The role and mechanisms of microvascular damage in the ischemic myocardium.

Following myocardial ischemic injury, the most effective clinical intervention is timely restoration of blood perfusion to ischemic but viable myocardium to reduce irreversible myocardial necrosis, limit infarct size, and prevent cardiac insufficiency. However, reperfusion itself may exacerbate cell death and myocardial injury, a process commonly referred to as ischemia/reperfusion (I/R) injury, which primarily involves cardiomyocytes and cardiac microvascular endothelial cells (CMECs) and is characterized by myocardial stunning, microvascular damage (MVD), reperfusion arrhythmia, and lethal reperfusion injury. MVD caused by I/R has been a neglected problem compared to myocardial injury. Clinically, the incidence of microvascular angina and/or no-reflow due to ineffective coronary perfusion accounts for 5-50% in patients after acute revascularization. MVD limiting drug diffusion into injured myocardium, is strongly associated with the development of heart failure. CMECs account for > 60% of the cardiac cellular components, and their role in myocardial I/R injury cannot be ignored. There are many studies on microvascular obstruction, but few studies on microvascular leakage, which may be mainly due to the lack of corresponding detection methods. In this review, we summarize the clinical manifestations, related mechanisms of MVD during myocardial I/R, laboratory and clinical examination means, as well as the research progress on potential therapies for MVD in recent years. Better understanding the characteristics and risk factors of MVD in patients after hemodynamic reconstruction is of great significance for managing MVD, preventing heart failure and improving patient prognosis.

Magnetic-Manipulated NK Cell Proliferation and Activation Enhance Immunotherapy of Orthotopic Liver Cancer.

The immunotherapy of deep solid tumors in the human body, such as liver cancer, still faces great challenges, especially the inactivation and insufficient infiltration of immune cells in solid tumor microenvironment. Natural killer (NK) cells are gaining ever-increasing attention owing to their unique features and are expected to play an important role in the liver cancer immunotherapy. However, NK cells are severely insufficient and inactivated in solid liver tumor due to the highly immunosuppressive intratumor microenvironment, resulting in poor clinical therapeutic efficacy. Herein, we propose a mild magnetocaloric regulation approach using a magnetogenetic nanoplatform MNPs@PEI-FA/pDNA (MPFD), which is synthesized by loading a heat-inducible plasmid DNA (HSP70-IL-2-EGFP) on polyethyleneimine (PEI)- and folic acid (FA)-modified ZnCoFe2O4@ZnMnFe2O4 magnetic nanoparticles (MNPs) to promote the proliferation and activation of tumor-infiltrating NK cells under magnetic manipulation without the limitation of penetration depth for orthotopic liver cancer immunotherapy. The magnetothermally responsive MPFD serves as a magnetism-heat nanotransducer to induce the gene transcription of IL-2 cytokine in orthotopic liver tumor for NK cell proliferation and activation. Both in vitro and in vivo results demonstrate that the remote mild magnetocaloric regulation (∼40 °C) by MPFD initiates the HSP70 promoter to trigger the overexpression of IL-2 cytokine for subsequent secretion, leading to in situ expansion and activation of tumor-infiltrating NK cells through the IL-2/IL-2 receptor (IL-2R) pathways and the resulting prominent tumor inhibition. This work not only evidences the great potential of magnetogenetic nanoplatform but also reveals the underlying proliferation and activation mechanism of NK cells in liver cancer treatment by magnetogenetic nanoplatform.

A prediction model to predict in-hospital mortality in patients with acute type B aortic dissection.

