The Development and Validation of an Intercultural Nursing Educator Profile Using the Delphi Method.

INTRODUCTION: Educators require focused training to foster the development of intercultural competence in nurses. Training programs for educators need to be based on a comprehensive profile with a focus on intercultural learning. This study aims to define and validate a profile of the Intercultural Nursing Educator (INE). METHOD: The Delphi method was used with an iterative, multi-stage process to transform opinions into group consensus. A total of 46 European, African, and American experts from the nursing and intercultural field participated. Inclusion criteria required English at a level of B2, expertise in the field of intercultural competence, experience in teaching intercultural competence in the nursing context, and publications focused on intercultural topics. RESULTS: The INE profile was developed and all 126 competencies were validated. DISCUSSION AND CONCLUSION: The profile is freely available on the project website and provides the basis for curricula, training programs and assessment of the required competences.

The impact of The Florence Network in advancing nursing and midwifery in Europe.

Diversity of the nursing workforce and multiculturalism of European cities have mandated the need for culturally sensitive nurses and midwives able to provide effective, engaging, high quality and socially just healthcare. The Florence Network is a professional network that aims to bring together like-minded professionals and to cultivate relationships amongst nurses and midwives from different European Union (EU) countries to create synergies on matters of common interest by transcending national and cultural barriers. A qualitative study based upon a focus group interview was conducted with six former Presidents and one present President of the Florence Network, each with a tenure of two years. The study explored the impact of the Florence Network in advancing cultural awareness and promoting educational, research and professional synergies. The outcome of the study identified that from the Presidents perspectives networks create awareness of cultural diversity, enable the delivery of multicultural nursing care and develop future leaders regarding global health-related issues. Furthermore, professional networks contribute to the refining of educational curricula, in developing applicable research evidence, and in sharing formal and informal professional knowledge.

Prevalence of osteoporosis in schizophrenia patients using the osteoporosis self-assessment tool for Asians.

OBJECTIVE: The aims of the current study were to investigate the prevalence and socio-demographic correlates of risk of osteoporosis in Singapore among patients with schizophrenia using the osteoporosis self-assessment tool for Asians (OSTA). METHOD: Data for the current study was drawn from a clinical database maintained at the Institute of Mental Health Singapore. The OSTA index was used to calculate the risk for osteoporosis among those aged 50 years and above. RESULTS: A total of 2569 patients were included in the study. About 34.6% met the criteria for osteoporosis using the OSTA cut-off of ≤ -1. Among the males 22.8% met criteria for high risk and 1.5% met criteria for very high risk, while among women 28.2% were at intermediate risk and 14.9% were at high risk of osteoporosis. The logistic regression analysis showed that older age and female gender were significantly associated with a higher risk of osteoporosis, while those with a history of hypertension and hyperlipidemia were less likely to be associated with a risk of osteoporosis. CONCLUSION: The OSTA could be a useful, inexpensive and quick tool to both identify those with osteoporosis as well as to measure the effectiveness of interventions meant to alleviate it.

Internalized stigma among psychiatric outpatients: Associations with quality of life, functioning, hope and self-esteem.

This study aimed to: (i) determine the prevalence, socio-demographic and clinical correlates of internalized stigma and (ii) explore the association between internalized stigma and quality of life, general functioning, hope and self-esteem, among a multi-ethnic Asian population of patients with mental disorders. This cross-sectional, survey recruited adult patients (n=280) who were seeking treatment at outpatient and affiliated clinics of the only tertiary psychiatric hospital in Singapore. Internalized stigma was measured using the Internalized Stigma of Mental Illness scale. 43.6% experienced moderate to high internalized stigma. After making adjustments in multiple logistic regression analysis, results revealed there were no significant socio-demographic or clinical correlates relating to internalized stigma. Individual logistic regression models found a negative relationship between quality of life, self-esteem, general functioning and internalized stigma whereby lower scores were associated with higher internalized stigma. In the final regression model, which included all psychosocial variables together, self-esteem was the only variable significantly and negatively associated with internalized stigma. The results of this study contribute to our understanding of the role internalized stigma plays in patients with mental illness, and the impact it can have on psychosocial aspects of their lives.

Hoarding symptoms among psychiatric outpatients: confirmatory factor analysis and psychometric properties of the Saving Inventory - Revised (SI-R).

