Australian and Danish nurses' and midwives' wellbeing during COVID-19: A comparison study.

Background: Most investigations of nurses' and midwives' psychological wellbeing during the COVID-19 pandemic have been conducted in a single setting. Aim: To assess and compare the psychological wellbeing of nurses and midwives in Australia and Denmark during the COVID-19 pandemic. Methods: Nurses and midwives employed at four metropolitan health services in Australia and one in Denmark completed an anonymous online survey, which assessed depression, anxiety, and stress symptoms (The Depression, Anxiety and Stress Scale - 21 Items (DASS-21)), and sociodemographic and employment factors. Findings: Completed surveys were received from 3001 nurses and midwives (1611 Australian and 1390 Danish). Overall, approximately one in seven of the nurses and midwives surveyed reported moderate to extremely severe levels of depression (n = 399, 13.5%), anxiety (n = 381, 12.9%) and stress (n = 394, 13.4%). Australian nurses' and midwives' scores on all DASS-21 subscales were significantly higher (representing higher levels of depression, anxiety and stress) than the scores for the Danish nurses and midwives. Fewer years of clinical experience, living in Australia and being employed on a part-time basis were significantly associated with higher levels of psychological distress. Discussion: A considerable proportion of nurses and midwives experienced distress during the COVID-19 pandemic; however, the proportion and severity varied by country. Australian nurses and midwives experienced higher levels of distress than their Danish colleagues. Conclusion: Nurses and midwives working in countries with relatively low numbers of COVID-19 cases and deaths are also likely to experience psychological distress. Nurses and midwives would benefit from targeted country-specific support and wellbeing initiatives.

Role of interferon regulatory factor 7 in serum-transfer arthritis: regulation of interferon-ß production.

OBJECTIVE: Innate immune responses activate synoviocytes and recruit inflammatory cells into the rheumatoid joint. Type I interferons (IFNs) play a role in autoimmunity, and IFN gene transcription is activated by IFN-regulatory factors (IRFs) in response to innate sensor recognition. The purpose of this study was to examine the effect of genetic deficiency of IRF-7 in a passive K/BxN serum-transfer model of arthritis. METHODS: Passive-transfer arthritis was induced in IRF-7(-/-) mice, and additional groups were treated with IFNß or poly(I-C). Clinical arthritis scoring, histologic assessment, micro-computed tomography, and synovial tissue quantitative polymerase chain reaction analysis were performed. Mouse serum was analyzed by enzyme-linked immunosorbent assay (ELISA). RESULTS: In the passive K/BxN serum-transfer model, arthritis severity was significantly increased in IRF-7(-/-) mice compared with wild-type (WT) mice. In addition, expression of IFNß in synovium and serum was decreased, potentially contributing to increased arthritis. IRF-7(-/-) mice injected with replacement IFNß had a decrease in arthritis. Poly(I-C) treatment diminished arthritis in IRF-7(-/-) mice, restored synovial IFNß gene expression, and increased serum levels of IFNß. In vitro studies demonstrated that poly(I-C) stimulation of fibroblast-like synoviocytes (FLS) from IRF-7(-/-) mice resulted in increased induction of proinflammatory gene expression as compared with FLS from WT mice; however, IFNß expression was not significantly different. In contrast, peritoneal macrophages from IRF-7(-/-) mice showed significantly less induction of IFNß in response to poly(I-C) stimulation. CONCLUSION: IRF-7 deficiency exacerbates arthritis and replacement treatment with IFNß or poly(I-C) decreases arthritis severity. Both macrophage- and synoviocyte-specific roles of IRF-7 likely contribute to the increased arthritis. IRF-7 might play an antiinflammatory role in passive-transfer arthritis through regulation of macrophage IFNß production.

The introduction of registered undergraduate students of midwifery in a tertiary hospital: Experiences of staff, supervisors, and women.