BACKGROUND: Acute type B aortic dissection (ABAD) is a life-threatening cardiovascular disease. A practicable and effective prediction model to predict and evaluate the risk of in-hospital death for ABAD is required. The present study aimed to construct a prediction model to predict the risk of in-hospital death in ABAD patients. METHODS: A total of 715 patients with ABAD were recruited in the first affiliated hospital of Xinjiang medical university from April 2012 to May 2021. The information on the demographic and clinical characteristics of all subjects was collected. The logistic regression analysis, receiver operating characteristic (ROC) curve analysis, and nomogram were applied to screen the appropriate predictors and to establish a prediction model for the risk of in-hospital mortality in ABAD. The receiver operator characteristic curve and calibration plot were applied to validate the performance of the prediction model. RESULTS: Of 53 (7.41%) subjects occurred in-hospital death in 715 ABAD patients. The variables including diastolic blood pressure (DBP), platelets, heart rate, neutrophil-lymphocyte ratio, D-dimer, C-reactive protein (CRP), white blood cell (WBC), hemoglobin, lactate dehydrogenase (LDH), procalcitonin, and left ventricular ejection fraction (LVEF) were shown a significant difference between the in-hospital death group and the in-hospital survival group (all P < 0.05). Furthermore, all these factors which existed differences, except CRP, were associated with in-hospital deaths in ABAD patients (all P < 0.05). Then, parameters containing LVEF, WBC, hemoglobin, LDH, and procalcitonin were identified as independent risk factors for in-hospital deaths in ABAD patients by adjusting compound variables (all P < 0.05). In addition, these independent factors were qualified as predictors to build a prediction model (AUC > 0.5, P < 0.05). The prediction model was shown a favorable discriminative ability (C index = 0.745) and demonstrated good consistency. CONCLUSIONS: The novel prediction model combined with WBC, hemoglobin, LDH, procalcitonin, and LVEF, was a practicable and valuable tool to predict in-hospital deaths in ABAD patients.

Teaching and learning in interprofessional ethics education: Tutors' perspectives.

BACKGROUND: Ethical dilemmas that arise in the clinical setting often require the collaboration of multiple disciplines to be resolved. However, medical and nursing curricula do not prioritize communication among disciplines regarding this issue. A common teaching strategy, problem-based learning, could be used to enhance communication among disciplines. Therefore, a university in southern Taiwan developed an interprofessional ethics education program based on problem-based learning strategies. This study described tutors' experience teaching in this program. AIM: To explore the phenomenon of teaching and learning in interprofessional ethics education for medical and nursing students from the perspectives of tutors. DESIGN: Phenomenological qualitative research. METHODS: Medical and nursing students completed a 6-week interprofessional ethics education program moderated by either physician or nurse tutors. At the conclusion of the ethics education program, all 14 tutors were invited to participate in focus group interviews. Among them, six tutors (three nursing tutors and three physician tutors) participated in additional individual interviews. All of the contents from the focus group interviews and individual interviews were recorded and transcribed. Using the phenomenological approach, the phenomenon of teaching and learning in interprofessional ethics education were generated. ETHICAL CONSIDERATION: The study was approved by the Institutional Review Board. FINDINGS: Three themes emerged from the tutors' teaching perspectives, including the instructor's motivation to teach, the use of narrative case scenarios, and the emphasis on improving interprofessional ethics communication. DISCUSSION: Problem-based learning creates an interprofessional communication platform in interprofessional ethics education. The phenomenon of value convergence between tutors and students, between different students' professions, and between different students' professional maturities is observed. CONCLUSION: Problem-based learning is an effective teaching strategy for creating a communication platform for interprofessional ethics education. Ethic curriculum should emphasize motivating instructor, use narrative case scenarios, and focus on interprofessional communication.

Progress on the mechanism of left-right asymmetrical patterning in bilaterians.

Left-right asymmetry is an essential feature in bilateral animals. The mechanism underlying the left-right asymmetrical organ morphogenesis is a central question in developmental biology. Studies in vertebrates show that left-right asymmetry formation needs three essential steps: the initial left-right symmetry breaking, the left-right asymmetrical gene expression, and the left-right asymmetrical organ morphogenesis. Many vertebrates use cilia to produce directional fluid flow to break symmetry during embryonic development, asymmetric Nodal-Pitx2 signaling to pattern the left-right asymmetry, and Pitx2 and other genes to control the morphogenesis of asymmetrical organs. In invertebrates, there are left-right mechanisms independent of cilia and even others more different from that of vertebrates. In this review, we summarize the major steps and relevant molecular mechanisms of left-right asymmetric development in vertebrates and invertebrates, aiming to provide a reference for the understanding of the origin and evolution of the left-right developmental mechanism.

[The Elephant in the Room: Integrative Care for Community Hospice Palliative Care in Taiwan: An Example of a Regional Teaching Hospital in Pingtung County].

