A Cultural Humility Approach to Inclusive and Equitable Nursing Care.

The nursing workforce does not represent the diversity of patients in their care. Nursing students historically have been taught cultural competence, with a core value for diversity, equity, and inclusion, but health inequities remain a problem. Cultural humility goes beyond cultural competency, offering nurses a perpetual learning role from the individual patients in their care. The concept of cultural humility also offers bedside nurses a way to overcome implicit and explicit bias through self-awareness and active listening, but it may not be well understood.

Improvement in patient-reported outcomes after lung transplantation is not impacted by the use of extracorporeal membrane oxygenation as a bridge to transplantation.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is increasingly used as a bridge to lung transplantation. The impact of preoperative ECMO on health-related quality of life (HRQL) and depressive symptoms after lung transplantation remains unknown, however. METHODS: In a single-center prospective cohort study, we assessed HRQL and depressive symptoms before and at 3, 6, and 12 months after lung transplantation using the Short Form 12 Physical and Mental Component Scores (SF12-PCS and SF12-MCS), Airway Questionnaire 20-Revised (AQ20R), EuroQol 5D (EQ5D), and Geriatric Depression Scale (GDS). Changes in HRQL were quantified by segmented linear mixed-effects models controlling for age, sex, diagnosis, preoperative forced expiratory volume in 1 second, 6-minute walk distance, and Lung Allocation Score. We compared changes in HRQL among subjects bridged with ECMO, subjects hospitalized but not on ECMO, and subjects called in for transplantation as outpatients. RESULTS: Out of 189 subjects, 17 were bridged to transplantation with ECMO. In all groups, improvements in HRQL following lung transplantation exceeded the minimally clinically important difference using the SF12-PCS, AQ20R, EQ5D, and GDS. HRQL defined by SF12-MCS did not change after transplantation. Improvements were generally similar among the groups, except for EQ5D, which showed a trend toward less benefit in the outpatients, possibly due to their better HRQL before lung transplantation. CONCLUSIONS: Subjects ill enough to require ECMO as a bridge to lung transplantation appear to achieve similar improvements in HRQL and depressive symptoms as those who do not. It is reassuring to both providers and patients that lung transplantation provides substantial improvements in HRQL, even for those patients who are critically ill in the run up to transplantation.

Gastroesophageal Reflux in the Intensive Care Unit Patient.

The incidence of gastroesophageal reflux disease (GERD) in the critically ill patient in the intensive care unit is unknown. Interventions used in critically ill patients, such as sedation, tracheal tubes, mechanical ventilation, enteral feedings, positioning, and medications, along with specific patient characteristics and comorbid conditions contribute to an increased risk for gastroesophageal reflux (GER) in this population. Critical care nurses have an integral role in helping identify critically ill patients at risk for GER or with known GERD, in preventing complications associated with these conditions.

Quantitative 3D evaluation of step ascent and descent in individuals with Down syndrome--analysis of a daily challenging task.

BACKGROUND: Step ascent and descent can perturb stability increasing the incidence of falls, especially in older individuals with functional limitations and intellectual disabilities, such as those with Down syndrome (DS). The aim of this study was to investigate the biomechanics and motor coordination of step ascent and descent in adults with DS and compare them with a group of healthy individuals, considering movement kinematics and kinetics. METHOD: Fourteen adults with DS and 12 similarly aged adults without DS who were free of known motor problems were quantitatively assessed during ascending and descending a step using an optoelectronic system (BTS SMART-D), force platforms and video recording. Kinematic and kinetic parameters were identified and calculated for each study participant and comparisons were made between the DS and a control group (CG). RESULTS: Despite similar age ranges, subjects in the DS group performed the step ascent and descent movements slower, with longer duration and with a more accentuated range of motion of the trunk and of the ankle joint than those in the CG. Additionally, the double stance phase on the step was substantially longer in the DS group when represented as a percentage of the entire stepping sequence (ascent, double stance on the step and descent). In terms of kinetics, ground force platform data revealed that the DS subjects showed higher instability in the medio-lateral direction during double support phase than similarly aged CG subjects and cannot be attributed to age-associated changes in stability. CONCLUSIONS: These findings help to elucidate the complex biomechanical strategy of people with DS during a step ascent and descent movement task and may have a major role in the multidimensional evaluation and tailored management for them.

Placement, relocation and end of life issues in aging adults with and without Down's syndrome: a retrospective study.

BACKGROUND: Aging adults with Down's syndrome (DS) experience more relocations and other life events than adults with intellectual disabilities aged 50 and older without DS. Age-related functional decline and the higher incidence of dementia were implicated as the contributing factors that led to relocation and nursing home placement. METHOD: A retrospective study of adults with intellectual disabilities who were born prior to the year 1946 was conducted to analyse the number of relocations experienced over a 5- and 10-year period. The cohort consisted of 140 individuals (61 with DS between ages 50-71 years, and 79 without DS between ages 57-89 years) who had been referred to a diagnostic and research clinic. RESULTS: Analyses revealed the number of relocations over a 5- and 10-year period were significantly greater in the DS group. Placement in a nursing home for end of life care was significantly higher in the DS group whereas the majority (90%) in the non-DS group remained in a group home setting. Mortality was significantly earlier in the DS group with the mean age at death to be 61.4 years compared with 73.2 years in the non-DS group. CONCLUSIONS: The present results suggest that aging adults with DS encounter more relocations, and are more likely to have their final placement for end of life care in a nursing home. In contrast, the adults without DS were subjected to less relocation and remained in the same group home setting.