BACKGROUND: The growing interest in problematic hoarding as an independent clinical condition has led to the development of the Saving Inventory-Revised (SI-R) to assess hoarding phenomenology. The SI-R is one of the most widely used instruments to measure hoarding symptoms; however, it lacks validation in non-Western samples. METHODS: The current study examined the construct, convergent, and discriminant validity of the SI-R among 500 outpatients at a psychiatric hospital in Singapore. The three-factor structure solution of the SI-R was fitted in a confirmatory factor analysis. RESULTS: The final model achieved mediocre fit (χ2 = 1026.02, df = 186; RMSEA = 0.095, SRMR = 0.06; CFI = 0.86; NNFI = 0.85). Two reverse-coded items (items 2 and 4) were removed due to insufficient factor loadings, resulting in the modified 21-item SI-R (SIR-21). Our findings indicate the need to further examine the construct validity of the SI-R, particularly in non-Western samples. Nonetheless, correlations with other hoarding-related constructs, such as anxiety (Beck Anxiety Inventory) and depression (Beck Depression Inventory-II), supported the convergent and discriminant validity of the SIR-21 in our sample. CONCLUSIONS: Findings in our current majority Chinese sample were consistent with previous observations from other Chinese samples. Implications were discussed from a cross-cultural perspective, such as cultural emphasis on saving for future use and overlap between the concepts of discarding and acquiring in Chinese samples. Future studies should also examine differences among other ethnic groups (e.g., Malay, Indian).

Psychometric properties of the positive mental health instrument among people with mental disorders: a cross-sectional study.

BACKGROUND: The Positive Mental Health (PMH) instrument was developed and validated to assess the level of PMH and its six dimensions in a multi-ethnic general population sample. This cross-sectional study examines the psychometric properties of the instrument for assessing the level of PMH among help-seeking patients with mental disorders. METHODS: The PMH instrument was tested among 360 out-patients with schizophrenia, depression or anxiety spectrum disorders, seeking treatment at a tertiary psychiatric hospital and its affiliated clinics in Singapore. All participants completed the PMH instrument along with measures of life satisfaction, mental and overall health and happiness. Reliability (internal consistency), construct (Exploratory Structural Equation Modeling (ESEM)) and criterion (convergent and divergent) validity of the PMH instrument were tested in this population. Items were also tested for item response theory and differential item functioning (IRT-DIF). RESULTS: ESEM on the PMH instrument showed good fit with the model reflecting six factors (general coping, personal growth and autonomy, spirituality, interpersonal skills, emotional support, and global affect). Internal consistency was high (Cronbach's alpha >0.85) for the instrument and its six subscales. The PMH instrument fulfilled expected correlations with related constructs and demonstrated adequate item discrimination and difficulty estimates; however, significant DIF was noted for few items for age, gender and ethnicity groups. CONCLUSIONS: The PMH instrument is a reliable and valid instrument for measuring PMH dimensions in patients with mental disorders. Further studies in larger samples are needed to assess the impact of DIF on PMH scores. The implications for the shift in focus from just the negative aspects of mental disorders to including positive components in the assessment of patients with mental disorders are immense, and can be applied in routine mental health practice and policy making.

Induction of pluripotency in adult equine fibroblasts without c-MYC.

Despite tremendous efforts on isolation of pluripotent equine embryonic stem (ES) cells, to date there are few reports about successful isolation of ESCs and no report of in vivo differentiation of this important companion species. We report the induction of pluripotency in adult equine fibroblasts via retroviral transduction with three transcription factors using OCT4, SOX2, and KLF4 in the absence of c-MYC. The cell lines were maintained beyond 27 passages (more than 11 months) and characterized. The equine iPS (EiPS) cells stained positive for alkaline phosphatase by histochemical staining and expressed OCT4, NANOG, SSEA1, and SSEA4. Gene expression analysis of the cells showed the expression of OCT4, SOX2 NANOG, and STAT3. The cell lines retained a euploid chromosome count of 64 after long-term culture cryopreservation. The EiPS demonstrated differentiation capacity for the three embryonic germ layers both in vitro by embryoid bodies (EBs) formation and in vivo by teratoma formation. In conclusion, we report the derivation of iPS cells from equine adult fibroblasts and long-term maintenance using either of the three reprogramming factors.