Taiwan has been an aging society since 2018. As a result, long-term care, end-of-life autonomy, and hospice care have received increasing attention. The government of Taiwan promotes home-based healthcare through the National Health Insurance System to enable the efficient utilization of medical resources and reduce overall medical costs. Taiwan's community hospice and palliative care network is expected to serve as the main care model supplementing partial hospitalization and institutional care. In this article, we review the history of and policies related to hospice and palliative care in Taiwan using a literature review and examining Pingtung County as a case study. The implementation of home-based palliative care is also outlined and policy revisions are proposed. The results are intended to provide a reference for healthcare authorities and medical institutions to promote community hospice and palliative care policies. The integrated care model can enhance the capacity of community-based palliative care, support patients receiving palliative care and their family members and caregivers, and ensure physical and psychological comfort for patients. This model contributes to the realization of older adults' preference for dying at home, which is especially pronounced in cultures where traditional Chinese ideas are deeply rooted.

The journey of embracing life: Mothers' perspectives of living with their children with retinoblastoma.

PURPOSE: This study aimed to explore the experience and views of mothers with children who have been diagnosed with retinoblastoma. DESIGN AND METHODS: A descriptive qualitative study was conducted in the period of 2019-2021. Interviews were conducted with 21 mothers of children diagnosed with retinoblastoma in Indonesia. Data were collected by semi-structured interviews and examined by content analysis. RESULTS: Mothers evolved from a sense of unacceptability to accepting challenges and gaining inner strength. Three themes were identified: 1) physical and psychological suffering, 2) awareness of changes and demands, and 3) keep moving forward. Mothers developed positive adaptive mechanisms for coping with the problems associated with having a child with retinoblastoma. Psychological adjustment and religious beliefs were key elements in their journeys toward embracing life in the moment. CONCLUSION: Findings illuminated psychological adaptation and coping strategies of mothers with seriously ill children and highlighted how difficulties and cultural norms shaped the adaptative process. Religion and health beliefs played varied and important roles in helping mothers to manage their stress and enhance their coping strategies. PRACTICE IMPLICATIONS: Our findings revealed that it is important to routinely assess social support, traditional health beliefs, and spirituality on mothers, facilitate mentoring to help mothers find their inner strengths, and develop intervention programs designed to promote psychological adjustment without delaying treatment.

[Living With Cancer: Clinical Application of Mindfulness on Cancer-Related Fatigue].

Cancer-related fatigue is the most common and longest-lasting symptom of discomfort experienced by cancer patients. Its effects on patients include physical, psychological, emotional, and cognitive stress, which greatly reduce quality of life. The field of mind-body integrated medicine has improved gradually in recent years, with many evidence-based studies supporting the efficacy of mindfulness as a symptom management strategy for cancer-related fatigue. Based on a review of the literature, this paper introduces the definition of cancer-related fatigue and related assessments and treatments, describes the origin of mindfulness and related concepts, and introduces mindfulness-based empirical treatment strategies for cancer-related fatigue, including mindfulness-based stress reduction and mindfulness-based cognitive therapy, and their effects. The findings are intended to provide clinicians with a reference for the future care of patients with cancer-related fatigue.

Illness Experiences of Advanced Cancer Patients in Taiwan.

The illness experiences of advanced cancer patients are discussed in a Taiwanese cultural context, using an interpretive ethnographic approach (interviews and participant observations) emphasizing holism and symbolic interactionism. A total of 23 advanced cancer patients from different counties in Taiwan were recruited over a 42-month period. The researcher followed their progress as they approached death to better understand their terminal cancer experiences. An interpretive analysis guided by Agar's hermeneutic cycle approach revealed five emic dimensions: feeling the oppression of death, fighting alongside family, intensifying bodily healing efforts, settling unfinished business, and ending the struggle to control pain. Implications for caregivers are discussed.

KLF2 induces the senescence of pancreatic cancer cells by cooperating with FOXO4 to upregulate p21.

Pancreatic cancer is one of the most common malignancies in the world. Senescence is frequently observed in the progression of pancreatic cancer. In a previous study, we showed that KLF2 inhibited the growth and migration of pancreatic cancer. However, the mechanisms are not fully understood. In this study, we showed that overexpression of KLF2 induced the senescence of pancreatic cancer cells and inhibited tumorigenesis, and knockdown of KLF2 inhibited senescence and p21 expression. In the molecular mechanism study, KLF2 was found to interact with FOXO4 and cooperated with FOXO4 to induce the expression of p21. Downregulation of p21 and FOXO4 impaired the induction of senescence by KLF2. Overall, this study revealed the functions and mechanisms of KLF2 in senescence and provided a novel explanation for the suppressive roles of KLF2 in pancreatic cancer.

