Effects of systematically varied thiourethane-functionalized filler concentration on polymerization behavior and relevant clinical properties of dental composites

Introduction of thiourethane (TU) oligomer to resin-based dental restorative materials reduces stress and improves fracture toughness without compromising conversion. Localization of TU at the resin-filler interface via silanization procedures may lead to more substantial stress reduction and clinical property enhancements. The objective of this study was to evaluate composite properties as a function of TU-functionalized filler concentration. TU oligomers were synthesized using click-chemistry techniques and subsequently silanized to barium glass filler. Resin-based composites were formulated using varying ratios of TU-functionalized filler and conventional methacrylate-silanized barium filler. Material property testing included thermogravimetric analysis, real-time polymerization kinetics and depth of cure, polymerization stress, stress relaxation and fracture toughness. Clinical property testing included water sorption/solubility, composite paste viscosity, and gloss and surface roughness measured before and after subjecting the samples to 6 h of continuous tooth brushing in a custom-built apparatus using a toothpaste/water mixture. Increasing TU-filler in the composite resulted in as much as a 78% reduction in stress, coupled with an increase in fracture toughness. Conversion was similar for all groups. After simulated tooth brushing, gloss reduction was lower for TU-containing composites and surface roughness was less than or equal to the control.

The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic

CLINICAL SCENARIO

A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful.

MANAGEMENT QUESTION

What are the psychological impacts of SJS/TEN on this man's life?

BACKGROUND

SJS and TEN have devastating outcomes for those affected.

OBJECTIVES

To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario.

METHODS

Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age.

RESULTS

Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression.

DISCUSSION AND RECOMMENDATION

The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

Subcortical volumetric abnormalities in bipolar disorder

Considerable uncertainty exists about the defining brain changes associated with bipolar disorder (BD). Understanding and quantifying the sources of uncertainty can help generate novel clinical hypotheses about etiology and assist in the development of biomarkers for indexing disease progression and prognosis. Here we were interested in quantifying case-control differences in intracranial volume (ICV) and each of eight subcortical brain measures: nucleus accumbens, amygdala, caudate, hippocampus, globus pallidus, putamen, thalamus, lateral ventricles. In a large study of 1710 BD patients and 2594 healthy controls, we found consistent volumetric reductions in BD patients for mean hippocampus (Cohen's d=-0.232; P=3.50 × 10-7) and thalamus (d=-0.148; P=4.27 × 10-3) and enlarged lateral ventricles (d=-0.260; P=3.93 × 10-5) in patients. No significant effect of age at illness onset was detected. Stratifying patients based on clinical subtype (BD type I or type II) revealed that BDI patients had significantly larger lateral ventricles and smaller hippocampus and amygdala than controls. However, when comparing BDI and BDII patients directly, we did not detect any significant differences in brain volume. This likely represents similar etiology between BD subtype classifications. Exploratory analyses revealed significantly larger thalamic volumes in patients taking lithium compared with patients not taking lithium. We detected no significant differences between BDII patients and controls in the largest such comparison to date. Findings in this study should be interpreted with caution and with careful consideration of the limitations inherent to meta-analyzed neuroimaging comparisons.

A novel approach to biomarker discovery in head and neck cancer using an autoantibody signature

Despite the dismal prognosis for patients with squamous cell carcinoma of the head and neck (SCCHN), there have been no novel treatments in over 40 years. Identification of novel tumor antigens in SCCHN will facilitate the identification of potential novel treatment targets. Tumor antigens are proteins selectively expressed by tumor cells and recognized by the host immune system. Phage-displayed tumor antigens were enriched by biopanning with normal and then SCCHN-specific serum. Ninety-six phage clones were sequenced for identification, and 21 clones were validated using Luminex. One of these proteins, L23, a novel tumor antigen in SCCHN, was validated as an oncogene. L23 is upregulated in SCCHN compared with normal keratinocytes. Knockdown of L23 inhibited proliferation, invasion and cell survival. Overexpression of L23 had the reverse effect. Overexpression of L23 in non malignant cells led to transformation. Injection of SCCHN cells with knockdown of L23 in mice, induced tumors that were significantly smaller than control tumors. In conclusion, the immunomic screen yielded a panel of antigens specific to SCCHN; one of these proteins, L23, is a novel oncogene in SCCHN.