Cancer stem cells: in the line of fire.

Most tumours appear to contain a sub-population(s) of self-renewing and expanding stem cells known as cancer stem cells (CSCs). The CSC model proposes that CSCs are at the apex of a hierarchically organized cell population, somewhat akin to normal tissue organization. Selection pressures may also facilitate the stochastic clonal expansion of sub-sets of cancer cells that may co-exist with CSCs and their progeny, moreover the trait of stemness may be more fluid than hitherto expected, and cells may switch between the stem and non-stem cell state. A large body of evidence points to the fact that CSCs are particularly resistant to radiotherapy and chemotherapy. In this review we discuss the basis of such resistance that highlights the roles of ABC transporters, aldehyde dehydrogenase (ALDH) activity, intracellular signalling pathways, the DNA damage response, hypoxia and proliferative quiescence as being significant determinants. In the light of such observations, we outline strategies for the successful eradication of CSCs, including targeting the self-renewal controlling pathways (Wnt, Notch and Hedgehog), ALDH activity and ABC transporters, blocking epithelial mesenchymal transition (EMT), differentiation therapy and niche targeting.

Postoperative hungry bone syndrome in patients with secondary hyperparathyroidism of renal origin.

BACKGROUND: Hungry bone syndrome (HBS) is a postoperative condition of severe hypocalcemia that can be seen in patients who have undergone parathyroidectomy (PTX) for secondary hyperparathyroidism (2HPT) of renal origin. This study examines HBS in patients after PTX for 2HPT. METHODS: Prospectively collected data was retrospectively reviewed in patients who underwent PTX for 2HPT of renal origin at a single institution. HBS was defined as the need for additional days of hospitalization or readmission for intravenous calcium supplementation due to clinical symptoms of hypocalcemia, including tingling, muscle spasms, and bone pain and/or immediate postoperative low serum calcium ≤7.5 mg/dl. RESULTS: Of 79 patients who underwent PTX for 2HPT, 27.8% (n = 22) experienced HBS. Young age (≤45 years, p = 0.02) was the only preoperative variable that predicted HBS. Most patients developed HBS within 18 h after surgery and required a prolonged hospital stay (19/22) compared to those requiring hospital readmission within the first 7 days (3/22). Initial postoperative serum calcium levels within 18 h of surgery were significantly lower in those patients who developed HBS (7.1 vs. 8.3 mg/dl, p = 0.001), and those patients also had a greater absolute decrease in serum calcium (2.8 vs. 3.5 mg/dl, p = 0.04). CONCLUSION: HBS develops in a significant proportion of patients generally within the first 18 h after subtotal PTX for 2HPT. The only identifiable preoperative risk factor for HBS was young age. Additionally, low initial calcium levels and greater absolute decrease in serum calcium may help identify those patients that will develop HBS requiring judicious calcium supplementation.

Cancer stem cells: problems for therapy?

Many, if not all, tumours contain a sub-population of self-renewing and expanding stem cells known as cancer stem cells (CSCs). The symmetric division of CSCs is one mechanism enabling expansion in their numbers as tumours grow, while epithelial-mesenchymal transition (EMT) is an increasingly recognized mechanism to generate further CSCs endowed with a more invasive and metastatic phenotype. Putative CSCs are prospectively isolated using methods based on either a surface marker or an intracellular enzyme activity and then assessed by a 'sphere-forming' assay in non-adherent culture and/or by their ability to initiate new tumour growth when xenotransplanted into immunocompromised mice-hence, these cells are often referred to as tumour-propagating cells (TPCs). Cell sub-populations enriched for tumour-initiating ability have also been found in murine tumours, countering the argument that xenografting human cells merely select human cells with an ability to grow in mice. Cancer progression can be viewed as an evolutionary process that generates new/multiple clones with a fresh identity; this may be a major obstacle to successful cancer stem cell eradication if treatment targets only a single type of stem cell. In this review, we first briefly discuss evidence that cancer can originate from normal stem cells or closely related descendants. We then outline the attributes of CSCs and review studies in which they have been identified in various cancers. Finally, we discuss the implications of these findings for successful cancer therapies, concentrating on the self-renewal pathways (Wnt, Notch, and Hedgehog), aldehyde dehydrogenase activity, EMT, miRNAs, and other epigenetic modifiers as potential targets for therapeutic manipulation.

