Experiences of Multidisciplinary Working: Perspectives from the Wessex Ghana Stroke Partnership.

INTRODUCTION: Substantial gaps remain in our understanding of stroke in Africa as well as in stroke care, practice and policy on the continent. The effective organization of preventative, therapeutic and rehabilitative stroke services continue to be challenging in many African countries. METHODOLOGY: In this article we define the nature, function and benefits of effective multidisciplinary team (MDT) working. The experiences and perspectives of members of the MDT were collated by focus group discussions as well as individual and country specific contributions. RESULTS: The experiences and perspectives of multidisciplinary team members from the United Kingdom and Ghana implementing these practices at the first stroke unit in Korle Bu Teaching Hospital, Accra, with a transparent discussion of successes and challenges faced throughout development of the service, is presented. MDT working has improved outcomes for patients and families who use the services, including encouraging better shared treatment planning and compliance. More stroke rehabilitation services are provided than previously, including greater self-management education and better secondary prevention care. CONCLUSION: It is hoped that this article will provide an inspirational model for others working to provide stroke care in low-resource settings in Africa and worldwide.

INTRODUCTION: Des lacunes substantielles subsistent dans notre compréhension de l'accident vasculaire cérébral en Afrique ainsi que dans les pratiques et politiques sur le continent. L'organisation efficace des services de prévention, de traitement et de réadaptation des AVC reste un défi dans de nombreux pays africains. MÉTHODOLOGIE: Dans cet article, nous définissons la nature, la fonction et les avantages d'une équipe multidisciplinaire efficace (PCT).Les expériences et les points de vue des membres de la PCT ont été recueillis par des discussions de groupes de réflexion ainsi que contributions individuelles et spécifiques à chaque pays. RÉSULTATS: Les expériences et les perspectives des membres d'équipes multidisciplinaires du Royaume-Uni et du Ghana, qui ont mis en œuvre ces pratiques dans la première unité d'AVC du de l'hôpital universitaire Korle Bu, à Accra, avec une discussion transparente des succès et des défis rencontrés tout au long du développement du service, sont présentées. Le travail de la PCT a amélioré les résultats pour les patients et les familles qui utilisent les services, notamment en encourageant un meilleur partage du traitement, l'organisation et la complaisance. Davantage de services de réadaptation après un AVC sont fournis plus qu'auparavant, y compris une meilleure éducation à l'autogestion et de meilleurs soins de prévention secondaire. CONCLUSION: Nous espérons que cet article constituera un modèle inspirant pour d'autres personnes travaillant à la prise en charge d'AVC dans des contextes à faibles ressources en Afrique et dans le monde. Mots clés: Unité de expériences, multidisciplinaire, Ghana, partenariat.

Effects of systematically varied thiourethane-functionalized filler concentration on polymerization behavior and relevant clinical properties of dental composites.

Introduction of thiourethane (TU) oligomer to resin-based dental restorative materials reduces stress and improves fracture toughness without compromising conversion. Localization of TU at the resin-filler interface via silanization procedures may lead to more substantial stress reduction and clinical property enhancements. The objective of this study was to evaluate composite properties as a function of TU-functionalized filler concentration. TU oligomers were synthesized using click-chemistry techniques and subsequently silanized to barium glass filler. Resin-based composites were formulated using varying ratios of TU-functionalized filler and conventional methacrylate-silanized barium filler. Material property testing included thermogravimetric analysis, real-time polymerization kinetics and depth of cure, polymerization stress, stress relaxation and fracture toughness. Clinical property testing included water sorption/solubility, composite paste viscosity, and gloss and surface roughness measured before and after subjecting the samples to 6 h of continuous tooth brushing in a custom-built apparatus using a toothpaste/water mixture. Increasing TU-filler in the composite resulted in as much as a 78% reduction in stress, coupled with an increase in fracture toughness. Conversion was similar for all groups. After simulated tooth brushing, gloss reduction was lower for TU-containing composites and surface roughness was less than or equal to the control.

The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic.

CLINICAL SCENARIO: A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful. MANAGEMENT QUESTION: What are the psychological impacts of SJS/TEN on this man's life? BACKGROUND: SJS and TEN have devastating outcomes for those affected. OBJECTIVES: To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario. METHODS: Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age. RESULTS: Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression. DISCUSSION AND RECOMMENDATION: The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

Subcortical volumetric abnormalities in bipolar disorder.