A prediction model based on platelet parameters, lipid levels, and angiographic characteristics to predict in-stent restenosis in coronary artery disease patients implanted with drug-eluting stents.

BACKGROUND: The present study was aimed to establish a prediction model for in-stent restenosis (ISR) in subjects who had undergone percutaneous coronary intervention (PCI) with drug-eluting stents (DESs). MATERIALS AND METHODS: A retrospective cohort study was conducted. From September 2010 to September 2013, we included 968 subjects who had received coronary follow-up angiography after primary PCI. The logistic regression analysis, receiver operator characteristic (ROC) analysis, nomogram analysis, Hosmer-Lemeshow χ2 statistic, and calibration curve were applied to build and evaluate the prediction model. RESULTS: Fifty-six patients (5.79%) occurred ISR. The platelet distribution width (PDW), total cholesterol (TC), systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and lesion vessels had significant differences between ISR and non-ISR groups (all P < 0.05). And these variables were independently associated with ISR (all P < 0.05). Furthermore, they were identified as predictors (all AUC > 0.5 and P < 0.05) to establish a prediction model. The prediction model showed a good value of area under curve (AUC) (95%CI): 0.72 (0.64-0.80), and its optimized cut-off was 6.39 with 71% sensitivity and 65% specificity to predict ISR. CONCLUSION: The incidence of ISR is 5.79% in CAD patients with DES implantation in the Xinjiang population, China. The prediction model based on PDW, SBP, TC, LDL-C, and lesion vessels was an effective model to predict ISR in CAD patients with DESs implantation.

Effect of dissolved organic matter on the phytoremediation of Cd-contaminated soil by cotton.

Dissolved organic matter (DOM) assists in the phytoremediation of heavy-metal-contaminated soils, but the effect of synergistic remediation of DOM on plants is unclear. This study investigated the effect of two DOM sources (cotton straw (CM) DOM and farmyard manure (FM) DOM) on cadmium (Cd) accumulation in Cd-contaminated soil by cotton and evaluated the phytoremediation effect of DOM. The results showed that adding DOM reduced the available nitrogen and increased organic matter, available phosphorus and available potassium. Applying DOM increased the proportions of Cd acid soluble fractions and reduced the proportions of Cd residual fractions by 1-7%. DOM application increased root length, root surface area and root volume compared to the control and had a promoting or inhibiting effect on cotton biomass, depending on the soil Cd concentration. Furthermore, applying DOM improved the Cd content and bioconcentration factor of cotton. The lower the molecular weight, hydrophilic components and aromaticity of DOM, the more conducive to Cd accumulation is in cotton. The correlation and random forest analyses also showed that CM showed high remediation potential. According to our study, DOM can improve the phytoremediation efficiency of cotton, especially in low-concentration contaminated soils. This study provides a basis for applying DOM in the phytoremediation of Cd-contaminated soils.

Overexpression of IκBα in cardiomyocytes alleviates hydrogen peroxide-induced apoptosis and autophagy by inhibiting NF-κB activation.

BACKGROUND: Inflammation and oxidative stress play predominant roles in the initiation and progression of ischaemia/reperfusion (I/R) injury, with nuclear factor kappa B (NF-κB) serving as a crucial mediator. Overexpression of the inhibitor of κB alpha (IκBα) gene is hypothesized to have protective effects against apoptosis and autophagy in cardiomyocytes subjected to hydrogen peroxide (H2O2) by inhibiting the NF-κB pathway. METHODS: The IκBαS32A, S36A gene was transfected via adeno-associated virus serotype 9 (AAV9) delivery into neonatal rat ventricular cardiomyocytes (NRVMs) prior to H2O2 treatment. NRVMs were divided into control, H2O2, GFP + H2O2, IκBα+H2O2, and pyrrolidine dithiocarbamate (PDTC) + H2O2 groups. Nuclear translocation of the NF-κB p65 subunit was evaluated by immunofluorescence and Western blotting. Cell viability was assessed by Cell Counting Kit-8 assay. Supernatant lactate dehydrogenase (LDH) and intracellular malondialdehyde (MDA) were measured to identify H2O2-stimulated cytotoxicity. Apoptosis was determined by Annexin V-PE/7-AAD staining, and the mitochondrial membrane potential (ΔΨm) was detected by JC-1 staining. Western blotting was used to detect apoptosis- and autophagy-related proteins. RESULTS: IκBα transfection significantly increased cell viability and ΔΨm but decreased the supernatant LDH and cellular MDA levels in cardiomyocytes exposed to H2O2. Meanwhile, IκBα overexpression decreased H2O2-induced apoptosis by upregulating the Bcl-2/Bax ratio and reduced autophagy by downregulating the expression of Beclin-1 and the LC3-II/LC3-I ratio. These effects partly accounted for the ability of IκBα to inhibit the NF-κB signalling pathway, as evidenced by decreases in p65 phosphorylation and nuclear translocation. Indeed, the effects of inactivation of NF-κB signalling with the specific inhibitor PDTC resembled the cardioprotective effects of IκBα during H2O2 stimulation. CONCLUSION: IκBα overexpression can ameliorate H2O2-induced apoptosis, autophagy, oxidative injury, and ΔΨm loss through inhibition of the NF-κB signalling pathway. These findings suggest that IκBα transfection can result in successful resistance to oxidative stress-induced damage by inhibiting NF-κB activation, which may provide a potential therapeutic target for the prevention of myocardial I/R injury.