Revisiting Wallace's haunt: coalescent simulations and comparative niche modeling reveal historical mechanisms that promoted avian population divergence in the Malay Archipelago.

Sundaland, a biogeographic region of Southeast Asia, is a major biodiversity hotspot. However, little is known about the relative importance of Pleistocene habitat barriers and rivers in structuring populations and promoting diversification here. We sampled 16 lowland rainforest bird species primarily from peninsular Malaysia and Borneo to test the long-standing hypothesis that animals on different Sundaic landmasses intermixed extensively when lower sea-levels during the Last Glacial Maximum (LGM) exposed land-bridges. This hypothesis was rejected in all but five species through coalescent simulations. Furthermore, we detected a range of phylogeographic patterns; Bornean populations are often genetically distinct from each other, despite their current habitat connectivity. Environmental niche modeling showed that the presence of unsuitable habitats between western and eastern Sundaland during the LGM coincided with deeper interpopulation genetic divergences. The location of this habitat barrier had been hypothesized previously based on other evidence. Paleo-riverine barriers are unlikely to have produced such a pattern, but we cannot rule out that they acted with habitat changes to impede population exchanges across the Sunda shelf. The distinctiveness of northeastern Borneo populations may be underlied by a combination of factors such as rivers, LGM expansion of montane forests and other aspects of regional physiography.

Finding cancer stem cells: are aldehyde dehydrogenases fit for purpose?

Despite many years of intensive effort, there is surprisingly little consensus on the most suitable markers with which to locate and isolate stem cells from adult tissues. By comparison, the study of cancer stem cells is still in its infancy; so, unsurprisingly, there is great uncertainty as to the identity of these cells. Stem cell markers can be broadly categorized into molecular determinants of self-renewal, clonogenicity, multipotentiality, adherence to the niche, and longevity. This review assesses the utility of recognizing cancer stem cells by virtue of high expression of aldehyde dehydrogenases (ALDHs), probably significant determinants of cell survival through their ability to detoxify many potentially cytotoxic molecules, and contributing to drug resistance. Antibodies are available against the ALDH enzyme family, but the vast majority of studies have used cell sorting techniques to enrich for cells expressing these enzymes. Live cells expressing high ALDH activity are usually identified by the ALDEFLUOR kit and sorted by fluorescence activated cell sorting (FACS). For many human tumours, but notably breast cancer, cell selection based upon ALDH activity appears to be a useful marker for enriching for cells with tumour-initiating activity (presumed cancer stem cells) in immunodeficient mice, and indeed the frequency of so-called ALDH(bri) cells in many tumours can be an independent prognostic indicator.

Deforestation and avian extinction on tropical landbridge islands.

There are few empirical data, particularly collected simultaneously from multiple sites, on extinctions resulting from human-driven land-use change. Southeast Asia has the highest deforestation rate in the world, but the resulting losses of biological diversity remain poorly documented. Between November 2006 and March 2008, we conducted bird surveys on six landbridge islands in Malaysia and Indonesia. These islands were surveyed previously for birds in the early 1900 s, when they were extensively forested. Our bird inventories of the islands were nearly complete, as indicated by sampling saturation curves and nonparametric true richness estimators. From zero (Pulau Malawali and Pulau Mantanani) to 15 (Pulau Bintan) diurnal resident landbird species were apparently extirpated since the early 1900 s. Adding comparable but published extinction data from Singapore to our regression analyses, we found there were proportionally fewer forest bird extinctions in areas with greater remaining forest cover. Nevertheless, the statistical evidence to support this relationship was weak, owing to our unavoidably small sample size. Bird species that are restricted to the Indomalayan region, lay few eggs, are heavier, and occupy a narrower habitat breadth, were most vulnerable to extinction on Pulau Bintan. This was the only island where sufficient data existed to analyze the correlates of extinction. Forest preservation and restoration are needed on these islands to conserve the remaining forest avifauna. Our study of landbridge islands indicates that deforestation may increasingly threaten Southeast Asian biodiversity.

Cell therapy for liver disease.

