSP1. Pretreatment of plasmatocytes with trypsin had no effect on PSP1-induced aggregation but PSP1-induced aggregations were readily dissociated by trypsin. This suggested that PSP1 is not an adhesion factor but induces adhesion by stimulating a change in the cell surface of plasmatocytes. Synthetic PSP1 also induced aggregation of plasmatocytes from other Lepidoptera indicating that regulation of hemocyte activity by PSP1-related peptides may be widespread. Arch.

Endogenous cortisol and lung damage in a predominantly smoking population

We examined the association of endogenous corticosteroid status with lung structure and function in a cross-sectional and longitudinal study in response to a recent finding of a relationship between plasma cortisol and rate of annual decline in airway function. We recruited 74 cigarette-smoking and 20 never-smoking volunteers 35 to 65 yr of age after publicity in local media. Exclusion criteria were FEV1 < 1.5 L or a history of airway disease. We performed spirometry and a high resolution CT lung scan and measured CO transfer, serum cortisol, and 24-h urinary cortisol excretion. There were no differences in serum or urinary cortisol between those with and those without low FEV1, low KCO, or high resolution CT (HRCT) emphysema, except that urinary cortisol was 19% higher in subjects with HRCT emphysema (p = 0.05). Log urinary cortisol/body weight was negatively correlated with KCO (p = 0.000) and KCO was lower in the highest tertile of urinary cortisol (p = 0.001). Subjects were restudied after 520 +/- 69 d. Changes in FEV1 and KCO showed no significant correlations with serum or urinary cortisol. We conclude that airway function does not relate to serum or urinary cortisol, but there may be a relationship between cortisol excretion and emphysema.

Structure of the insect cytokine peptide plasmatocyte-spreading peptide 1 from Pseudoplusia includens

The structure of the recently identified plasmatocyte spreading peptide from the moth Pseudoplusia includens (PSP1) has been determined by NMR spectroscopy. This novel insect cytokine consists of 23 amino acid residues and a single disulfide bond. Torsion angle dynamics calculations utilizing a total of 337 distance constraints yielded an ensemble of 30 structures with an average backbone root mean square deviation for residues 7-22 of 0.18 A from the mean structure. The structure consists of a disordered N-terminal region and a well defined core that is stabilized by numerous hydrophobic interactions and a short beta-hairpin. Structural comparisons confirm that PSP1 adopts an epidermal growth factor (EGF)-like fold with close similarity to the C-terminal subdomain of EGF-like module 5 of human thrombomodulin. The combination of the three-dimensional structure of PSP1 and the extensive literature on EGF-receptor interactions should accelerate the process of identifying the specific residues responsible for receptor binding activity of this family of immunoregulatory peptides.

Plasmatocyte spreading peptide is encoded by an mRNA differentially expressed in tissues of the moth Pseudoplusia includens

It has long been known that blood cells (hemocytes) are an essential component of the invertebrate immune system, yet little is known about the molecules mediating their function. Recently, we identified plasmatocyte spreading peptide (PSP1) from the moth Pseudoplusia includens which regulates the trafficking and adhesion of a hemocyte subclass called plasmatocytes. Here, we report the cloning of a cDNA (p15) that encodes a PSP1 precursor protein. Northern blot analysis revealed that a homologous prepro-PSP1 mRNA is expressed in fat body, and that other PSP1-related transcripts are expressed in nervous tissue and hemocytes. Coupled in vitro transcription/translation reactions indicated that p15 produces a protein recognized by a PSP1 polyclonal antibody. Immunoblotting experiments further revealed that a putative pro-PSP1 protein is present in P. includens plasma and fat body.