Considerable uncertainty exists about the defining brain changes associated with bipolar disorder (BD). Understanding and quantifying the sources of uncertainty can help generate novel clinical hypotheses about etiology and assist in the development of biomarkers for indexing disease progression and prognosis. Here we were interested in quantifying case-control differences in intracranial volume (ICV) and each of eight subcortical brain measures: nucleus accumbens, amygdala, caudate, hippocampus, globus pallidus, putamen, thalamus, lateral ventricles. In a large study of 1710 BD patients and 2594 healthy controls, we found consistent volumetric reductions in BD patients for mean hippocampus (Cohen's d=-0.232; P=3.50 × 10-7) and thalamus (d=-0.148; P=4.27 × 10-3) and enlarged lateral ventricles (d=-0.260; P=3.93 × 10-5) in patients. No significant effect of age at illness onset was detected. Stratifying patients based on clinical subtype (BD type I or type II) revealed that BDI patients had significantly larger lateral ventricles and smaller hippocampus and amygdala than controls. However, when comparing BDI and BDII patients directly, we did not detect any significant differences in brain volume. This likely represents similar etiology between BD subtype classifications. Exploratory analyses revealed significantly larger thalamic volumes in patients taking lithium compared with patients not taking lithium. We detected no significant differences between BDII patients and controls in the largest such comparison to date. Findings in this study should be interpreted with caution and with careful consideration of the limitations inherent to meta-analyzed neuroimaging comparisons.

Left Frontoparietal Control Network Connectivity Moderates the Effect of Amyloid on Cognitive Decline in Preclinical Alzheimer's Disease: The A4 Study.

BACKGROUND: Stronger resting-state functional connectivity of the default mode and frontoparietal control networks has been associated with cognitive resilience to Alzheimer's disease related pathology and neurodegeneration in smaller cohort studies. OBJECTIVES: We investigated whether these networks are associated with longitudinal CR to AD biomarkers of beta-amyloid (Aß). DESIGN: Longitudinal mixed. SETTING: The Anti-Amyloid Treatment in Asymptomatic Alzheimer's Disease (A4) study and its natural history observation arm, the Longitudinal Evaluation of Amyloid Risk and Neurodegeneration (LEARN) study. PARTICIPANTS: A sample of 1,021 cognitively unimpaired older adults (mean age = 71.2 years [SD = 4.7 years], 61% women, 42% APOEε4 carriers, 52% Aß positive). MEASUREMENTS: Global cognitive performance (Preclinical Alzheimer's Cognitive Composite) was assessed over an average 5.4 year follow-up period (SD = 2 years). Cortical Aß and functional connectivity (left and right frontoparietal control and default mode networks) were estimated from fMRI and PET, respectively, at baseline. Covariates included baseline age, APOEε4 carrier status, years of education, adjusted gray matter volume, head motion, study group, cumulative treatment exposure, and cognitive test version. RESULTS: Mixed effects models revealed that functional connectivity of the left frontoparietal control network moderated the negative effect of Aß on cognitive change (p = .025) such that stronger connectivity was associated with reduced Aß-related cognitive decline. CONCLUSIONS: Our results demonstrate a potential protective effect of functional connectivity in preclinical AD, such that stronger connectivity in this network is associated with slower Aß-related cognitive decline.

The cellular Na+ pump as a site of action for carbon monoxide and glutamate: a mechanism for long-term modulation of cellular activity.

Carbon monoxide (CO) induces a long-lasting alteration in cerebellar alpha 3-Na,K-ATPase independent of [Na+] but linked to cGMP synthesis and localized to Purkinje neurons. The action of CO is absent in Purkinje neuron-deficient mice, mimicked by 8-Br-cGMP, and blocked by inhibition of PKG. Glutamate (Glu) and metabotropic agonists mimic the action of CO, an effect that requires PKC and is associated with CO synthesis. These data suggest that CO regulates Na,K-ATPase through cGMP and PKG, and that Glu regulates CO through mGluRs. This system is also modulated by NMDA agonists and nitric oxide, possibly via Glu release, as well as by free radicals. These findings offer a mechanism by which CO, Glu, and free radicals can exert specific effects on synaptic transmission (relevant to long-term changes in cell excitability), as well as more general actions on energy metabolism (relevant to the pathophysiology of excitotoxicity).

