From the Other Side of the Bed: Lived Experiences of Registered Nurses as Family Caregivers.

BACKGROUND: To provide patient- and family-centered care, health care providers must understand the caregiver experience. Evidence suggests that registered nurses functioning as family caregivers (RNFCs) may have unique experiences and challenges. PURPOSE: The purpose of this study was to explore the lived experiences of RNFCs during an adult family member's episode of care in the southern United States. METHODS: A descriptive phenomenological approach was used to describe the essence of the RNFC experience throughout an episode of care. Twenty-five participants were recruited for semistructured, audio-recorded interviews. Data were analyzed using descriptive data analysis and constant comparison techniques. RESULTS: Participants were predominantly female (88%). The essence of the phenomenon was dual roles. Five themes emerged: (1) blurring the boundaries, (2) revealing my identity, (3) having insider knowledge, (4) managing expectations, and (5) learning from my experience. CONCLUSIONS: While caregiver experiences may be similar, RNFCs struggle with dual roles of registered nurse and caregiver, occasionally blurring boundaries of care.

Feasibility study of colestipol as an oral phosphate binder in hemodialysis patients.

BACKGROUND: Currently available calcium- and aluminium-based phosphate binders are dose limited because of potential toxicity, and newer proprietary phosphate binders are expensive. We examined phosphate-binding effects of the bile acid sequestrant colestipol, a non-proprietary drug that is in the same class as sevelamer. METHODS: The trial was an 8 week prospective feasibility study in stable hemodialysis patients using colestipol as the only phosphate binder, preceded and followed by a washout phase of all other phosphate binders. The primary study endpoint was weekly measurements of serum phosphate. Secondary endpoints were serum calcium, lipids and coagulation status. Analyses used random effects mixed models. RESULTS: Thirty patients were screened for participation of which 26 met criteria for treatment. At a mean dose of 8.8 g/24 h of colestipol by study end, serum phosphate dropped from 2.24 to 1.96 mmol/L (P < 0.001). Three patients required calcium supplementation. LDL cholesterol dropped from 1.75 to 1.2 mmol/L (P < 0.001). Three patients dropped out because of side effects or intolerance of the required dose. CONCLUSION: The results support the feasibility of a larger trial to determine the efficacy of colestipol as a phosphate binder and that other non-proprietary anion-exchange resins may also warrant investigation.

The Christchurch earthquake: dialysis experience and emergency planning.

On 22 February 2011, a large earthquake struck the Canterbury region in New Zealand. There was extensive damage to buildings and infrastructure. The following day 42 haemodialysis patients were flown to Auckland where they acutely dialysed through the efforts of the Auckland, Waitemata and Counties-Manukau dialysis team. Patients and support people were subsequently distributed to a designated Upper North Island District Health Board for longer-term ongoing dialysis care. The last evacuated haemodialysis patient returned to Christchurch on 9 May 2011. Surprisingly there was a dearth of crush syndrome patients requiring dialysis. The evacuation and reception of a large number of dialysis patients was a novel experience for the New Zealand dialysis community. A planning guide for dialysis emergency is available to assist with similar future natural disasters.

Biomimetic-Membrane-Protected Plasmonic Nanostructures as Dual-Modality Contrast Agents for Correlated Surface-Enhanced Raman Scattering and Photoacoustic Detection of Hidden Tumor Lesions.