The clinical demand for whole organ transplantation for the treatment of end-stage liver disease far outstrips supply. As a result, research efforts have focused on hepatocyte therapies to support this scarce clinical resource, including the investigation of alternative cell sources, in particular bone marrow cells (BMCs). In animal models of metabolic liver disease, adopting strategies that provide a selective advantage for transplanted hepatocytes have proved to be highly effective in repopulating recipient livers, and the current relatively poor success rate of hepatocyte transplants in humans can be attributed to the lack of a clinically applicable procedure to induce a similar repopulation of the human liver. Autologous BMCs have been transplanted in a number of clinical trials involving patients with liver cirrhosis; modest improvements in liver health have been reported, but the mechanisms responsible for these effects are currently unknown. Transplanted hepatocytes can effectively repopulate a metabolically deficient liver, provided that a selective advantage exists for the donor cells. Some reports suggest that BMCs can differentiate into hepatocytes, but for the treatment of cirrhosis, the primary goal is to render the ingressing cells capable of degrading the excessive collagen associated with the disease. This review presents the progress and discusses some of the problems that need to be overcome in the field of cell transplantation for the treatment of metabolic and fibrogenic liver diseases.

Number crunching in the cancer stem cell market.

Like their normal counterparts, many tumours are thought to have a hierarchical organization, albeit a disorganized one. Accordingly, the concept of cancer stem cells has emerged, and that these cells are responsible for perpetuating tumour existence. Operationally, cancer stem cells are regarded as prospectively purified cells that are the most effective at tumour initiation in an in vivo assay, usually after xenotransplantation to NOD/SCID mice. The conventional wisdom is that such tumour-initiating cells are rare based upon having to xenotransplant large numbers of human tumour cells into immunodeficient mice to propagate the tumour, but new evidence indicates that perhaps these cells are not so rare, at least in malignant melanoma, if a supportive soil is provided for the transplanted cells along with further restriction of the murine host's immune response.

Bone marrow-derived cells and epithelial tumours: more than just an inflammatory relationship.

PURPOSE OF REVIEW: Cancer-associated fibroblasts/myofibroblasts and inflammatory cells produce a vast array of growth factors, chemokines and extracellular matrix (ECM) components that facilitate cancer progression, invasion/metastasis and neovascularization. This review highlights some surprisingly novel mechanisms of this paracrine relationship. RECENT FINDINGS: Mesenchymal stem/stromal cells (MSCs) are known for their tropism towards certain tumours, but now we find that cross-talk between tumours and MSCs leads to greater tumour motility and metastasis. Two closely related populations of immature myeloid cells, so-called 'cap cells' and myeloid-derived suppressor cells (MDSCs) also cross-talk with tumour cells, promoting invasion and metastasis through matrix metalloproteinase (MMP) secretion, as well as contributing to neovascularization and T-cell tolerance. The contribution of bone marrow-derived cells (BMDCs) to tumour neovascularization is controversial, but BMD--endothelial progenitor cells (EPCs)--are strongly implicated in the angiogenic switch in a mouse model. BMDCs are also credited with the creation of premetastatic niches to which metastatic cells adhere via integrins. SUMMARY: There is no doubt that BMDCs are not simply bystanders in the tumour battleground. The mechanisms through which they aid tumour progression are numerous; effective treatments that combat BMDC-tumour cross-talk are surely on the way.

A retrospective study of the diagnostic accuracy of fine-needle aspiration for breast lesions and implications for future use.

In recent years, the use of fine-needle aspiration (FNA) in the diagnosis of breast lesions has declined in many institutions. We sought to evaluate the role of FNA for breast lesions and the annual rate of the procedure at our institution over a 4(1/2) year period (May 2002-October 2006). A total of 831 FNAs were performed, with 258 (31%) having histologic follow-up. The number of FNAs obtained was 159 from 5/02 to 4/03, 192 from 5/03 to 4/04, 194 from 5/04 to 4/05, 191 from 5/05 to 4/06, and 95 from 5/06 to 10/06. Each case was placed into one of four categories: nondiagnostic (9%), benign (77.5%), atypical/suspicious (5.5%), or malignant (8%). Surgical tissue was available for 37% of nondiagnostic cases, 22% of benign cases, 80% of atypical/suspicious cases, and 72% of malignant cases. The overall sensitivity and specificity for FNA was 83 and 92% respectively. The overall positive and negative predictive values were 83 and 92% respectively. There were no false-positive cases, indicating a positive predictive value of 100% for a Dx of malignancy. For cases with surgical follow-up, the false-negative rate was 5.4%. Although there is a national trend away from FNAs of breast lesion, this has not been the experience at our institution. Although FNA may not be ideal in the initial evaluation of suspicious lesions, we argue that FNA for clinically benign palpable lesions and recurrent carcinomas has significant value.

