Biosynthesis of Vitroprocines by α-Oxoamine Synthase and Oxidoreductase Identified from Vibrio sp. QWI-06.

A specific α-oxoamine synthase (VsAOS-2) and an oxidoreductase (VsOR) identified from marine Vibrio sp. QWI-06 were involved in the decarboxylative condensation of l-tyrosine to lauroyl-CoA following the reduction of the ketone group to form vitroprocine-type compound 1. The intermediates and products were characterized through HR-MS and their MS/MS fragmentations. This study reveals the biosynthetic pathway of vitroprocines and provides a useful model for elucidating the reaction mechanism underlying the production of amino acid-polyketide derivatives in microorganisms.

Structural insights into the substrate selectivity of α-oxoamine synthases from marine Vibrio sp. QWI-06.

Pyridoxal phosphate (PLP)-dependent α-oxoamine synthases are generally believed to be responsible for offloading and elongating polyketides or catalyzing the condensation of amino acids and acyl-CoA thioester substrates, such as serine into sphingolipids and cysteate into sulfonolipids. Previously, we discovered vitroprocines, which are tyrosine- and phenylalanine-polyketide derivatives, as potential new antibiotics from the genus Vibrio. Using bioinformatics analysis, we identified putative genes of PLP-dependent enzyme from marine Vibrio sp. QWI-06, implying a capability to produce amino-polyketide derivatives. One of these genes was cloned, and the recombinant protein, termed Vibrio sp. QWI-06 α-oxoamine synthases-1 (VsAOS1), was overexpressed for structural and biochemical characterization. The crystal structure of the dimeric VsAOS1 was determined at 1.8-Å resolution in the presence of L-glycine. The electron density map indicated a glycine molecule occupying the pyridoxal binding site in one monomer, suggesting a snapshot of the initiation process upon the loading of amino acid substrate. In mass spectrometry analysis, VsAOS1 strictly acted to condense L-glycine with C12 or C16 acyl-CoA, including unsaturated acyl analog. Furthermore, a single residue replacement of VsAOS1 (G243S) allowed the enzyme to generate sphingoid derivative when L-serine and lauroyl-CoA were used as substrates. Our data elucidate the mechanism of substrate binding and selectivity by the VsAOS1 and provide a thorough understanding of the molecular basis for the amino acid preference of AOS members.

Proteomics Approach for Biomarker Research in Major Depression: Antidepressant Effects.

BACKGROUND: The proteomics approach is the new mantra in disease biomarker research in areas such as major depression (MD). Current protocols for investigating biomarkers in biological fluid often employ both immuno- based and non-immuno-based technologies. METHOD: The immuno-based method is used normally in measuring well-known disease biomarkers, and commercial kits are often available. Immuno-based methods such as radio-immunoassay and enzyme-linked immunosorbent assay are sensitive and specific. However, tedious sample preparations such as filtration and centrifugation are required. Non-immuno-based technologies, such as matrix-assisted laser desorption/ionization- time of flight mass spectrometry has been proven to be useful techniques to rapidly screen disease biomarkers in human biological fluids. The mass spectrometer provides a powerful research tool in the proteomics field, not only in biomarker discovery but also in biomarker validation. A bioinformation tool like principal component analysis is a statistical procedure that utilizes proteomics data. CONCLUSION: In this article, we review the proteomics approaches in MD biomarker research and the data after the antidepressants treatment. And it covers a selection of advances in the realm of proteomics and its promise for major depression biomarker discovery and antidepressant effects. These technologies have opened new approaches to identifying signaling biomarkers associated with the cellular metabolism, cell life cycle, and detection of disease.

Detection of α-defensin in blister fluids as potential biomarkers for bullous pemphigoid patients by matrix-assisted laser desorption ionization/time-of-flight mass spectrometry.

BACKGROUND: Bullous pemphigoid (BP) is a chronic blistering disease that manifests as multiple tense bullae on the limbs and body. Detecting biomarkers present in skin fluids may assist in the early diagnosis and treatment of BP. In this study, a modern mass spectrometric method was developed for screening biomarkers in blister fluids collected from patients. METHODS: Blister fluids collected from BP patients and physically injured patients were analyzed and compared using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). The blister fluids were mixed with MALDI matrix solution on the target plate; after drying, they were analyzed by MALDI-TOF MS. RESULTS: Alpha-defensins 1-3 were detected in the samples collected from all BP patients and absent in all patients with physical injuries. Therefore, alpha-defensins 1-3 are potential biomarkers for BP and can be used to differentiate between blisters caused by BP and those caused by physical injuries. Compared to traditional skin biopsy methods that use immunofluorescent stains, analyzing biomarkers in blister fluids using MALDI-TOF is a more rapid and less invasive method. CONCLUSIONS: MALDI-TOF-MS is a non-invasive and efficient method that is able to rapidly distinguish between blisters caused by BP and those caused by physical injuries.