BACKGROUND: The Registered Undergraduate Student of Midwifery (RUSOM) workforce model provides final year midwifery students an opportunity of paid employment and gain experience as an assistant to midwives. A RUSOM supports the work of midwives by providing care to women and their newborns. Little is known about how the RUSOM role impacts the range of stakeholders in maternity care settings. AIM: To evaluate the acceptability of the RUSOM role, how it is experienced by staff and women, and its impact on quality of care. METHODS: A mixed-methods approach including 9 qualitative focus groups (n = 41) and 4 descriptive surveys (n = 135) was used. FINDINGS: The introduction of the RUSOM role has numerous benefits for the service, midwifery staff, women, and the RUSOM themselves. The RUSOM relieved the burden on the postnatal ward, giving midwives more time to work at their higher end of scope in direct clinical care. Having a clear scope of practice for the role ensured there were clear boundaries between the RUSOM and the midwife, resulting in the positive satisfaction for the maternity services team and women in their care. DISCUSSION: Employing RUSOM staff has both immediate and long-term benefits for maternity services. The role had the potential to improve the professional development of upcoming midwives, leading to high quality and experienced graduates that are an invaluable asset to a maternity service. CONCLUSION: The positive outcome from this evaluation provides evidence for the expansion of the RUSOM model which can enhance the quality of care for women.

Synoviocyte innate immune responses: II. Pivotal role of IFN regulatory factor 3.

Innate immune responses contribute to synovial inflammation in rheumatoid arthritis. The present study was designed to investigate the contribution of IFN regulatory factor (IRF)3 and IRF7 to type I IFN-regulated gene expression in synoviocytes. Fibroblast-like synoviocytes were stimulated with polyinosinic-polycytidylic acid (poly [I-C]) after transfection with IRF3 or IRF7 small interfering RNA to knockdown transcription factor expression. Western blots, luciferase assay after transfection with reporter constructs, quantitative PCR, and AP-1 DNA binding ELISA were performed to evaluate the role of IRF3 and IRF7 in poly (I-C)-induced signaling and synoviocyte gene expression. IRF3 regulates IFN-stimulated response element (ISRE) promoter activity as well as IFN-beta, IRF5, IRF7, RANTES, IFN-inducible protein-10, MCP-1, and MIP1alpha gene expression in response to poly (I-C). IRF7 knockdown modestly decreased a subset of genes and ISRE activity, although the results were not statistically significant. Surprisingly, IRF3 knockdown almost completely blocked expression of additional genes in which the ISRE is not traditionally considered a dominant promoter site in fibroblast-like synoviocytes, including matrix metalloproteinase (MMP)3, MMP9, IL-6, and IL-8. Transcription factor activation studies demonstrated a role for IRF3 in regulation of c-Jun phosphorylation and AP-1 binding. IRF3 rather than IRF7 regulates poly (I-C)-induced type I IFN responses in human synoviocytes by increasing ISRE promoter activity. IRF3 also partially regulates expression of other cytokines and MMP through activation of c-Jun and the AP-1 promoter site. Targeting synoviocyte IRF3 represents a potential approach to suppress diverse mediators while limiting suppression of IRF7-mediated immune responses.

Targeting interferon regulatory factors to inhibit activation of the type I IFN response: implications for treatment of autoimmune disorders.

The type I interferon (IFN) response plays a critical role in autoimmunity and is induced by innate receptor ligation and activation of IFN-regulatory factors (IRF). The present study investigated the roles and functional hierarchy of IRF3, IRF5, and IRF7 in expression of cytokines, chemokines, and matrix metalloproteinases in human THP1 monocytic cells. Targeted IRF knockdown was followed by evaluation of gene expression, promoter activation, and mRNA stability to determine the role of IRF as potential targets for modulating IFN responses in patients with autoimmune diseases. IRF played a distinct role in regulation of type I IFN gene expression in human monocytic cells and specifically regulated gene expression through the IFN-stimulated response element, with no contribution to transcription of traditionally AP-1 or NF-kB regulated genes. IRF7 regulated IL-6 gene expression by increasing IL-6 mRNA stability. IRF regulation of inflammation and induction of the IFN signature might contribute to the pathogenesis of autoimmune diseases and therefore represent novel therapeutic targets.

Immediate impact of the COVID-19 pandemic on the work and personal lives of Australian hospital clinical staff.