Phronesis of nurses: A response to moral distress.

BACKGROUND: As moral action could help nurses reduce moral distress, it is necessary to carry out qualitative research to present the experiences in which nurses apply moral action. AIM: To describe and analyze the phronesis applied by nurses in the face of moral distress. RESEARCH DESIGN: The research participants were invited to participate in in-depth interviews. The research materials were based on the stories described by the research participants and recorded by means of first-person narrative. Narrative analysis was applied to interpret the nurses' phronesis. PARTICIPANTS: Twenty-seven nurses from Taiwan. ETHICAL CONSIDERATIONS: The Institutional Review Board of the Kaohsiung Medical University Hospital in Taiwan confirmed that this study passed the research ethical review. FINDINGS: According to the narrative analysis results, the phenomenon of moral distress contains difficulty, action, and idea transformation. The difficulty is the source of moral distress, action is the practice of moral courage, and idea transformation is the nurse's emotional movement. Action and idea transformation are collectively called phronesis in this study. DISCUSSION: Moral distress refers to a state of suffering caused by situations in which nurses cannot carry out their ethical intentions. Phronesis is the process through which nurses take actions and relocate the subjects and is an ethical way to find relief from moral distress. Starting with empathy and respectful attitudes arising from self-reflection, nurses may be helped to get relief from the suffering of moral distress. CONCLUSION: Phronesis can help nurses positively face the emotional strain of moral distress. This article puts forward a narrative method to complete the four steps of phronesis: write about the care experience, identify the difficulties in the stories, seek the possibility of action, and form a new care attitude, which could help nurses learn to reduce their moral distress.

Cardioprotective effects of constitutively active MEK1 against H2O2-induced apoptosis and autophagy in cardiomyocytes via the ERK1/2 signaling pathway.

Oxidative stress injury is one of the main mechanisms of ischemia-reperfusion (I/R) injury. The extracellular signal-regulated kinase (ERK1/2) pathway plays an important role in cardioprotective during acute myocardial infarction. In this study, we used constitutively active MEK1 gene (CaMEK) transfection strategy to investigate whether CaMEK provides a protective effect against apoptosis and autophagy induced by Hydrogen peroxide (H2O2) in neonatal rat cardiac ventricular cardiomyocytes (NCMs) and the underlying mechanisms. As a result, CaMEK attenuated H2O2-induced apoptosis and cytotoxicity in NCMs, evidenced by decreased apoptotic cells and the ratio of Bax/Bcl-2, increased the mitochondrial membrane potential (Δψm) and cell vitality and reduced the level of lactate dehydrogenase (LDH). Further studies revealed that CaMEK attenuated H2O2-induced autophagy, evidenced by the decreased LC3-Ⅱ/LC3-Ⅰratio and SQSTM1/p62 (p62) degradation. Furthermore, we demonstrated that CaMEK phosphorylated the ERK1/2 pathway-related proteins, ERK1/2, p70S6K and GSK3ß, in NCMs with H2O2 stimulation. In contrast, these effects could be reversed by co-treatment with the ERK1/2 inhibitor, PD98059. These results suggest that CaMEK plays an important role in protecting cardiomyocytes against H2O2-induced injury and autophagy in NCMs via ERK1/2 pathway. Therefore, transfection of CaMEK may provide a hopeful therapeutic strategy for I/R.