Rapid and simple analysis of disease-associated biomarkers of Taiwanese patients with schizophrenia using matrix-assisted laser desorption ionization mass spectrometry.

BACKGROUND: Matrix-assisted laser desorption ionization/time-of-flight mass spectrometry (MALDI-TOF MS) is an extremely sensitive analytical tool for characterizing biological compounds in bio samples. In this study, we applied MALDI-TOF MS to assess potential protein biomarkers in the peripheral blood mononuclear cells (PBMCs) of patients with schizophrenia in the acute phase, recovery phase and healthy controls in Taiwan. METHODS: We recruited 40 participants, including 20 pairs of patients diagnosed with schizophrenia in the acute phase, after four-week treatment with drug in the recovery phase, and 20 healthy controls. The schizophrenic patients were diagnosed using Structured Clinical Interview for DSM-IV Axis I Disorders (SCID), and severity was assessed by a positive and negative symptom scale at baseline and at endpoint following four-week treatment with drug. The patients' PBMCs biomarkers were rapidly measured using a technique that combines MALDI-TOF MS and principle component analysis. A receiver operating characteristic curve was created for the evaluated biomarker. RESULTS: Significant differences in α-defensins 1-3 were found between the patients in acute phase with schizophrenia and the healthy controls, but not between the schizophrenic patients in recovery phase and healthy controls or between the schizophrenic patients in acute phase and in recovery phase. CONCLUSIONS: α-Defensins can be biomarkers of Taiwanese patients with schizophrenia, thus supporting the hypothesis that the inflammatory response and immunity system is correlated with the pathophysiology of schizophrenia. Moreover, the result also implies that α-defensins may be related in schizophrenia-associated disease not in efficacy of drug-treatment.

Rapid detection of alteration of serum IgG in patients with schizophrenia after risperidone treatment by matrix-assisted laser desorption ionization/time-of-flight mass spectrometry.

RATIONALE: The aim of the study was to use a technique that combines acid hydrolysis and matrix-assisted laser desorption ionization/time-of-flight mass spectrometry (MALDI-TOF MS) in order to detect the serum biomarkers of patients diagnosed with schizophrenia both before and after four-week antipsychotic treatment with risperidone. METHODS: During this study's two-year period, inpatients were diagnosed with schizophrenia using the Structured Clinical Interview for DSM-IV Axis I Disorders. Severity was then evaluated using the Positive and Negative Syndrome Scale both at baseline and at endpoint following four-week treatment with risperidone. The patients' serum biomarkers were quickly measured using acid hydrolysis and MALDI-TOF MS. The resulting peptides were then analyzed using MALDI-TOF MS. We constructed a receiver operating characteristic (ROC) curve for the evaluated biomarkers. RESULTS: We recruited 20 pairs of participants for this study. The experimental group was treated with serum protein with HCl for 10 minutes to effectively hydrolyze abundant proteins. The target peptide, the immunoglobulin gamma chain (IgG), was then rapidly detected using this manner. A significant difference was found in the IgG levels of patients with schizophrenia before and after antipsychotic treatment. We constructed a ROC curve based on the IgG, and the area under said curve was 0.969. In comparison to conventional detection protocols, this method takes only minutes to complete and is also less costly. CONCLUSIONS: This study found that applying acid hydrolysis with MALDI-TOF MS technology could rapidly differentiate serum IgG levels in patients with schizophrenia before and after being treated with risperidone. This IgG difference may enhance the understanding of mechanism of antipsychotic treatment of schizophrenia. Copyright © 2016 John Wiley & Sons, Ltd.

Attenuated glial reaction in experimental proliferative vitreoretinopathy treated with liposomal doxorubicin.