Objective This study investigated the short-term psychosocial effects of the COVID-19 pandemic on hospital clinical staff, specifically their self-reported concerns and perceived impact on their work and personal lives. Methods Nurses, midwives, doctors and allied health staff at a large metropolitan tertiary health service in Melbourne, Australia, completed an anonymous online cross-sectional survey between 15 May and 10 June 2020. The survey assessed respondents' COVID-19 contact status, concerns related to COVID-19 and other effects of COVID-19. Space was provided for free-text comments. Results Respondents were mostly concerned about contracting COVID-19, infecting family members and caring for patients with COVID-19. Concerns about accessing and using personal protective equipment, redeployment and their ability to provide high-quality patient care during the pandemic were also reported. Pregnant staff expressed uncertainty about the possible impact of COVID-19 on their pregnancy. Despite their concerns, few staff had considered resigning, and positive aspects of the pandemic were also described. Conclusion The COVID-19 pandemic has had a considerable impact on the work and personal lives of hospital clinical staff. Staff, particularly those who are pregnant, would benefit from targeted well-being and support initiatives that address their concerns and help them manage their work and personal lives. What is known about the topic? The COVID-19 pandemic is having an impact on healthcare workers' psychological well-being. Little is known about their COVID-19-related concerns and the perceived impact of the pandemic on their work and personal lives, particularly hospital clinical staff during the 'first wave' of the pandemic in Australia. What does this paper add? This paper contributes to a small but emerging evidence base about the impact of the COVID-19 pandemic on the work and personal lives of hospital clinical staff. Most staff were concerned about their own health and the risk to their families, friends and colleagues. Despite their concerns, few had considered resigning. Uncertainty about the possible impact of COVID-19 on pregnancy was also reported. What are the implications for practitioners? During the current and future pandemics, staff, especially those who are pregnant, would benefit from targeted well-being and support initiatives that address their concerns and help them manage the impact on their health, work and personal lives.

Psychological well-being of Australian hospital clinical staff during the COVID-19 pandemic.

Objective This study assessed the psychological well-being of Australian hospital clinical staff during the COVID-19 pandemic. Methods An anonymous online cross-sectional survey was conducted in a large metropolitan tertiary health service located in Melbourne, Australia. The survey was completed by nurses, midwives, doctors and allied health (AH) staff between 15 May and 10 June 2020. The Depression, Anxiety and Stress Scale - 21 items (DASS-21) assessed the psychological well-being of respondents in the previous week. Results In all, 668 people responded to the survey (nurses/midwives, n=391; doctors, n=138; AH staff, n=139). Of these, 108 (16.2%) had direct contact with people with a COVID-19 diagnosis. Approximately one-quarter of respondents reported symptoms of psychological distress. Between 11% (AH staff) and 29% (nurses/midwives) had anxiety scores in the mild to extremely severe ranges. Nurses and midwives had significantly higher anxiety scores than doctors (P<0.001) and AH staff (P<0.001). Direct contact with people with a COVID-19 diagnosis (P<0.001) and being a nurse or midwife (P<0.001) were associated with higher anxiety scores. Higher ratings of the health service's pandemic response and staff support strategies were protective against depression (P<0.001), anxiety (P<0.05) and stress (P<0.001). Conclusions The COVID-19 pandemic had a significant effect on the psychological well-being of hospital clinical staff, particularly nurses and midwives. Staff would benefit from (additional) targeted supportive interventions during the current and future outbreaks of infectious diseases. What is known about the topic? The outbreak of COVID-19 is having, and will have, a considerable effect on health services. No Australian data about the effect of COVID-19 on the psychological well-being of hospital clinical staff are available. What does this paper add? Australia healthcare providers have experienced considerable emotional distress during the COVID-19 pandemic, particularly nurses and midwives and clinical staff who have had direct contact with people with a COVID-19 diagnosis. In this study, nurses and midwives had significantly higher levels of anxiety, depression and stress during the pandemic than general Australian adult population norms, and significantly more severe anxiety symptoms than medical and AH staff. Despite a lower number of COVID-19 cases and a lower death rate than in other countries, the proportion of Australian hospital clinical staff experiencing distress is similar to that found in other countries. What are the implications for practitioners? Targeted well-being interventions are required to support hospital clinical staff during the current and future outbreaks of infectious diseases and other 'crises' or adverse events.

Synoviocyte innate immune responses: I. Differential regulation of interferon responses and the JNK pathway by MAPK kinases.