Macrophage migration inhibitory factor plays an essential role in ischemic preconditioning-mediated cardioprotection.

Ischemic preconditioning (IPC) is an endogenous protection strategy against myocardial ischemia-reperfusion (I/R) injury. Macrophage migration inhibitory factor (MIF) released from the myocardium subjected to brief periods of ischemia confers cardioprotection. We hypothesized that MIF plays an essential role in IPC-induced cardioprotection. I/R was induced either ex vivo or in vivo in male wild-type (WT) and MIF knockout (MIFKO) mice with or without proceeding IPC (three cycles of 5-min ischemia and 5-min reperfusion). Indices of myocardial injury, regional inflammation and cardiac function were determined to evaluate the extent of I/R injury. Activations of the reperfusion injury salvage kinase (RISK) pathway, AMP-activated protein kinase (AMPK) and their downstream components were investigated to explore the underlying mechanisms. IPC conferred prominent protection in WT hearts evidenced by reduced infarct size (by 33-35%), myocyte apoptosis and enzymatic markers of tissue injury, ROS production, inflammatory cell infiltration and MCP1/CCR2 expression (all P<0.05). IPC also ameliorated cardiac dysfunction both ex vivo and in vivo These protective effects were abolished in MIFKO hearts. Notably, IPC mediated further activations of RISK pathway, AMPK and the membrane translocation of GLUT4 in WT hearts. Deletion of MIF blunted these changes in response to IPC, which is the likely basis for the absence of protective effects of IPC against I/R injury. In conclusion, MIF plays a critical role in IPC-mediated cardioprotection under ischemic stress by activating RISK signaling pathway and AMPK. These results provide an insight for developing a novel therapeutic strategy that target MIF to protect ischemic hearts.

Apolipoprotein A1 is associated with SYNTAX score in patients with a non-ST segment elevation myocardial infarction.

BACKGROUND: The study was designed to investigate lipid profile and SYNTAX score in patients with non-ST segment elevation myocardial infarction (NSTEMI). METHODS: 311 patients with NSTEMI were enrolled. The demographic, clinical data, blood samples and SYNTAX score were documented. The Pearson linear correlation was used to detect confounding factors linearly correlated with SYNTAX score. The significantly correlated confounding factors were put into the multiple linear regressions. RESULTS: The Pearson linear correlation showed that high-density lipoprotein- cholesterol (HDL-C) and apolipoprotein A1 (ApoA1) were significantly correlated with Syntax Score (r = - 0.119, P = 0.044 and r = - 0.182, P = 0.002, respectively). The multiple linear regressions for Syntax Score were built using HDL-C and ApoA1, respectively. After the adjustment of other significantly correlated confounding factors such as white blood cell count (WBC), myohemoglobin (MB), glutamic-oxalacetic transaminase (AST) and creatinine, the ApoA1 still showed significant association with Syntax Score (ß = - 0.151, P = 0.028). The area under curve was (AUC) 0.624 and the optimal cutoff value is 1.07 g/L when using ApoA1 to predict moderate and severe coronary artery lesions. The patients with ApoA1 ≥ 1.07 g/L and < 1.07 g/L have the Syntax Scores of 12.21 ± 11.58 and 16.33 ± 11.53, respectively (P = 0.001). CONCLUSIONS: The ApoA1 is the only lipid factor significantly associated with complexity of coronary artery lesion in patients with NSTEMI, the patients with ApoA1 < 1.07 g/L may have more complex coronary artery lesions.

Phenomenon of moral distress through the aspect of interpretive interactionism.