Optical imaging and spectroscopic modalities are of considerable current interest for in vivo cancer detection and image-guided surgery, but the turbid or scattering nature of biomedical tissues has severely limited their abilities to detect buried or occluded tumor lesions. Here we report the development of a dual-modality plasmonic nanostructure based on colloidal gold nanostars (AuNSs) for simultaneous surface-enhanced Raman scattering (SERS) and photoacoustic (PA) detection of tumor phantoms embedded (hidden) in ex vivo animal tissues. By using red blood cell membranes as a naturally derived biomimetic coating, we show that this class of dual-modality contrast agents can provide both Raman spectroscopic and PA signals for the detection and differentiation of hidden solid tumors with greatly improved depths of tissue penetration. Compared to previous polymer-coated AuNSs, the biomimetic coatings are also able to minimize protein adsorption and cellular uptake when exposed to human plasma without compromising their SERS or PA signals. We further show that tumor-targeting peptides (such as cyclic RGD) can be noncovalently inserted for targeting the ανß3-integrin receptors expressed on metastatic cancer cells and tracked via both SERS and PA imaging (PAI). Finally, we demonstrate image-guided resections of tumor-mimicking phantoms comprising metastatic tumor cells buried under layers of skin and fat tissues (6 mm in thickness). Specifically, PAI was used to determine the precise tumor location, while SERS spectroscopic signals were used for tumor identification and differentiation. This work opens the possibility of using these biomimetic dual-modality nanoparticles with superior signal and biological stability for intraoperative cancer detection and resection.

Navigating challenges: insights into chronic kidney disease care in South Auckland.

The burden of chronic kidney disease is increasing throughout New Zealand, resulting in growing strain on patients, families and the healthcare system. The population of South Auckland is the most diverse in New Zealand and it is particularly vulnerable to the effects of chronic kidney disease due its demography and its many communities that endure significant hardships. This article explores the prevailing challenges identified by renal physicians and nurse specialists over 35 years of caring for patients with chronic kidney disease in South Auckland.

Ethnic differences in creatinine kinetics in a New Zealand end-stage kidney disease cohort.

BACKGROUND: Recent data have suggested that glomerular filtration rate (GFR) is better predicted in New Zealand (NZ) Maori and Pacific People using the equations for Black people that predict higher GFR for any given serum creatinine. We hypothesized that this might be due to a higher rate of creatinine generation in NZ Maori and Pacific People. AIM: To compare creatinine kinetics between different ethnic groups in a cohort of NZ peritoneal dialysis patients. METHODS: In this retrospective single-centre observational study, creatinine kinetics in 181 patients were determined from timed serum samples, peritoneal dialysate and urine collections between 1 October 2004 and 31 July 2011. Ethnicity was classified as Asian, NZ European, NZ Maori and Pacific People. RESULTS: A total of 799 samples from 181 patients were analysed: 194 in Asians, 127 in NZ Europeans, 268 in NZ Maori, 207 in Pacific People. Pacific People had the highest serum creatinine and lean body mass, and the highest creatinine generation rate at 1349 mg/day, compared with 1049 for Asians, 1186 for NZ Europeans and 1094 for NZ Maori (P = 0.0001). After adjustment for confounding factors, Pacific People had a greater creatinine generation by 140 mg/day compared with NZ Europeans (P = 0.047). CONCLUSION: Pacific People on peritoneal dialysis in NZ have higher serum creatinine, lean body mass and creatinine generation than other ethnic groups. This is consistent with previous observations that equations for predicting GFR in Black people may have increased accuracy in some Australasian non-White non-Asian populations.

White Matter Metabolite Ratios Predict Cognitive Outcome in Pediatric Traumatic Brain Injury.

The prognostic ability of global white matter and gray matter metabolite ratios following pediatric traumatic brain injury (TBI) and their relationship to 12-month neuropsychological assessments of intelligence quotient (IQ), attention, and memory is presented. Three-dimensional proton magnetic resonance spectroscopic imaging (MRSI) in pediatric subjects with complicated mild (cMild), moderate, and severe TBI was acquired acutely (6-18 days) and 12 months post-injury and compared to age-matched typically developing adolescents. A global linear regression model, co-registering MRSI metabolite maps with 3D high-resolution magnetic resonance images, was used to identify longitudinal white matter and gray matter metabolite ratio changes. Acutely, gray matter NAA/Cr, white matter NAA/Cr, and white matter NAA/Cho ratios were significantly lower in TBI groups compared to controls. Gray matter NAA/Cho was reduced only in the severe TBI group. At 12 months, all metabolite ratios normalized to control levels in each of the TBI groups. Acute gray matter and white matter NAA ratios were significantly correlated to 12-month assessments of IQ, attention, and memory. These findings suggest that whole brain gray matter and white matter metabolite ratios reflect longitudinal changes in neuronal metabolism following TBI, which can be used to predict neuropsychological outcomes in pediatric subjects.