Perineural Invasion in Head and Neck Cancer.

Perineural invasion (PNI) is a mechanism of tumor dissemination that can provide a challenge to tumor eradication and that is correlated with poor survival. Squamous cell carcinoma, the most common type of head and neck cancer, has a high prevalence of PNI. This review provides an overview of clinical studies on the outcomes and factors associated with PNI in head and neck cancer and on findings on cancer-nerve crosstalk.

Identification and Preliminary Characterization of a Ca2+- Dependent High-Affinity Binding Site for Inositol-1,4,5-Trisphosphate from Chenopodium rubrum.

Using a radioligand-binding assay we have identified a Ca2+- dependent high-affinity D-myo-inositol-1,4,5-trisphosphate (InsP3) binding site in a membrane vesicle preparation from Chenopodium rubrum. Millimolar concentrations of Ca2+ were required to observe specific binding of [3H]InsP3. A stable equilibrium between bound and free ligand was established within 5 min and bound [3H]InsP3 could be completely displaced by InsP3 in a time- and concentration-dependent manner. Displacement assays indicated a single class of binding sites with an estimated dissociation constant of 142 [plus or minus] 17 nM. Other inositol phosphates bound to the receptor with much lower affinity. The glycosaminoglycan heparin was an effective competitor for the binding site (inhibitor concentration for 50% displacement = 534 nM). ATP at higher, although physiologically relevant, concentrations (inhibitor concentration for 50% displacement = 241 [mu]M) also displaced [3H]InsP3 from the receptor. Recent studies in animals have highlighted the importance of Ca2+ regulation of InsP3-induced Ca2+ release. The potential for the operation of similar regulatory mechanisms in plants is discussed.

Evidence for more extensive deposits of epitopes of oxidized low density lipoprotein in aortas of young people with elevated serum thiocyanate levels. PDAY Research Group.

Elevated levels of low density lipoprotein (LDL) and smoking have long been recognized as risk factors for atherosclerosis and coronary heart disease (CHD). However, the mechanisms by which these factors contribute to the disease have not been fully elucidated. It has been postulated from in vitro studies using serum and LDL from smokers that smoking increases the oxidation of LDL, which in turn contributes to atherogenesis. We know of no direct evidence linking oxidized LDL (oxLDL) in human arteries to increased atherosclerosis in individuals who show elevated serum thiocyanate levels (HST) as an indicator of recent smoking. We have studied arterial samples from smokers micromorphometrically and found that 'smokers' have a greater area in which oxLDL can be identified in the early stages of the disease than do "nonsmokers', i.e., individuals with low serum thiocyanate levels (LST). This study demonstrates a positive correlation between the extent of oxLDL in the fatty streaks as well as the fatty plaques of standardized core sample areas of the thoracic and abdominal aortas of a sample group of young people, aged 15-34, who have evidence of recent smoking based on their postmortem serum thiocyanate levels.

A two-platform task reveals a deficit in the ability of rats to return to the start location in the water maze.

The ability of rats to return to the start location was examined with a 4-arm radial water maze. The task required rats to find 2 hidden platforms in sequence. Rats were released from 1 of 3 arms and there was a platform located in the fourth arm. Once a rat found this platform, a 2nd platform was raised in another location, which was either the start location, for 1 group, or another fixed location, for a control group. Across 3 experiments, all rats learned the location of the 1st fixed platform in 80 to 120 trials. However, rats had difficulty finding a 2nd platform if it was at the start location. Control groups revealed that rats could learn 2 platform locations and that the difficulty in learning to return to the start location did not seem to be attributable to its aversive nature. In separate groups, exposure to the start location was increased by starting the rats from an initially stable platform. Rats still did not readily learn to return to the start location. The authors suggest that start location, when varied, cannot readily be used to define the location of a hidden platform.

Total joint replacement in extremities with below-knee amputations.

Patients with knee and hip joint diseases or fractures in a limb with a distal portion amputated were successfully treated with total joint arthroplasties. Two patients with below-knee amputations recieved total joint replacements. One underwent a total hip arthroplasty and the other had a total knee arthryplasty on the side of the amputation. Physical therapy was modified minimally for the two patients in comparison to other patients with total joint replacements. Prosthetic changes were required in both cases. With new prostheses, both patients were able to return to work.