Cigarette smoke inhalation and lung damage in smoking volunteers

Cigarette smoking is the dominant risk factor for chronic obstructive pulmonary disease (COPD) but only 10-15% of smokers develop the condition. Risk does not relate closely to cumulative cigarette consumption, perhaps because smokers vary in the degree and depth of smoke inhalation. This study examined the role of smoke inhalation in the development of COPD. Eighty current smokers and 20 lifetime nonsmoking volunteers (aged 35-65 yrs) were recruited. Lung function variables were measured and high-resolution computed tomography (HRCT) scans performed. Smoke inhalation was assessed by CO boost (the increment of expired carbon monoxide 5 min after smoking a cigarette) and serum cotinine. Mean CO boost was 6.3 parts per million (ppm) in smokers with low CO transfer coefficients (KCO) and 2.9 ppm in those with normal KCO (p=0.006); 7.2 ppm in smokers with both HRCT-defined emphysema and a low KCO and 2.6 ppm in those with neither abnormality (p=0.002); 4.5 ppm in smokers with HRCT-defined emphysema alone and 2.8 ppm in those without (p=0.08). Mean serum cotinine was 328 ng x mL(-1) in smokers with chronic productive cough and 243 ng x mL(-1) in those without (p=0.005). Lifetime nonsmokers had normal HRCT scans, lung function and serum cotinine. Emphysema is associated with high alveolar smoke exposure as measured by CO boost. Productive coughing is associated with high nicotine uptake, probably from airway smoke particle deposition.

Effect of SERCA pump inhibitors on chemoresponses in Paramecium

Inhibitors of SERCA (sarcoplasmic/endoplasmic reticulum Ca(2+)-dependent ATPase) calcium pumps were used to investigate the involvement of internal Ca2+ stores in the GTP response in Paramecium. External application of these inhibitors was found to dramatically alter the typical behavioral and electrophysiological responses of Paramecium to extracellular chemical stimulation. In particular, 2,5-di-tert-butylhydroquinone (BHQ) strongly inhibited the backward swimming response of paramecia to externally applied GTP, though it did not inhibit the associated whirling response. BHQ also prolonged the normally brief electro-physiological response of these cells to GTP. BHQ completely blocked the behavioral and electrophysiological responses of Paramecium to extracellular Ba2+, but had no measurable effect on the behavioral or electrophysiological responses of these cells to another depolarizing stimulus, elevated external K+ concentration. These results suggest the involvement of nonciliary Ca2+ ions in the GTP and Ba2+ responses.

Isolation and identification of a plasmatocyte-spreading peptide from the hemolymph of the lepidopteran insect Pseudoplusia includens

Insect blood cells (hemocytes) play an essential role in defense against parasites and other pathogenic organisms that infect insects. A key class of hemocytes involved in insect cellular immunity is plasmatocytes. Here we describe the isolation and identification of a peptide from the moth Pseudoplusia includens that mediates the spreading of plasmatocytes to foreign surfaces. This peptide, designated plasmatocyte-spreading peptide (PSP1), contains 23 amino acid residues in the following sequence: H-ENFNGGCLAGYMRTADGRCKPTF-OH. In vitro assays using the synthetic peptide at concentrations >/=2 nM induced plasmatocytes from P. includens to spread on the surface of culture dishes. Injection of this peptide into P. includens larvae caused a transient depletion of plasmatocytes from circulation. Labeling studies indicated that this peptide induced 75% of plasmatocytes that were double-labeled by the monoclonal antibodies 49G3A3 and 43E9A8 to spread, whereas plasma induced significantly more plasmatocytes to spread. This suggests that only a certain subpopulation of plasmatocytes responds to the peptide and that other peptidyl factors mediate plasmatocyte adhesion responses.

Effect of a screening profile on the diagnosis of nonaccidental burns in children

STUDY OBJECTIVE

To determine if awareness of factors associated with burn abuse increases recognition and reporting by emergency physicians.

DESIGN

The study consisted of a retrospective chart review and a subsequent intervention.

SETTING

An urban pediatric emergency department (ED).

PARTICIPANTS

All patients with the diagnosis of burn seen in the ED.

INTERVENTION

The retrospective chart review (October 1, 1990, to September 30, 1991) determined the number of patients seen in the ED, diagnosed with burns, and reported to the department of social service. We then determined whether or not the department of social service, after completion of their investigation, "verified" that abuse had occurred. In addition, other services provided to the family by the department of social services were determined. The prospective study (April 1, 1992, to March 30, 1993) introduced a checklist of 13 factors associated with abusive burns into the history and physical examination of all burn victims presenting to the ED. Changes in overall referrals to the department of social service as well as in the numbers of cases in which abuse were verified or services offered were then determined.