Impact of methodologic choice for automatic detection of different aspects of brain atrophy by using temporal lobe epilepsy as a model

BACKGROUND AND PURPOSE

VBM, DBM, and cortical thickness measurement techniques are commonly used automated methods to detect structural brain changes based on MR imaging. The goal of this study was to demonstrate the pathology detected by the 3 methods and to provide guidance as to which method to choose for specific research questions. This goal was accomplished by 1) identifying structural abnormalities associated with TLE with (TLE-mts) and without (TLE-no) hippocampal sclerosis, which are known to be associated with different types of brain atrophy, by using these 3 methods; and 2) determining the aspect of the disease pathology identified by each method.

MATERIALS AND METHODS

T1-weighted MR images were acquired for 15 TLE-mts patients, 14 TLE-no patients, and 33 controls on a high-field 4T scanner. Optimized VBM was carried out by using SPM software, DBM was performed by using a fluid-flow registration algorithm, and cortical thickness was analyzed by using FS-CT.

RESULTS

In TLE-mts, the most pronounced volume losses were identified in the ipsilateral hippocampus and mesial temporal region, bilateral thalamus, and cerebellum, by using SPM-VBM and DBM. In TLE-no, the most widespread changes were cortical and identified by using FS-CT, affecting the bilateral temporal lobes, insula, and frontal and occipital lobes. DBM revealed 2 clusters of reduced volume complementing FS-CT analysis. SPM-VBM did not show any significant volume losses in TLE-no.

CONCLUSIONS

These results demonstrate that the 3 methods detect different aspects of brain atrophy and that the choice of the method should be guided by the suspected pathology of the disease.

End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs

OBJECTIVE

To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units.

METHODS

A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia.

RESULTS

Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent.

CONCLUSIONS

Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.

End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs

OBJECTIVE: To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS: A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS: Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS: Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.

A professional code of ethics provides guidance for genetic nursing practice

While ethical quandaries and dilemmas are commonplace for nurses, recent advances in human genetics have and will continue to create new challenges and controversies. Throughout time, nursing has been an ethical endeavour, with nurses viewing the ethical mandates of their responsibilities on a par with other core dimensions of their professional life. The (American) profession's code of ethics, Code for nurses with interpretive statements, provides direction for practice and for the fulfillment of ethical obligations. The explication of these ethical norms and values that shape professional practice is necessary as nurses confront the integration of genetic services into health care. The goal of preserving professional integrity and ethical soundness in the context of genetic health care mandates that nurses rely on and act upon the profession's national and international codes of ethics.

Assisted suicide: how nurses should respond

However compassionate the motives behind assisted suicide initiatives, the risks and harm for patients, health professionals and the public are too great. The moral and professional challenge should not revolve around assisted suicide but be directed at reversing the dying person's despair and fulfilling the obligation to provide competent and committed care to the dying.

Unraveling ethical issues in palliative care

OBJECTIVES

To describe the ethical issues inherent in palliative care and the essential role of nurses in addressing the ethical dimensions of professional practice.

DATA SOURCE

Review articles, research studies, and books related to ethical issues in palliative care.

CONCLUSIONS

Nurses in all roles and practice settings confront numerous ethical concerns. Some of the most perplexing and troubling ethical issues arise within the context of palliative care. Being prepared to deal with these ethical issues can foster patient and family well-being and protect the integrity of the nurse.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses have a vital role in improving the quality of end-of-life care. Attention to the ethical dimension of palliative care is necessary to accomplishing this.