JNK is a key regulator of matrix metalloproteinase production in rheumatoid arthritis. It is regulated by two upstream kinases known as MKK4 and MKK7. Previous studies demonstrated that only MKK7 is required for cytokine-mediated JNK activation and matrix metalloproteinase expression in cultured fibroblast-like synoviocytes (FLS). However, the functions of MKK4 and MKK7 in synoviocyte innate immune responses have not been determined. TNF, peptidoglycan (PGN), and LPS stimulation led to higher and more prolonged MKK7 phosphorylation compared with MKK4 in FLS. However, this pattern was reversed in poly(I-C) stimulated cells. siRNA knockdown studies showed that TNF, PGN, and LPS-induced JNK and c-Jun phosphorylation are MKK7 dependent, while poly(I-C) responses require both MKK4 and MKK7. Poly(I-C)-induced expression of IP-10, RANTES, and IFN-beta mRNA was decreased in MKK4- or MKK7-deficient FLS. However, MKK4 and MKK7 deficiency did not affect phosphorylation of IkappaB kinase-related kinases in the TLR3 signaling pathway. MKK7, but not MKK4 deficiency, significantly decreased poly(I-C)-mediated IRF3 dimerization, DNA binding, and IFN-sensitive response element-mediated gene transcription. These results were mimicked by the JNK inhibitor SP600125, indicating that JNK can directly phosphorylate IRF3. In contrast, deficiency of either MKK4 or MKK7 decreased AP-1 transcriptional activity. Therefore, JNK is differentially regulated by MKK4 and MKK7 depending on the stimulus. MKK7 is the primary activator of JNK in TNF, LPS, and PGN responses. However, TLR3 requires both MKK4 and MKK7, with the former activating c-Jun and the latter activating both c-Jun and IRF3 through JNK-dependent mechanisms.

Guiding climate change adaptation within vulnerable natural resource management systems.

Climate change has the potential to compromise the sustainability of natural resources in Mediterranean climatic systems, such that short-term reactive responses will increasingly be insufficient to ensure effective management. There is a simultaneous need for both the clear articulation of the vulnerabilities of specific management systems to climate risk, and the development of appropriate short- and long-term strategic planning responses that anticipate environmental change or allow for sustainable adaptive management in response to trends in resource condition. Governments are developing climate change adaptation policy frameworks, but without the recognition of the importance of responding strategically, regional stakeholders will struggle to manage future climate risk. In a partnership between the South Australian Government, the Adelaide and Mt Lofty Ranges Natural Resource Management Board and the regional community, a range of available research approaches to support regional climate change adaptation decision-making, were applied and critically examined, including: scenario modelling; applied and participatory Geographical Information Systems modelling; environmental risk analysis; and participatory action learning. As managers apply ideas for adaptation within their own biophysical and socio-cultural contexts, there would be both successes and failures, but a learning orientation to societal change will enable improvements over time. A base-line target for regional responses to climate change is the ownership of the issue by stakeholders, which leads to an acceptance that effective actions to adapt are now both possible and vitally important. Beyond such baseline knowledge, the research suggests that there is a range of tools from the social and physical sciences available to guide adaptation decision-making.

Art therapy: promoting wellbeing in rural and remote communities.

Art therapy encompasses both preventative and curative activities and aims to improve ways of engaging those who might be reticent in seeking more traditional forms of psychological support offered through 'talking therapies'. The Longreach base of the Royal Flying Doctor Service in Queensland provides mental health support to people living in rural and remote locations in central western Queensland and has been complemented since 2006 by the addition of a full-time art therapist. This paper provides an overview of art therapy and a description of this innovative approach to addressing mental health needs in a rural and remote setting.

An analysis of network brokerage and geographic location in fifteenth-century AD Northern Iroquoia.

Iroquoian villagers living in present-day Jefferson County, New York, at the headwaters of the St. Lawrence River and the east shore of Lake Ontario, played important roles in regional interactions during the fifteenth century AD, as brokers linking populations on the north shore of Lake Ontario with populations in eastern New York. This study employs a social network analysis and least cost path analysis to assess the degree to which geographical location may have facilitated the brokerage positions of site clusters within pan-Iroquoian social networks. The results indicate that location was a significant factor in determining brokerage. In the sixteenth century AD, when Jefferson County was abandoned, measurable increases in social distance between other Iroquoian populations obtained. These results add to our understandings of the dynamic social landscape of fifteenth and sixteenth century AD northern Iroquoia, complementing recent analyses elsewhere of the roles played in regional interaction networks by populations located along geopolitical frontiers.

Primer: signal transduction in rheumatic disease--a clinician's guide.

Signaling pathways enable cells to respond and adapt to environmental stimuli. For instance, extracellular ligands, such as proinflammatory cytokines or pathogen components, bind receptors on the surface of cells that trigger downstream signaling cascades driven by enzymes called kinases. Ultimately, kinases activate transcription factors that bind to DNA and alter the expression of target genes, the products of which allow the cell to respond to the initial stimulus. A variety of chronic inflammatory diseases are associated with altered cellular signaling. Some of the signal cascades that are involved in inflammation and autoimmunity include those mediated by mitogen-activated protein kinases, nuclear factor-kappaB, interferon regulatory factor and Toll-like receptors, NOD-like receptors and the inflammasome, and phosphatidylinositol-3-kinases. Understanding these intracellular pathways might lead to new approaches to the treatment of inflammatory disease, including the use of orally bioavailable small molecules that regulate cytokine function and production.