In Situ Vaccination Following Intratumoral Injection of IL2 and Poly-l-lysine/Iron Oxide/CpG Nanoparticles to a Radiated Tumor Site.

The in situ vaccine effect of radiation therapy (RT) has been shown to be limited in both preclinical and clinical settings, possibly due to the inadequacy of RT alone to stimulate in situ vaccination in immunologically "cold" tumor microenvironments (TMEs) and the mixed effects of RT in promoting tumor infiltration of both effector and suppressor immune cells. To address these limitations, we combined intratumoral injection of the radiated site with IL2 and a multifunctional nanoparticle (PIC). The local injection of these agents produced a cooperative effect that favorably immunomodulated the irradiated TME, enhancing the activation of tumor-infiltrating T cells and improving systemic anti-tumor T cell immunity. In syngeneic murine tumor models, the PIC+IL2+RT combination significantly improved the tumor response, surpassing the single or dual combinations of these treatments. Furthermore, this treatment led to the activation of tumor-specific immune memory and improved abscopal effects. Our findings suggest that this strategy can be used to augment the in situ vaccine effect of RT in clinical settings.

The estimation of glomerular filtration rate in an Australian and New Zealand cohort.

BACKGROUND: Accurate estimation of glomerular filtration rate (GFR) allows early detection of renal disease and maximizes opportunity for intervention. AIM: To assess the accuracy of estimated GFR (eGFR) in an Australian and New Zealand cohort with chronic kidney disease using the 4-variable Modification of Diet in Renal Disease equation (MDRD(4V)), the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, and the Cockcroft and Gault equation with actual and ideal body weight. METHODS: Retrospective review of patients who had measured GFR (mGFR) by 51Cr-EDTA clearance and simultaneous measurements of serum biochemistry and anthropometrics. eGFR was compared with mGFR using the concordance correlation coefficient (CCC) and Bland-Altman measures of agreement. RESULTS: 178 patients had 441 radioisotope measurements of GFR. Mean mGFR of was 22.6 mL/min per 1.73 m(2) . The MDRD(4V) equation using the 'black' correction factor was most accurate with a mean eGFR of 19.74 (CCC 0.733, bias -2.86). The CKD-EPI equations also using the 'black' correction factors were almost as good at 19.11 (CCC 0.719, bias -3.49). The Cockcroft-Gault creatinine clearance values had the poorest agreement with mGFR. In the 18 nonwhite non-Asian patients, the MDRD(4V) and CKD-EPI equations were generally less accurate although the use of the 'black' correction factor resulted in greater accuracy for both equations. CONCLUSION: The MDRD(4V) equation was the most accurate. However, its accuracy might be less for nonwhite non-Asian patients if the 'black' correction factor is omitted. Further study of the estimation of GFR in Australian and New Zealand ethnic subgroups would be helpful.

Biomimetic Surface-Enhanced Raman Scattering Nanoparticles with Improved Dispersibility, Signal Brightness, and Tumor Targeting Functions.