A road map for navigating end-of-life care

As nurses begin to develop the sensitivities and skills necessary to preserve the integrity of clinical care and professional life, they must recognize the legitimacy of their perspectives and the value and consequences they have for the well-being of patient and family care. Nurses have much to contribute to the development of ethical practice environments for patients, families, multidisciplinary team members, and themselves. The frenzied, and at times anesthetized, culture of clinical settings can mitigate against the kind of deliberate reflection that is necessary if nurses are to act with ethical integrity. Knowing the rules of the road for end-of-life care and being attentive to common warning signs and addressing them proactively, enables nurses to provide patients and families with the highest quality care at the end of life.

A validated dyspepsia symptom score

BACKGROUND

The primary endpoint in clinical trials involving patients with non-ulcer dyspepsia is subjective, i.e., reduction in symptomatology. Three attributes, reproducibility, responsiveness and validity, are necessary for the use of a symptom scoring system in a clinical trial.

METHODS

The four most common symptoms in 50 dyspeptic patients were determined. To check the reproducibility of the symptom score, 48 patients and thirty control subjects were interviewed on two occasions (T0, T1), prior to any diagnostic or therapeutic intervention. Responsiveness was assessed by comparing the symptom scores of patients before (T0) and after (T2) treatment. Validity was assessed by comparing the symptom scores of dyspeptic patients to those of healthy volunteer subjects.

RESULTS

Reproducibility The median T0 (16.00 and 6.90) and T1 (15.00 and 6.56) scores of the patients and controls did not significantly vary during the one-week interval. Responsiveness The symptom scores at T0 had decreased at T2 for patients with gastro-oesophageal reflux (17.00 to 11.50, p = 0.0014), non-ulcer dyspepsia where Helicobacter pylori was eradicated (16.00 to 7.00 p = 0.0014), and duodenal ulceration (18.50 to 7.50, p = 0.0117) while there was an insignificant decrease (18.00 to 13.00, p = 0.0642) in non-ulcer dyspepsia patients who received a prokinetic agent. Validity The mean rank symptom score of 74 patients (71.74) was significantly higher than that of the control population (26.83), (p = 0.0001). The mean time taken to perform the questionnaire was 3.6 minutes.

CONCLUSION

This questionnaire is suitable for the assessment of symptoms in patients with dyspepsia.

Assisted suicide: the wrong answer

One of the most complex and troubling issues facing society and health care professionals is physician-assisted suicide (PAS). The convergence of significant trends in legislation, judicial decisions, research, and public sentiment has highlighted its importance. A broad spectrum of societal opinion and philosophical, religious, legal, and professional debate surrounds PAS.

Learning from practice? Mental health nurses' perceptions and experiences of clinical supervision

In recent years nursing as a whole has moved from a position of apparently little manifest concern in the issue of 'clinical supervision' to a veritable explosion of interest which is beginning to find expression in the literature. Beginning with a discussion of clinical supervision from within a psychodynamically informed interpersonal nursing framework this paper reports on a small scale qualitative inquiry which aimed to explore mental health nurses' perceptions and experiences of clinical supervision. Analysis of data derived from a series of semi-structured interviews provides very encouraging early indications that mental health nurses are becoming better able to reflect upon the nature of their own formative learning needs and so to take seriously their need for professional support as they strive towards a more therapeutic relationship with their patients. However, whilst all of the participants in the study had a positive perception of the potential value of clinical supervision, there is clear evidence to suggest that their actual experience was that 'good enough supervision' was more the exception than the rule. The participants' perceptions and experiences are described and the implications for research, practice, education and the management of service delivery systems are outlined.

Determinants of the willingness to endorse assisted suicide. A survey of physicians, nurses, and social workers

The authors surveyed 1,137 physicians, nurses, and social workers (overall response = 48%) to characterize the willingness to endorse assisted suicide. Willingness to endorse varied among disciplines and was negatively correlated with level of religious belief (r = -0.35, P < 0.0001), knowledge of symptom management (r = -0.21, P < 0.0001), and time managing symptoms (r = -0.21, P < 0.0001). On multivariate analysis, the significant predictors were lesser religious belief (P < 0.0001), greater concern about analgesic toxicity (P = 0.001), diminished empathy (P = 0.03), lesser knowledge of symptom management (P < 0.04), and the interaction between religious belief and knowledge of symptom management (P = 0.04). Professionals' attitudes toward assisted suicide are influenced by diverse personal attributes, among which may be competence in symptom management and burnout.