PURPOSE: We investigated the therapeutic effect of liposomal doxorubicin (Lipo-dox) on experimental proliferative vitreoretinopathy (PVR). METHODS: The toxicity of Lipo-dox was determined in vitro in cultured rabbit retinal pigment epithelium (RPE) cells by tetrazolium-based (MTT) assay for cell viability performed 48 and 96 hours after treatment, and in vivo by electroretinography and histopathology. The therapeutic effect of intravitreous injection of Lipo-dox was evaluated in a rabbit model of PVR induced by injection of rabbit RPE cells after gas compression of the vitreous. The presence of PVR was determined by indirect ophthalmoscopy on days 1, 7, 14, 21, and 28 after injection. Western blot and immunofluorescence studies were performed to evaluate the expression of the glial markers vimentin and glial fibrillary acidic protein (GFAP). A pharmacokinetic study also was performed and analyzed by liquid chromatography coupled with tandem mass spectrometry (LC-MS). RESULTS: The 50% inhibitory concentrations (IC50) of doxorubicin (Doxo) and Lipo-dox in RPE cells were 0.01-0.1 and 0.1-1.0 µg/mL, respectively. Lipo-dox (10 µg/mL) did not reduce the amplitude reduction in the ERG study or produce obvious retinal toxicity. Lipo-dox still could be detected in the vitreous 7 days after injection. The Lipo-dox (10 µg/mL)-treated eyes showed lower grade PVR than did the untreated eyes. Lipo-dox also decreased the retinal expression levels of vimentin and GFAP. CONCLUSIONS: Lipo-dox can attenuate the severity of experimental PVR, and reduces the glial cell expression of intermediate filaments in PVR retinas. Lipo-dox has a wider safe dosage range and a longer half-life in the vitreous than does primary Doxo.

Limited PEG tube use: the experience of long-term care directions.

AIMS AND OBJECTIVES: To describe long-term care nursing directors' experiences with percutaneous endoscopic gastrostomy to understand the limited use of it in Taiwanese long-term care facilities. BACKGROUND: Percutaneous endoscopic gastrostomy tubes, used in Western countries since 1980, have not been readily used in Taiwanese long-term care facilities since their introduction in 1995. Instead, nasogastric tubes are used for extended periods. The reasons for limited percutaneous endoscopic gastrostomy use among long-term care residents are unknown. DESIGN: A phenomenologic qualitative design using in-depth semi-structured interviews collected the percutaneous endoscopic gastrostomy use experiences of directors of long-term care facilities. The directors also provided descriptive data on the prevalence of feeding tubes among their residents. METHODS: Eight directors of long-term care facilities in southern Taiwan participated in tape-recorded interviews. Data were thematically analysed using the methods of Strauss and Corbin. Feeding tube prevalence data were analysed using descriptive statistics. RESULTS: Four themes emerged as contributing to limited percutaneous endoscopic gastrostomy use in long-term care facilities: acceptability, availability, affordability and accountability. Over one-third of the residents required feeding tubes with 97% of those having nasogastric tube. Nasogastric tubes were used for a year or more in over half of the patients requiring enteral feeding. CONCLUSION: Chinese cultural values play a significant role in influencing end-of-life care and decisions about percutaneous endoscopic gastrostomy use. Nursing directors in long-term care assume a gatekeeper role to promote acceptability, provide availability and ensure accountability of nutritional interventions. Policy makers must be engaged to promote the affordability of percutaneous endoscopic gastrostomy use among long-term care residents. RELEVANCE TO CLINICAL PRACTICE: To improve nutritional outcomes among long-term care residents, nurses must acknowledge the Chinese culture related to percutaneous endoscopic gastrostomy tubes. Professionals must provide sufficient information about the advantages of percutaneous endoscopic gastrostomy tubes and discuss with families the meaning of quality of life and suffering at the end-of-life.

Clinical applicability of the World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF) to mothers of children with asthma in Taiwan.