The development of biocompatible and nontoxic surface-enhanced Raman scattering (SERS) nanoparticles is of considerable current interest because of their attractive biomedical applications such as ultrasensitive in vitro diagnostics, in vivo tumor imaging, and spectroscopy-guided cancer surgery. However, current SERS nanoparticles are prepared and stored in aqueous solution, have limited stability and dispersibility, and are not suitable for lyophilization and storage by freeze-drying or other means. Here, we report a simple but robust method to coat colloidal SERS nanoparticles by naturally derived biomimetic red blood cell membranes (RBCM), leading to a dramatic improvement in stability and dispersibility under freeze-thawing, lyophilization, heating, and physiological conditions. The results demonstrate that the lyophilized SERS nanoparticles in the solid form can be readily dissolved and dispersed in physiological buffer solutions. A surprising finding is that the RBCM-coated SERS particles are considerably brighter (by as much as 5-fold) than PEGylated SERS particles under similar experimental conditions. This additional enhancement is believed to arise from the hydrophobic nature of RBCM's hydrocarbon chains, which is known to reduce electronic dampening and boost electromagnetic field enhancement. A further advantage in using biomimetic membrane coatings is that the bilayer membrane structure allows nonvalent insertion of molecular ligands for tumor targeting. In particular, we show that cyclic-RGD, a tumor-targeting peptide, can be efficiently inserted into the membrane coatings of SERS nanoparticles for targeting the ανß3 integrin receptors expressed on cancer cells. Thus, biomimetic RBCMs provide major advantages over traditional polyethylene glycols for preparing SERS nanoparticles with improved dispersibility, higher signal intensity, and more efficient biofunctionalization.

Nephrogenic systemic fibrosis, in patients with end-stage kidney disease on dialysis, in the greater Auckland region, from 2000-2006.

AIM: Nephrogenic systemic fibrosis (NSF) is a rare and serious disease characterised by thickening and hardening of the skin with fibrosis of the dermis with CD34-positive fibrocytes. NSF occurs in patients with renal failure and has been linked to exposure of gadolinium contrast agents. The Auckland region has a population of 1.3 million with consultation and dialysis services for patients with end stage kidney disease provided by two separate renal units. The aim of this study was to determine the incidence and frequency of NSF in the Auckland region and determine the risk based on exposure to gadolinium based contrast agents. METHODS: A retrospective case notes review of all patients with end stage kidney disease under the care of the renal services between 1(st) January 2000 and 31(st) December 2006 was undertaken. All cases of proven or suspected NSF were identified. Using a picture archive and communications support system all imaging and exposure to contrast was identified. RESULTS: Three cases of biopsy proven NSF and two further cases of clinical NSF were identified. In all cases there was exposure to Gadolinium. This risk of NSF on exposure to any gadolinium based contrast agents was 0.67%. Gadodiamide was used in one institution where all five cases of NSF were seen, gadodiamide was used in 1% of patients in the other institution with no recognised cases. CONCLUSION: The incidence of NSF is low with the greatest risk on exposure to linear, non-ionic chelates, with no ethnic predisposition.

Evolving White Matter Injury following Pediatric Traumatic Brain Injury.

This study is unique in that it examines the evolution of white matter injury very early and at 12 months post-injury in pediatric patients following traumatic brain injury (TBI). Diffusion tensor imaging (DTI) was acquired at two time-points: acutely at 6-17 days and 12 months following a complicated mild (cMild)/moderate (mod) or severe TBI. Regional measures of anisotropy and diffusivity were compared between TBI groups and against a group of age-matched healthy controls and used to predict performance on measures of attention, memory, and intellectual functioning at 12-months post-injury. Analysis of the acute DTI data using tract based spatial statistics revealed a small number of regional decreases in fractional anisotropy (FA) in both the cMild/mod and severe TBI groups compared with controls. These changes were observed in the occipital white matter, anterior limb of the internal capsule (ALIC)/basal ganglia, and corpus callosum. The severe TBI group showed regional differences in axial diffusivity (AD) in the brainstem and corpus callosum that were not seen in the cMild/mod TBI group. By 12-months, widespread decreases in FA and increases in apparent diffusion coefficient (ADC) and radial diffusivity (RD) were observed in both TBI groups compared with controls, with the overall number of regions with abnormal DTI metrics increasing over time. The early changes in regional DTI metrics were associated with 12-month performance IQ scores. These findings suggest that there may be regional differences in the brain's reparative processes or that mechanisms associated with the brain's plasticity to recover may also be region based.