Pilot-scale evaluation of separate-stage nitrification using an attached-growth, moving-bed media process.

Submerged attached-growth processes, both fixed and moving bed, are becoming more popular. These processes may or may not be used in combination with suspended-growth treatment. The objective of this project was to evaluate a tertiary attached-growth, moving-bed media nitrification system based on the ammonia-nitrogen removal rates and effluent concentrations that could be achieved. A pilot-scale system for nitrification of secondary municipal wastewater effluent was operated for 142 days. The minimum aeration requirements for media mixing provided sufficient dissolved oxygen. The generation of biological solids from nitrification was insignificant. Design effluent ammonia-nitrogen concentrations (<6 mg/L) were achieved at influent loading rates greater than design (1.18 g ammonia-nitrogen/[m2 x d]) coincident with detention times shorter than design conditions (4 hours). Empirical relationships for the ammonia-nitrogen removal rate and effluent concentration as a function of influent ammonia-nitrogen loading were developed. Detention time is believed to be an important parameter affecting these relationships.

The psychometric properties of the Multi-Dimensional Observation Scale for Elderly Subjects (MOSES) in middle aged and older populations of people with mental retardation.

OBJECTIVE: To assess the internal consistency, inter-scale correlations and factor structure of the MOSES with older adults with mental retardation. METHOD: A series of outpatients with mental retardation were assessed with the MOSES. 163 middle aged and older adults with mental retardation living in community settings participated. RESULTS: The subscales and total scale of the Multi-Dimension Observation Scale for Elderly Subjects (MOSES) were highly internally consistent. The pattern of correlations between the five scales was very similar to that reported by Dalton et al. (1999). The results of a factor analysis using varimax rotation indicated a three-factor structure corresponding to adaptive behavior, externalizing and internalizing maladaptive behaviors. CONCLUSIONS: The MOSES appears to be was a psychometrically adequate instrument to screen older adults with mental retardation.

Challenging behaviours should not be considered as depressive equivalents in individuals with intellectual disability.

BACKGROUND: Depression is one of the most common forms of psychopathology in people with intellectual disability (ID). The present study evaluated the utility of an expanded assessment of psychiatric symptoms and challenging behaviours, as measured by the Clinical Behavior Checklist for Persons with Intellectual Disabilities (CBCPID). METHODS: The CBCPID was administered to 92 people with ID, 35 of whom were diagnosed with a depressive disorder. RESULTS: Item and factor analysis of the scale indicated that depression was best assessed using the core DSM-IV symptoms of depressive disorder. Challenging behaviours such as self-injury or aggression were not closely associated with depression. Short scales using the core DSM-IV symptoms of depression were highly internally consistent. There was also evidence of the validity of these scales. CONCLUSIONS: This study found no evidence that challenging behaviours were depressive equivalents in this population. The present authors conclude that the assessment of depression in people with ID should focus on the core DSM-IV symptoms of depression.

Developmental trajectories of brain volume abnormalities in children and adolescents with attention-deficit/hyperactivity disorder.

CONTEXT: Various anatomic brain abnormalities have been reported for attention-deficit/hyperactivity disorder (ADHD), with varying methods, small samples, cross-sectional designs, and without accounting for stimulant drug exposure. OBJECTIVE: To compare regional brain volumes at initial scan and their change over time in medicated and previously unmedicated male and female patients with ADHD and healthy controls. DESIGN, SETTING, AND PARTICIPANTS: Case-control study conducted from 1991-2001 at the National Institute of Mental Health, Bethesda, Md, of 152 children and adolescents with ADHD (age range, 5-18 years) and 139 age- and sex-matched controls (age range, 4.5-19 years) recruited from the local community, who contributed 544 anatomic magnetic resonance images. MAIN OUTCOME MEASURES: Using completely automated methods, initial volumes and prospective age-related changes of total cerebrum, cerebellum, gray and white matter for the 4 major lobes, and caudate nucleus of the brain were compared in patients and controls. RESULTS: On initial scan, patients with ADHD had significantly smaller brain volumes in all regions, even after adjustment for significant covariates. This global difference was reflected in smaller total cerebral volumes (-3.2%, adjusted F(1,280) = 8.30, P =.004) and in significantly smaller cerebellar volumes (-3.5%, adjusted F(1,280) = 12.29, P =.001). Compared with controls, previously unmedicated children with ADHD demonstrated significantly smaller total cerebral volumes (overall F(2,288) = 6.65; all pairwise comparisons Bonferroni corrected, -5.8%; P =.002) and cerebellar volumes (-6.2%, F( 2,288) = 8.97, P<.001). Unmedicated children with ADHD also exhibited strikingly smaller total white matter volumes (F(2,288) = 11.65) compared with controls (-10.7%, P<.001) and with medicated children with ADHD (-8.9%, P<.001). Volumetric abnormalities persisted with age in total and regional cerebral measures (P =.002) and in the cerebellum (P =.003). Caudate nucleus volumes were initially abnormal for patients with ADHD (P =.05), but diagnostic differences disappeared as caudate volumes decreased for patients and controls during adolescence. Results were comparable for male and female patients on all measures. Frontal and temporal gray matter, caudate, and cerebellar volumes correlated significantly with parent- and clinician-rated severity measures within the ADHD sample (Pearson coefficients between -0.16 and -0.26; all P values were <.05). CONCLUSIONS: Developmental trajectories for all structures, except caudate, remain roughly parallel for patients and controls during childhood and adolescence, suggesting that genetic and/or early environmental influences on brain development in ADHD are fixed, nonprogressive, and unrelated to stimulant treatment.