AIMS: This study examined the clinical applicability of the World Health Organization Quality of Life Scale brief version (WHOQOL-BREF) to mothers of children with asthma in Taiwan. BACKGROUND: The WHOQOL-BREF scale has been culturally adapted for Taiwan and applied to a variety of ill and healthy subjects in hospitals and the community and to the general population in the 2001 National Health Interview Survey in Taiwan. Its application to explore the QOL of mothers of children with asthma in Taiwan allows future cross-population comparisons. DESIGN: A cross-sectional survey. METHODS: Internal consistency, test-retest reliability; content validity, criterion-related validity and discriminant validity were assessed. A total of 229 mothers participated in the study. RESULTS: The WHOQOL-BREF showed acceptable psychometric properties. Internal consistency of 0.63-0.84, content validity r = 0.39-0.65 (p < 0.01) and criterion-related validity r = 0.28-0.65 (p < 0.05) were reported. Discriminant validity was also found, especially in the domain of physical health. Issues of QOL for mothers, especially in the realm of physical health need more support and attention from health professionals. CONCLUSIONS: This study supports the clinical applicability of the WHOQOL-BREF scale as a measure of QOL of mothers of children with asthma. Future studies to compare the QOL measured by WHOQOL-BREF in female caregivers of children with other chronic health conditions are suggested. RELEVANCE TO CLINICAL PRACTICE: Our findings show that mothers are hardly ever free from the strains of the daily-care of an asthmatic and bear the uncertainties for the unending illness. The health care team is responsible for providing collaborative care approaches in hospital, home and school health care settings for children with asthma and their mothers.

Study of human neutrophil peptides in saliva by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

Matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry is used to rapidly characterize the human neutrophil peptides - HNP 1, 2, and 3 - in saliva. The saliva excreted from the parotid and sublingual/submandibular glands of 70 individuals were collected and examined using MALDI-TOF. The MALDI approach requires no sample pretreatment other than mixing the saliva-absorbing material with the matrix and drying under ambient conditions. Tissue paper was the best material for collecting the saliva samples because of its strong texture and high absorbance, and sinapinic acid was the best MALDI matrix for the analysis of the HNPs. HNPs were detected in almost all the samples collected from the parotid glands, with no obvious differences among age or gender. In contrast, the distribution of the HNPs in the samples collected from the sublingual/submandibular glands was age-dependent: no HNPs were detected for those collected from individuals younger than 30, but the HNPs were present in all of the samples collected from those older than 60 years. The increased probability of detecting saliva HNPs with age suggests that HNPs may function as a biomarker for aging.

Serum free hemoglobin as a novel potential biomarker for acute ischemic stroke.

OBJECTIVE: Currently, no practical biomarker is available for the diagnosis of acute ischemic stroke. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) has being applied extensively to analyze large biomolecules such as proteins. The technique is likely to be of remarkable value as indicators of systemic processes such as atherosclerosis and stroke. The aim of this study is to identify potential protein biomarkers for ischemic stroke diagnosis utilizing MALDI-TOF MS. METHODS: Serum samples obtained from acute ischemic stroke patients (n = 47) and controls (n = 34) were analyzed by MALDI-TOF MS. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS), subtype by the Trial of Org 10172 in Acute Stroke Treatment (TOAST), functional outcome by the modified Rankin Scale (mRS) and infarct volume by the diffusion-weighted images. Risk factors and routine laboratory data of the stroke patients were registered prospectively. RESULTS: The peaks of hemoglobin (Hb) alpha-chain and beta-chain were differentially expressed between stroke patients and controls (p < 0.0001). Hb ions were detected in the samples collected from 33 (70.2%) stroke patients and 5 (14.7%) controls. The sensitivity is 70.2% and the specificity is 85.3%. Among stroke patients, there is no significant correlation (p > 0.05) between Hb peaks and the NIHSS, TOAST, mRS, stroke risk factors, infarct volume, infarct location and laboratory data. CONCLUSIONS: Serum free Hb may serve as a novel potential biomarker for the diagnosis of acute ischemic stroke. The clinical value of this potential biomarker may be clarified by further studies quantifying serum free Hb levels.

Evaluation of the sterility, stability, and efficacy of bevacizumab stored in multiple-dose vials for 6 months.