RESULTS

Prior to any intervention, 3% (3/87) of burns presenting to the ED from 1990 to 1991 were reported to the department of social service. This contrasted with 12.1% (26/215) of burns presenting after introduction of the checklist. Burn victims, 1/87 (1%), in the retrospective study and 16/215 (7.4%) burn victims in the prospective study received social service intervention after a report was initiated by the ED staff (P < .002). Burn injuries 1/87 (1%) and 7/215 (3.3%), reported during the two studies were substantiated as abusive by social services.

CONCLUSION

We conclude that the use of the checklist increased effective social service referral for burn abuse.

Extracellular GTP causes membrane-potential oscillations through the parallel activation of Mg2+ and Na+ currents in Paramecium tetraurelia

Paramecium tetraurelia responds to extracellular GTP (>/= 10 nm) with repeated episodes of prolonged backward swimming. These backward swimming events cause repulsion from the stimulus and are the behavioral consequence of an oscillating membrane depolarization. Ion substitution experiments showed that either Mg2+ or Na+ could support these responses in wild-type cells, with increasing concentrations of either cation increasing the extent of backward swimming. Applying GTP to cells under voltage clamp elicited oscillating inward currents with a periodicity similar to that of the membrane-potential and behavioral responses. These currents were also Mg2+- and Na+-dependent, suggesting that GTP acts through Mg2+-specific (IMg) and Na+-specific (INa) conductances that have been described previously in Paramecium. This suggestion is strengthened by the finding that Mg2+ failed to support normal behavioral or electrophysiological responses to GTP in a mutant that specifically lacks IMg ("eccentric"), while Na+ failed to support GTP responses in "fast-2," a mutant that specifically lacks INa. Both mutants responded normally to GTP if the alternative cation was provided. As IMg and INa are both Ca2+-dependent currents, the characteristic GTP behavior could result from oscillations in intracellular Ca2+ concentration. Indeed, applying GTP to cells in the absence of either Mg2+ or Na+ revealed a minor inward current with a periodicity similar to that of the depolarizations. This current persisted when known voltage-dependent Ca2+ currents were blocked pharmacologically or genetically, which implies that it may represent the activation of a novel purinergic-receptor-coupled Ca2+ conductance.

External GTP alters the motility and elicits an oscillating membrane depolarization in Paramecium tetraurelia

Paramecium, a unicellular ciliated protist, alters its motility in response to various stimuli. Externally added GTP transiently induced alternating forward and backward swimming interspersed with whirling at a concentration as low as 0.1 microM. ATP was 1000-fold less active, whereas CTP and UTP produced essentially no response. The response to the nonhydrolyzable GTP analogs guanosine 5'-[gamma-thio]triphosphate and guanosine 5'-[beta, gamma-imido]triphosphate was indistinguishable from that to GTP. This behavioral response was correlated with an unusual transient and oscillating membrane depolarization in both wild-type cells and the mutant pawn B, which is defective in the voltage-dependent Ca2+ current required for action potentials. This is a specific effect of external GTP on the excitability of a eukaryotic cell and, to our knowledge, is the first purinergic effect to be discovered in a microorganism.

An automated assay for quantifying the swimming behavior of Paramecium and its use to study cation responses

Paramecium tetraurelia is a ciliated protist that alters its swimming behavior in response to various stimuli. Like the sensory responses of many organisms, these responses in Paramecium show adaptation to continued stimulation. For quantitative studies of the initial response to stimulation, and of the time course of adaptation, we have developed a computerized motion analysis assay that can detect deviations from the normal swimming pattern in a population of cells. The motion of an average of ten cells was quantified during periods ranging from 15 to 60 seconds, with a time resolution of 1/15 seconds. During normal forward swimming, the maximum deviation from a straight-line path was less than 17 degrees. Path deviations above this threshold value were defined as changes in swimming direction. The percentage of total path time that cells spent deviating from forward swimming was defined as percent directional changes (PDC). This parameter was used to construct dose-response curves for the behavioral effects of various externally added cations known to induce behavioral changes and also to show the time course of adaptation to a depolarizing K+ stimulus. This assay is a valuable tool for studies of chemoeffectors or mutations that alter the swimming behavior of Paramecium and may also be applicable to other motile organisms.