Assisted suicide: clinical realities and ethical challenges

The increasing attention to assisted suicide, as evidenced by recent legislation, initiatives, court decisions, and research, propels the issue to a new level of importance and urgency within society and the health professions. Nurses cannot help but be confronted by and struggle with the complex moral and professional quandaries related to assisted suicide. Critical care nurses must continue to evaluate the implications of the possible legalization of assisted suicide and to define the boundaries of morally acceptable professional practice. The challenges to the roles and responsibilities of critical care nurses that might occur if assisted suicide were legalized must be thoughtfully and responsibly explored.

Assisted suicide: clinical realities and ethical challenges

The increasing attention to assisted suicide, as evidenced by recent legislation, initiatives, court decisions, and research, propels the issue to a new level of importance and urgency within society and the health professions. Nurses cannot help but be confronted by and struggle with the complex moral and professional quandaries related to assisted suicide. Critical care nurses must continue to evaluate the implications of the possible legalization of assisted suicide and to define the boundaries of morally acceptable professional practice. The challenges to the roles and responsibilities of critical care nurses that might occur if assisted suicide were legalized must be thoughtfully and responsibly explored.

End-of-life decisions: the role of the nurse

Nurses confront the clinical realities and controversies of end-of-life decisions in all practice settings and professional roles. It is imperative that nurses consider these issues and understand the ethical and professional parameters of practice. A code of ethics and professional position statements can provide guidance and support as nurses attempt to fulfill their professional obligations and deliver competent and compassionate end-of-life care.

A professional code of ethics: providing a moral compass for turbulent times

PURPOSES/OBJECTIVES

To describe the importance of a professional code of ethics and values in guiding and supporting the practice of nurses and to present the proposed Oncology Nursing Society (ONS) Statement of Core Values.

DATA SOURCES

Published articles and books on nursing ethics and bioethics, as well as authors' clinical experiences.

DATA SYNTHESIS

Ethical quandaries are commonplace for nurses, and the contemporary context of health care has created new concerns and redefined others. Throughout its history, nursing has been an ethical endeavor, with nurses attempting to sift through complex ethical issues and fulfill their professional responsibilities. A professional code of ethics and values explicates the goals and norms of the profession and provides direction for practice.

CONCLUSION

Together, the profession's code of ethics and the proposed ONS Statement of Core Values serve as a resource to guide oncology nurses as they develop an ethically competent practice and confront contemporary ethical challenges.

IMPLICATIONS FOR NURSING PRACTICE

The goal of developing an ethically competent practice, maintaining professional integrity, and rendering quality patient care is of vital concern to oncology nurses. Familiarity with and commitment to the primary ethical precepts and values of the profession are essential to accomplishing this goal.

Priority ethical issues in oncology nursing: current approaches and future directions

PURPOSE/OBJECTIVES

To describe ethical issues determined to be highly important to oncology nurses and to discuss strategies by which the Oncology Nursing Society (ONS) can address these priority concerns.

DATA SOURCES

Survey on oncology nurses regarding ethical issues; nursing literature.

DATA SYNTHESIS

Nine priority ethical issues of oncology nurses are identified. Past, current, and future ONS activities that address these priority issues are discussed.

IMPLICATIONS FOR NURSING PRACTICE

ONS must support activities to increase the knowledge, confidence, and involvement of oncology nurses in discussions and decision making related to the ethical issues.

CONCLUSIONS

The top three priority ethical issues for oncology nurses are assisted suicide, end-of-life decisions, and pain management. Efforts should be made to increase ethics expertise among the ONS membership.