PURPOSE: The aim of this study was to determine the sterility, stability, and efficacy of a commercially available brand of bevacizumab for 6 months of being stored in multidose vials at 4 degrees C. METHODS: Bevacizumab was aseptically and repeatedly drawn four to five times from new vials into syringes for clinical use within the first month; the remaining bevacizumab was left in the vials and refrigerated at 4 degrees C for 0, 1, 3, and 6 months for research. Each time before bevacizumab was withdrawn and every weekend when it was not sampled, the rubber top of each vial was disinfected by using 10% povidone-iodine solution and an isopropyl alcohol wipe. Each vial had been sampled for less than 12 times during the experimental periods. All vials were analyzed for microbial growth. The stability of bevacizumab was analyzed by MALDI-TOF MS (matrix-assisted laser desorption ionization/time-of-flight mass spectrometry). The efficacy of bevacizumab was analyzed by enzyme-linked immunosorbent assay (ELISA). At each time period, bevacizumab was mixed with vascular endothelial growth factor (VEGF)-165 and left undisturbed for 3 h. The efficacy of bevacizumab was then evaluated by measuring the concentration of residual-free VEGF-165. RESULTS: No microbial growth was obtained from any of the bevacizumab samples during each time period, indicating that the bevacizumab stored at 4 degrees C after the vials had been pierced remained sterile. MALDI-TOF MS analysis revealed that the 1-, 3-, and 6-month samples were stable, and there were no molecular-weight changes among any of the samples. The level of degradation of bevacizumab at 1, 3, and 6 months was compared with that of the control (0 months). The results of ELISA showed less than 10% degradation at all time periods. CONCLUSIONS: This study suggests that if aseptic precautions are followed while using bevacizumab, the contents of multiple-dose vials stored at 4 degrees C will remain sterile. The anti-VEGF activity of bevacizumab stored at 4 degrees C will remain stable for up to 6 months.

Acid hydrolysis followed by matrix-assisted laser desorption/ionization mass spectrometry for the rapid diagnosis of serum protein biomarkers in patients with major depression.

We have developed a technique combining acid hydrolysis with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) for the rapid study of the changes in the levels of positive and negative acute phase protein biomarkers in the sera of patients suffering from major depression. The serum proteins were first precipitated using an organic solvent; after separation, they were subjected to hydrochloric acid hydrolysis (6 M HCl) for 10 min. The resulting peptides were characterized using MALDI-TOF MS. Short-term treatment of the serum proteins with HCl efficiently removed interference from the abundant protein - albumin - and produced abundant peptide ion signals in the range of m/z 4000-10 000. This approach allowed us to rapidly detect the peptide ions originating from transferrin (a common negative acute phase protein) and fibrinogen (a common positive acute phase protein). The average ratios and (standard deviations) of the ion signals derived from transferrin/fibrinogen were 3.58 (+/-1.93) for the healthy control subjects and 1.02 (+/-0.52) for the patients suffering from major depression. The differences in transferrin/fibrinogen ratios between healthy controls and patients suggest that major depression will induce internal inflammation and cause either an increase in the level of fibrinogen or a decrease in the level of transferrin.

Using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry to rapidly screen for albuminuria.

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) is used as an alternative method for the rapid diagnosis of albuminuria. This technique requires no further sample pretreatment than simply mixing the urine sample with a MALDI matrix and drying under ambient conditions. The resulting MALDI mass spectra reveal albumin ions having charges ranging from +1 to +5. The detection of albumin is possible using any of the three most common MALDI matrices - sinapinic acid (SA), 2,5-dihydroxybenzoic acid (2,5-DHB), or 4-hydroxy-alpha-cyanocinnamic acid (alpha-CHC). Using this analytical approach, the limit of detection for albumin in urine is 10(-6) M, approximately 5 to 10 times lower than that detectable through conventional chemical testing.

The effects of tai chi exercise on elders with osteoarthritis: a longitudinal study.

PURPOSE: Tai Chi exercise has been proven to be beneficial among elders with osteoarthritis (OA). The long-term effects of this exercise remain unclear. The purpose of this study was to evaluate the effects of the Tai Chi exercise for Arthritis (TCEA) program on the physical status and quality of life of OA elders. METHODS: This was a time series study with one group design. Subjects diagnosed with OA of the lower extremities, aged 60 years or over, were recruited from an outpatient clinic at a community teaching hospital. Thirteen participants joined a TCEA exercise class three times per week for 2 years. Physical status including body mass index (BMI), lean body mass, hand grasp strength, flexibility, and equilibrium were measured four times-at baseline, 3 months, 1 year, and 2 years of the TCEA exercise class. Quality of life was also measured at these time points. RESULTS: Lean body mass was significantly decreased within the study period (p < .05). Participants experienced significant improvements in physical functioning, role limitations, and social functioning on the dimensions of quality of life (SF-36) (p < .05). CONCLUSION: Elderly people with OA should be encouraged to exercise using Tai Chi for maintaining physical function and improving quality of life.

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry for the detection of hemoglobins as the protein biomarkers for fecal occult blood.