AID expression levels determine the extent of cMyc oncogenic translocations and the incidence of B cell tumor development.

Immunoglobulin (Ig) isotype switching is a recombination event that changes the constant domain of antibody genes and is catalyzed by activation-induced cytidine deaminase (AID). Upon recruitment to Ig genes, AID deaminates cytidines at switch (S) recombination sites, leading to the formation of DNA breaks. In addition to their role in isotype switching, AID-induced lesions promote Igh-cMyc chromosomal translocations and tumor development. However, cMyc translocations are also present in lymphocytes from healthy humans and mice, and thus, it remains unclear whether AID directly contributes to the dynamics of B cell transformation. Using a plasmacytoma mouse model, we show that AID(+/-) mice have reduced AID expression levels and display haploinsufficiency both in the context of isotype switching and plasmacytomagenesis. At the Ig loci, AID(+/-) lymphocytes show impaired intra- and inter-switch recombination, and a substantial decrease in the frequency of S mutations and chromosomal breaks. In AID(+/-) mice, these defects correlate with a marked decrease in the accumulation of B cell clones carrying Igh-cMyc translocations during tumor latency. These results thus provide a causality link between the extent of AID enzymatic activity, the number of emerging Igh-cMyc-translocated cells, and the incidence of B cell transformation.

Application of liver stem cells for cell therapy.

The worldwide shortage of donor livers to transplant end stage liver disease patients has prompted the search for alternative cell therapies for intractable liver disease. Embryonic stem cells can be readily differentiated into hepatocytes, and their transplantation into animals has improved liver function in the absence of teratoma formation: their use in bioartificial liver support is an obvious application. In animal models of liver disease, adopting strategies to provide a selective advantage for transplanted foetal or adult hepatocytes have proved highly effective in repopulating recipient livers, but the poor success of today's hepatocyte transplants can be attributed to the lack of a clinically applicable procedure to force a similar repopulation of the human liver. The activation of bipotential hepatic progenitor cells is clearly vital for survival in many cases of acute liver failure, but surprisingly little progress has been made with these cells in terms of transplantation. Finally there is the controversial subject of autologous bone marrow, and while the contribution of these indigenous cells to liver turnover seems at best, trivial, results from a small number of phase 1 studies of transplantation of bone marrow to cirrhotic patients have been moderately encouraging.

Laparoscopic-assisted axillary dissection in breast cancer surgery.

BACKGROUND: Significant morbidity such as pain, paresthesia, and arm stiffness has often been associated with axillary dissection for breast cancer. We report our experience of 30 patients with stage I and II invasive ductal carcinoma of the breast who underwent laparoscopic-assisted axillary dissection together with segmental mastectomy. METHODS: Tumours were situated in the upper or lower lateral quadrants only. In all cases, initial exposure for axillary dissection was performed through the breast periareolar incision. A 10-mm 30 degrees laparoscope was introduced through the breast incision to gain entry to the axilla. A separate stab incision in the lower aspect of the axilla was used for introduction of the 5-mm Harmonic shears (Ethicon Endo-Surgery, Inc, Cincinnati, OH). A grasping forceps was introduced through the main incision alongside the endoscope. Subsequent axillary dissection was performed laparoscopically, and the axillary content was removed through the breast incision. RESULTS: Average yield of lymph nodes was 15 (range 7 to 25). There were no intraoperative complications. Immediately postsurgery, all patients were able to fully mobilize the upper limb, facilitated by absence of an axillary scar. Patients also reported minimal pain, paresthesia, with no stiffness or frozen shoulder. CONCLUSION: Laparoscopic-assisted axillary dissection offers a safe and improved approach to the axilla, which can be incorporated into breast cancer surgery.