Alpha2 macroglobulin elevation without an acute phase response in depressed adults with Down's syndrome: implications.

Studies of immune function during depression in persons without intellectual disability (ID) have revealed elevated levels of alpha2 macroglobulin (alpha2M) and an acute phase protein (APP) response. Clinical observation suggests that people with Down's syndrome (DS) may have associated genetic abnormalities in their immune systems. The APP response and alpha2M changes in depressed versus non-depressed adults with DS was the subject of the present study. The serum pan-proteinase inhibitor alpha2M, and the AP proteins c-reactive protein (CRP), alpha1 antitrypsin (alpha1AT), ceruloplasmin (Cp), beta2 Macroglobulin (beta2M), transthyretin (Trans), serum amyloid protein (SAP), and albumin (Alb) were measured in 38 adults with DS, 19 of whom were diagnosed with and 19 without depression using a sandwich enzyme-linked immunosorbent assay (ELISA). The DSM-IV criteria were used for diagnoses. Medical and neurological examinations excluded medical disorders associated with APP response. Only alpha2M and CRP were significantly different in the depressed versus non-depressed groups. The alpha2M was higher, a response similar to one observed in depressed people without ID, but the CRP was lower in the depressed group, especially in those subjects not on psychotropic medications, contrary to the expected APP response to depression. The results suggest that alpha2M elevation in depressed adults with DS is independent of the APP response. An alternative explanation for its elevation is proposed linking the core symptom of depression with the mammalian dormancy/hibernation process. Further studies are needed to confirm that alpha2M elevation is specific to depression and that it might provide a helpful marker for the diagnosis of depression in people with ID.

Reunions between adoptees and birth parents: the adoptive parents' view.

This article looks at the reactions of adoptive parents to reunions between their adopted children and the children's birth parents. The focus is on how adoptive parents feel the reunion affects the family's integrity. Three types of family responses are identified: (1) closed, (2) divided, and (3) open. Acceptance of the differences between families created by adoption of children and those created by childbirth was a factor in the families' openness. Closed families saw no difference, and reunion suggested to the adults that they had failed as parents. Parents in open families understood the difference in families, saw the children as separate, and felt no threat to their competence as parents. Families' need for boundaries is examined, and the way the concept of family is constructed is discussed. Implications for the practice of adoption are considered.

Reunions between adoptees and birth parents: the adoptees' experience.

One hundred fourteen adult adoptees who had reunions with their birth parents responded to a mail questionnaire about these reunions. Some had been found by their birth parent, and others had searched for this parent. Those who searched were stimulated to do so by a life-cycle transition, by a need to get background information, and by a need to complete their sense of identity. For most of these adoptees, their self-esteem improved and their relationship with their adoptive parents was strengthened as a result of the reunion. These respondents advocate open adoption and better preparation for the adoptive family about adoptees' need to connect with their birth families.

Effects of discrimination training on reading improvement among adults.

This study examined the effects of discrimination training on improving reading skills for young adults. 90 college students (M age = 26.2 yr.), who were identified as low achievers with below average reading skills, were randomly assigned to one of three training conditions: the General Discrimination Group, the Reading Discrimination Group, and the Study Skills Group. Following 10 days of training, the subjects were tested on a standard reading achievement test, a problem-solving test, and a measure of cognitive style. Minimal differences between the pre- and posttraining scores for all three training conditions were noted. These findings contrast with developmental research that has indicated the importance of discrimination ability and suggest distinctive problems of adults with poor reading skills.

[A case of echinococcal cyst in the round ligament of the liver. Preliminary note]. / Su un caso di cisti da echinococco del legamento rotondo del fegato. Nota preliminare.

Hydatidosis is an endemic condition in many countries. The parasite may infect any tissues but the most commonly affected are the liver (70%), lungs (10%), muscles (4.7%), spleen (2.1%) and brain (1.4%) with bone, thyroid, breast and pancreas infections rarely encountered. An observed case of hydatid cyst of the round ligament of the liver is described. The aetiology, physiopathology and diagnosis of the case are briefly reviewed with emphasis on the fact that laparoscopy was better able to clarify the diagnosis than scintigraphy or echography.