In this study, we discover that hemoglobins (Hb), highly water-soluble globular proteins that are the most predominant proteins detected by matrix-assisted laser desorption ionization/time-of-flight (MALDI-TOF) mass spectrometry in blood, can be used as protein biomarkers for fecal occult blood (FOB). Hemoglobins were extracted from the feces with pure water and separated from the solids in feces through centrifugation. Singly charged molecular ions of Hb-related alpha chains (theoretical MW: 15 126) and beta chains (theoretical MW: 15 867) were detected by MALDI-TOF operated in linear mode using 4-hydroxy-alpha-cyanocinnamic acid (alpha-CHC) as the matrix (with a volumetric ratio of 1:1). The detection limit of FOB using this method is estimated to be lower than 0.1 microg blood per mg of feces, which is approximately 10 to 100 times lower than that of the conventional chemical approaches. The foods and dietary supplements that commonly interfere with the conventional chemical assays of FOB - such as animal blood food products and tablets containing iron and vitamin C - do not interfere with the detection of Hb biomarkers during MALDI-TOF analysis.

Reliability and validity of a chinese version of the pediatric asthma symptoms scale.

As a construct, asthmatic severity provides a framework to understand the different reaction in children to their condition. Assessing asthmatic severity is a challenging task for most researchers and clinicians due to a lack of valid instruments to measure the severity of asthma of children in home settings. The purpose of this study was to examine the psychometric properties of a Chinese version of the Pediatric Asthma Symptoms Scale (C-PASS) as applied to an ethnic Chinese population in Taiwan. Firstly, five pediatric nurses holding masters' degrees assessed consistency between Chinese and English versions of the Pediatric Asthma Symptoms Scale. Secondly, internal consistent reliability, split-half reliability, content validity, criterion-related validity, and construct validity were established. An 8-item C-PASS was completed by mothers of 70 children (65.7% boys) of ages 8.35 years. Both the internal consistency and Guttman split-half reliability were .87. The content validity index (CVI) was over .80. The correlation coefficient between C-PASS and concurrent measures of the rating of lost control of life by mothers was .273 (p = .022). The criterion-related validity was supported for C-PASS. Factor analysis indicated that a scale of two dimensions accounted for 67.92% of the variance. A high inter-correlation was further identified between these two dimensions. Results showed C-PASS to be a reliable and valid instrument when used on Taiwanese children with asthma. It can serve as a valuable assessment tool in clinical practice to identify asthmatic severity levels for which intervention is advised.

Factors predicting nurses' consideration of leaving their job during the SARS outbreak.

Taiwan was affected by an outbreak of severe acute respiratory syndrome (SARS) in early 2003. A questionnaire survey was conducted to determine (1) the perceptions of risk of SARS infection in nurses; (2) the proportion of nurses considering leaving their job; and (3) work as well as non-work factors related to nurses' consideration of leaving their job because of the SARS outbreak. Nearly three quarters (71.9%) of the participants believed they were 'at great risk of exposure to SARS', 49.9% felt 'an increase in workload', and 32.4% thought that people avoided them because of their job; 7.6% of the nurses not only considered that they should not care for SARS patients but were looking for another job or considering resignation. The main predictors of nurses' consideration of leaving their job were shorter tenure, increased work stress, perceived risk of fatality from SARS, and affected social relationships. The findings are important in view of potential impending threats of pandemics such as avian influenza.

[Therapeutic play].

Atraumatic care is one of the important principles in pediatric nursing. Immature cognitive development, however, and limited coping ability exacerbate tension when children are ill and require hospitalization. Therapeutic play has been demonstrated as an effective nursing intervention. Through therapeutic play, children can acquire opportunities to express themselves and deal with stress related to health experiences. Also, nurses can gain insights into children's cognition, perception, and needs. This paper introduces concepts of therapeutic play. We hope that nurses will be able to incorporate it into pediatric nursing practice and provide care as atraumatically as possible.

Process of self-identity transformation in women with autistic adolescent.

The purpose of this study was to understand the self-identity transformation in women with adolescent autistic children. In this study, in-depth interviews were used to collect data. Eight mothers were recruited who had autistic children aged 13-21 and who were those children's primary caregivers. Each mother was interviewed from one to four times. Four themes emerged through these mothers rethinking their connection with others during middle age. These included (1) relationships revisited; (2) self-awareness inspiration; (3) reconnection constructed; and (4) new self-identity formed. Results are hoped to provide valuable information for health professionals to understand how mothers of autistic adolescents connect with others and with their self-identity during middle age.