Pregnancy and dermatologic surgery.

The physiologic changes of pregnancy and risks to the fetus require attention during dermatologic surgery. Elective surgery should be performed in the second trimester or the postpartum period. Cosmetic work should occur after delivery to avoid hypertrophic or hyperpigmented scars. Skin preparatory agents and anesthetics may have fetal implications and should be chosen with care. Antibiotic selection for any infections must take into account possible maternal and fetal risks. Attention to detail and awareness of the changes in pregnancy should lead to safe surgery in the pregnant patient.

Pityrosporum folliculitis: diagnosis and management in 6 female adolescents with acne vulgaris.

BACKGROUND: Pityrosporum folliculitis is a common inflammatory skin disorder that may mimic acne vulgaris. Some adolescents with recalcitrant follicular pustules or papules may have acne and Pityrosporum folliculitis simultaneously. Clinical response is dependent on treating both conditions. OBJECTIVES: To demonstrate the similarity in clinical manifestation between acne vulgaris and Pityrosporum folliculitis, the benefit of potassium hydroxide preparation, and the benefit of appropriate antifungal therapy. PATIENTS: We describe 6 female adolescents with concurrent Pityrosporum folliculitis infection and acne vulgaris. INTERVENTION: A potassium hydroxide examination was performed on all 6 patients from the exudate of follicular pustules exhibiting spores consistent with yeast. All patients were treated with oral antifungals, and 5 of the 6 patients were also treated with topical antifungals. RESULTS: Six of 6 patients improved with antifungal treatment. All patients also required some ongoing therapy for their acne. CONCLUSIONS: These patients demonstrate that follicular papulopustular inflammation of the face, back, and chest may be due to a combination of acne vulgaris and Pityrosporum folliculitis, a common yet less frequently identified disorder. Symptoms often wax and wane depending on the patient's activities, time of the year, current treatment regimens, and other factors. Pityrosporum folliculitis will often worsen with traditional acne therapy and dramatically respond to antifungal therapy.

Rheumatoid arthritis: regulation of synovial inflammation.

Rheumatoid arthritis (RA) is a systemic, inflammatory autoimmune disorder that presents as a symmetric polyarthritis associated with swelling and pain in multiple joints, often initially occurring in the joints of the hands and feet. Articular inflammation causes activation and proliferation of the synovial lining, expression of inflammatory cytokines, chemokine-mediated recruitment of additional inflammatory cells, as well as B cell activation with autoantibody production. A vicious cycle of altered cytokine and signal transduction pathways and inhibition of programmed cell death contribute to synoviocyte and osteoclast mediated cartilage and bone destruction. A combination of targeted interventions at various stages in the pathogenesis of RA will likely be required to control symptoms in certain patients with this complex and potentially disabling disease. The regulation of rheumatoid synovial inflammation will be reviewed, followed by a brief summary of the therapeutic implications of these advances, including strategies targeting key cytokines, signal transduction molecules, co-stimulatory molecules, B cells, chemokines, and adhesion molecules.

Inflammatory tinea pedis/manuum masquerading as bacterial cellulitis.

BACKGROUND: Tinea pedis and tinea manuum in children are more common than previously recognized. Clinical presentations of dermatophyte infections may vary in children and may be difficult to diagnose. OBJECTIVE: To show the necessity of potassium hydroxide preparations and/or fungal cultures in assessing suspicious cases of cellulitis in children who may have dermatophyte infections. PATIENTS: We describe 4 children with inflammatory tinea pedis or tinea manuum who were initially misdiagnosed as having bacterial cellulitis. INTERVENTION: A potassium hydroxide examination was performed on 3 patients. Fungal cultures were performed on 2 patients. RESULTS: Inflammatory/bullous dermatophyte infections were detected by potassium hydroxide examination in all 4 patients and all 4 children successfully responded to topical antifungal therapy. CONCLUSIONS: These cases demonstrate that inflammatory tinnea pedis/manuum can masquerade as cellulitis in children. Early potassium hydroxide examination can allow appropriate antifungal treatment to be initiated before fungal culture results are finalized.