When values conflict with obligations: safeguards for nurses

Increasingly, nurses are being confronted with clinical situations that challenge their personal and professional integrity. For integrity to be preserved, safeguards must be developed and an environment that supports ethical practice fostered. Standards such as those promulgated by the JCAHO provide an important opportunity for nurses to create mechanisms to assure that diverse religious, cultural, and ethical beliefs of nurses are respected and upheld.

The cellular Na+ pump as a site of action for carbon monoxide and glutamate: a mechanism for long-term modulation of cellular activity

Carbon monoxide (CO) induces a long-lasting alteration in cerebellar alpha 3-Na,K-ATPase independent of [Na+] but linked to cGMP synthesis and localized to Purkinje neurons. The action of CO is absent in Purkinje neuron-deficient mice, mimicked by 8-Br-cGMP, and blocked by inhibition of PKG. Glutamate (Glu) and metabotropic agonists mimic the action of CO, an effect that requires PKC and is associated with CO synthesis. These data suggest that CO regulates Na,K-ATPase through cGMP and PKG, and that Glu regulates CO through mGluRs. This system is also modulated by NMDA agonists and nitric oxide, possibly via Glu release, as well as by free radicals. These findings offer a mechanism by which CO, Glu, and free radicals can exert specific effects on synaptic transmission (relevant to long-term changes in cell excitability), as well as more general actions on energy metabolism (relevant to the pathophysiology of excitotoxicity).

Atrial natriuretic peptide modulates sodium and potassium-activated adenosine triphosphatase through a mechanism involving cyclic GMP and cyclic GMP-dependent protein kinase

Prior studies indicate that the natriuretic effects of atrial natriuretic peptide (ANP) are due, in part, to an inhibition of the passive movement of sodium ions from tubular lumen through apical cation channels into renal tubular epithelium. The present work demonstrates that ANP also exerts a potent inhibitory effect on the active pumping of sodium ions by renal tubular sodium and potassium-activated adenosine triphosphatase (Na, K-ATPase). This action of ANP is relatively long lasting, is due to a change in enzyme Vmax and is specific for ouabain-sensitive activity. Enzyme modulation occurs with an EC50 for ANP of 0.1 nM, is independent of intracellular [Na+] and is associated with an increase in tissue cyclic GMP (cGMP), but not cyclic AMP (cAMP). Modulation of Na, K-ATPase by ANP is mimicked by 8-bromo-cGMP and okadaic acid (OA) and is blocked by KT 5823, a selective inhibitor of cGMP-dependent protein kinase (PKG), but not by KT 5720, a selective inhibitor of cyclic AMP-dependent protein kinase (PKA), which suggests that the action of ANP on the sodium pump involves cGMP-mediated changes in protein phosphorylation. Regulation of renal Na, K-ATPase activity also occurs with nitric oxide-generating compounds, such as nitroglycerin and sodium nitroprusside (SNP). However, the ability of ANP to modulate Na, K-ATPase does not appear to involve this latter pathway because the effects of ANP on the sodium pump cannot be blocked by either N omega-nitro-L-arginine, an inhibitor of NO synthase, or hemoglobin, which blocks NO through binding.(ABSTRACT TRUNCATED AT 250 WORDS)

Seeing to one's self. Those who care for persons with AIDS must also preserve their own well-being

Those who care for persons with AIDS face a number of special issues. They must understand the complex clinical course of the disease, be ready to cope with its devastating effects on patients, know how to address social prejudices against persons with AIDS, and be prepared to deal with the stresses of providing care under difficult circumstances. To be effective, care givers must know how to take care of themselves. Having a philosophy of care is one key component of self-care because it gives care givers a clear sense of direction and helps them enjoy a greater sense of well-being and personal satisfaction. Creating a motivating environment, taking responsibility for the challenges and stresses of the job, building a supportive team, understanding the AIDS experience, and confronting the effects of grief are also important components in the self-care of the AIDS care giver.