BACKGROUND: Most previous studies on moral distress focused on the factors that cause moral distress, paying inadequate attention to the moral conflict of nurses' values, the physician-nurse power hierarchy, and the influence of the culture. RESEARCH OBJECTIVE: To analyze the main causes for moral distress with interpretive interactionism. RESEARCH DESIGN: A qualitative study was adopted. PARTICIPANTS: Through purposeful sampling, 32 nurses from 12 different departments were chosen as the samples. ETHICAL CONSIDERATIONS: Approval from the Institutional Review Board of the Kaohsiung Medical University Hospital. FINDINGS: Moral distress is likely to occur in the following clinical situations: patients have no idea about their diseases; the medical decisions fail to meet the optimum benefit of patients; and patients with terminal cancers are not given a proper death. The reason why nurses become trapped in moral distress is that they fail to achieve moral goodness. Inadequate confidence, the physician-nurse power hierarchy, and the Oriental culture affect nurses' goodness-based intention for patients, which deteriorates moral distress. DISCUSSION: The main cause for moral distress is the moral goodness of nurses. If nurses' goodness-based intention for patients is inconsistent with the moral objective of achieving optimum benefit for patients, it leads to moral distress. Culture is an essential background factor of care for patients. In the Oriental culture, family members influence patients' right to know about their diseases, the choice of treatment, and patients' autonomy of not receiving cardio-pulmonary resuscitation. This results in moral distress in medical care. CONCLUSION: The occurrence of moral distress demonstrates that nurses have moral characteristics such as goodness and caring. It is suggested that appropriate educational strategies can be adopted to weaken the power hierarchy between physicians and nurses and enhance nurses' confidence and cultural sensitivity, so as to reduce the moral distress of nurses.

The meaning of rituals after a stillbirth: A qualitative study of mothers with a stillborn baby.

AIMS AND OBJECTIVES: To explore the meaning of rituals that women and their families perform after a stillbirth. BACKGROUND: A cultural taboo in Taiwan prohibits discussing death; thus, parents of stillborn babies have no established public mourning or burial ceremonies to perform for their stillborn children. Stillbirths are often treated as if they had never happened. DESIGN: Qualitative descriptive study. METHODS: In-depth interviews, which were transcribed and content analysed, were conducted with a purposive sample of 16 women discharged from two teaching hospitals in Taiwan after they had a stillbirth. RESULTS: Families engaged in rituals for two underlying reasons: to benefit the deceased child and the immediate family. The meanings of the rituals for the child are presented through three themes: (i) sending the baby's spirit to a safe place, (ii) protecting it from suffering and (iii) preparing it for a better reincarnation. The meanings of rituals for the families are presented through four themes: (i) releasing parental guilt by doing their best for the deceased child, (ii) cutting bonds with the child, (iii) avoiding additional misfortune should they mishandle the funeral and (iv) praying for a successful subsequent pregnancy. CONCLUSIONS: Death-related rituals are highly culturally diverse. This study fills a gap about Asian cultures. Participating in rituals permits a mother to do something for her deceased child, helps relieve her guilt and lets her cope with the stillbirth. Rituals after a stillbirth can help a woman recover from grieving and allow her to hope for a successful subsequent pregnancy. RELEVANCE TO CLINICAL PRACTICE: Health professionals should discuss with bereaved parents what rituals they would like to perform and then respect their decisions. A continuum of care and support that exists from the prenatal diagnosis through the stillbirth and beyond is recommended for parents and families during this difficult time.

Clinical characteristics, treatments, and outcomes of patients with anti-N-methyl-d-aspartate receptor encephalitis: A systematic review of reported cases.

Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is a recently recognized autoimmune disorder which is responsive to immunotherapy. However, the outcomes of different immunotherapies have not been defined and there have been few studies that carried out a comparison among them. To provide an overview of the clinical characteristics, treatments, and outcomes of anti-NMDAR encephalitis, we systematically reviewed the literature in the PubMed, Medline, Embase, Cochrane Library, BioMedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wan-fang databases. Eighty-three studies with a total of 432 patients were included. The median age was 22years. Two hundred ninety-three (68%) patients were female, 87 (21%) of 412 patients had a tumor, including 68 (78%) patients with ovarian teratoma. Pediatric patients had a higher ratio of seizures to psychiatric symptoms as the initial manifestation (p=0.0012), a lower proportion with a tumor (p<0.0001) and CSF pleocytosis (p=0.0163), and a better outcome (p=0.0064) than adults. Patients who died had a higher proportion of CSF pleocytosis than the patients who survived (p=0.0021). There were no significant differences among three first-line immunotherapy used alone (p=0.9172) or among combinations of every two of them (p=0.3059). With regard to the use of corticosteroid and IVIG, there were no significant differences between the outcomes of early combined treatment and sequential treatment (p=0.7277), or between using corticosteroid first and IVIG first (p=0.5422). Our findings suggest that the clinical characteristics and outcomes for pediatric patients were different from adult patients, and no significant differences were found among different immunotherapies.