Longitudinal Metabolite Changes after Traumatic Brain Injury: A Prospective Pediatric Magnetic Resonance Spectroscopic Imaging Study.

The aims of this study were to evaluate longitudinal metabolite changes in traumatic brain injury (TBI) subjects and determine whether early magnetic resonance spectroscopic imaging (MRSI) changes in discrete brain regions predict 1-year neuropsychological outcomes. Three-dimensional (3D) proton MRSI was performed in pediatric subjects with complicated mild (cMild), moderate, and severe injury, acutely (6-17 days) and 1-year post-injury along with neurological and cognitive testing. Longitudinal analysis found that in the cMild/Moderate group, all MRSI ratios from 12 regions returned to control levels at 1 year. In the severe group, only cortical gray matter regions fully recovered to control levels whereas N-acetylaspartate (NAA) ratios from the hemispheric white matter and subcortical regions remained statistically different from controls. A factor analysis reduced the data to two loading factors that significantly differentiated between TBI groups; one included acute regional NAA variables and another consisted of clinically observed variables (e.g., days in coma). Using scores calculated from the two loading factors in a logistic regression model, we found that the percent accuracy for classification of TBI groups was greatest for the dichotomized attention measure (93%), followed by Full Scale Intelligence Quotient at 91%, and the combined memory Z-score measure (90%). Using the acute basal ganglia NAA/creatine (Cr) ratio alone achieved a higher percent accuracy of 94.7% for the attention measure whereas the acute thalamic NAA/Cr ratio alone achieved a higher percent accuracy of 91.9% for the memory measure. These results support the conclusions that reduced NAA is an early indicator of tissue injury and that measurements from subcortical brain regions are more predictive of long-term cognitive outcome.

Measured rates of fluoride/metal association correlate with rates of superoxide/metal reactions for Fe(III)EDTA(H2O)- and related complexes.

The effects of 10 paramagnetic metal complexes (Fe(III)EDTA(H2O)-, Fe(III)EDTA(OH)2-, Fe(III)PDTA-, Fe(III)DTPA2-, Fe(III)2O(TTHA)2-, Fe(III)(CN)6(3-), Mn(II)EDTA(H2O)2-, Mn(II)PDTA2-, Mn(II)beta-EDDADP2-, and Mn(II)PO4(-)) on F- ion 19F NMR transverse relaxation rates (R2 = 1/T2) were studied in aqueous solutions as a function of temperature. Consistent with efficient relaxation requiring formation of a metal/F- bond, only the substitution inert complexes Fe(III)(CN)6(3-) and Fe(III)EDTA(OH)2- had no measured effect on T2 relaxation of the F- 19F resonance. For the remaining eight complexes, kinetic parameters (apparent second-order rate constants and activation enthalpies) for metal/F- association were determined from the dependence of the observed relaxation enhancements on complex concentration and temperature. Apparent metal/F- association rate constants for these complexes (k(app,F-)) spanned 5 orders of magnitude. In addition, we measured the rates at which O2*- reacts with Fe(III)PDTA-, Mn(II)EDTA(H2O)2-, Mn(II)PDTA2-, and Mn(II)beta-EDDADP2- by pulse radiolysis. Although no intermediate is observed during the reduction of Fe(III)PDTA- by O2*-, each of the Mn(II) complexes reacts with formation of a transient intermediate presumed to form via ligand exchange. These reactivity patterns are consistent with literature precedents for similar complexes. With these data, both k(app,O2-) and k(app,F-) are available for each of the eight reactive complexes. A plot of log(k(app,O2-)) versus log(k(app,F-)) for these eight showed a linear correlation with a slope approximately 1. This correlation suggests that rapid metal/O2*- reactions of these complexes occur via an inner-sphere mechanism whereas formation of an intermediate coordination complex limits the overall rate. This hypothesis is also supported by the very low rates at which the substitution inert complexes (Fe(III)(CN)6(3-) and Fe(III)EDTA(OH)2-) are reduced by O2*-. These results suggest that F- 19F NMR relaxation can be used to predict the reactivities of other Fe(III) complexes toward reduction by O2*-, a key step in the biological production of reactive oxygen species.

A Phenomenological Study of the Office Environments of Clinical Social Workers.

OBJECTIVE: The purpose of this study was to explore the meaning and uses of the office space among licensed clinical social workers in private practice. BACKGROUND: Previous research suggests the importance of the office space in clinical practice in regard to therapeutic alliance, client behavior, and the well-being of the therapist. However, therapist offices contain much variation in design. This study looked further into specifically how the therapy room is important through the perspective of the licensed clinical social workers in order to identify common themes. METHODS: Seven licensed clinical social workers in private psychotherapy practice were interviewed in their offices. Phenomenological research methods were used to explore and analyze their experiences. RESULTS: While the offices contained many physical differences, the intentions behind the designs were similar. Three themes emerged regarding how participants used and designed their spaces. First, participants used their offices to provide care for clients and themselves. Second, participants used their spaces to communicate therapeutic messages and to reveal and/or conceal aspects of themselves. Third, participants also used their space in direct practice. CONCLUSION: This phenomenological study provided insight into the importance and use of the psychotherapy office space. These findings may be helpful for therapists designing or redesigning their own practice spaces.

Functional communication training during reinforcement schedule thinning: An analysis of 25 applications.

Two principal goals of functional communication training (FCT) are (a) to eliminate destructive behavior and (b) to establish a more acceptable, yet functionally equivalent, communication response (FCR). A related and critically important goal is to thin the schedule of reinforcement for the FCR to levels that can be reasonably managed by caregivers. Researchers have described several approaches to thinning FCT reinforcement schedules. We summarize the results of 25 consecutive applications (among 20 cases) in which schedule-thinning procedures employed discriminative stimuli to signal when the FCR would and would not produce reinforcement (i.e., using multiple schedules, response restriction, or chained schedules). Results suggest that schedule-thinning procedures that use discriminative stimuli can maintain the effectiveness of FCT while they minimize the need for punishment or other supplemental procedures.

pi-Indenyl tin(II) and lead(II) compounds.

The syntheses and structures of the first indenyl-substituted tin(II) complexes, [Sn{1,3-(SiMe3)2C9H5}2] and [Sn(C5Me5)-{1,3-(SiMe3)2C9H5}], are described; the lead(II) analogue of the latter compound has also been prepared and structurally characterized.

Gender role, sexual orientation and suicide risk.

BACKGROUND: There has been interest in the relationship between homosexuality, gender role and suicide risk. Though homosexuals are more likely to identify as cross-gender, research has not simultaneously examined sexual orientation and gender role in assessing suicide risk. In the current study, the unique and interactive effects of sexual orientation and gender role were assessed in regard to suicidal ideation, related psychopathology and measures of coping. METHODS: 77 participants were recruited from an undergraduate psychology subject pool (n=47) or from gay, lesbian and transgender student organizations (n=30) and assessed on measures of gender role, homosexuality, and psychopathology. RESULTS: Consistent with expectations, cross-gender role (i.e., personality traits associated with the opposite sex) is a unique predictor of suicidal symptoms. Moreover, gender role accounted for more of the overall variance in suicidal symptoms, positive problem orientation, peer acceptance and support, than sexual orientation. After accounting for gender role, sexual orientation contributed little to the variance in suicidal symptoms, associated pathology and problem-solving deficits. There was no support for gender role by sexual orientation interaction effects. LIMITATIONS: The cross-sectional nature of the data limits statements regarding causality. CONCLUSIONS: Cross-gendered individuals, regardless of sexual orientation, appear to have higher risk for suicidal symptoms. Researchers and clinicians should assess gender role in evaluations of youth samples.