Assisted suicide: clinical realities and ethical challenges.

The increasing attention to assisted suicide, as evidenced by recent legislation, initiatives, court decisions, and research, propels the issue to a new level of importance and urgency within society and the health professions. Nurses cannot help but be confronted by and struggle with the complex moral and professional quandaries related to assisted suicide. Critical care nurses must continue to evaluate the implications of the possible legalization of assisted suicide and to define the boundaries of morally acceptable professional practice. The challenges to the roles and responsibilities of critical care nurses that might occur if assisted suicide were legalized must be thoughtfully and responsibly explored.

End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs.

OBJECTIVE: To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS: A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS: Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS: Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.

A professional code of ethics: providing a moral compass for turbulent times.

PURPOSES/OBJECTIVES: To describe the importance of a professional code of ethics and values in guiding and supporting the practice of nurses and to present the proposed Oncology Nursing Society (ONS) Statement of Core Values. DATA SOURCES: Published articles and books on nursing ethics and bioethics, as well as authors' clinical experiences. DATA SYNTHESIS: Ethical quandaries are commonplace for nurses, and the contemporary context of health care has created new concerns and redefined others. Throughout its history, nursing has been an ethical endeavor, with nurses attempting to sift through complex ethical issues and fulfill their professional responsibilities. A professional code of ethics and values explicates the goals and norms of the profession and provides direction for practice. CONCLUSION: Together, the profession's code of ethics and the proposed ONS Statement of Core Values serve as a resource to guide oncology nurses as they develop an ethically competent practice and confront contemporary ethical challenges. IMPLICATIONS FOR NURSING PRACTICE: The goal of developing an ethically competent practice, maintaining professional integrity, and rendering quality patient care is of vital concern to oncology nurses. Familiarity with and commitment to the primary ethical precepts and values of the profession are essential to accomplishing this goal.

Priority ethical issues in oncology nursing: current approaches and future directions.

PURPOSE/OBJECTIVES: To describe ethical issues determined to be highly important to oncology nurses and to discuss strategies by which the Oncology Nursing Society (ONS) can address these priority concerns. DATA SOURCES: Survey on oncology nurses regarding ethical issues; nursing literature. DATA SYNTHESIS: Nine priority ethical issues of oncology nurses are identified. Past, current, and future ONS activities that address these priority issues are discussed. IMPLICATIONS FOR NURSING PRACTICE: ONS must support activities to increase the knowledge, confidence, and involvement of oncology nurses in discussions and decision making related to the ethical issues. CONCLUSIONS: The top three priority ethical issues for oncology nurses are assisted suicide, end-of-life decisions, and pain management. Efforts should be made to increase ethics expertise among the ONS membership.

Unraveling ethical issues in palliative care.

OBJECTIVES: To describe the ethical issues inherent in palliative care and the essential role of nurses in addressing the ethical dimensions of professional practice. DATA SOURCE: Review articles, research studies, and books related to ethical issues in palliative care. CONCLUSIONS: Nurses in all roles and practice settings confront numerous ethical concerns. Some of the most perplexing and troubling ethical issues arise within the context of palliative care. Being prepared to deal with these ethical issues can foster patient and family well-being and protect the integrity of the nurse. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses have a vital role in improving the quality of end-of-life care. Attention to the ethical dimension of palliative care is necessary to accomplishing this.

Cancer in the older adult: understanding age-related changes.

As the population ages, nurses will be working with increased numbers of elderly cancer patients. It is imperative that nurses gain an understanding of the aging process and an appreciation of the cancer experience in the older adult. By aggravating or influencing cancer-related symptoms and their treatments, or by inducing non-cancer related symptoms, concurrent health problems may inadvertently be thought to be associated with malignancy progression. An in-depth investigation of a patient's history may reveal a vast number of actual and potential health problems; the areas that pose special concerns for the elderly are nutrition, pain, and psychosocial aspects, such as depression and confusion.

When values conflict with obligations: safeguards for nurses.

Increasingly, nurses are being confronted with clinical situations that challenge their personal and professional integrity. For integrity to be preserved, safeguards must be developed and an environment that supports ethical practice fostered. Standards such as those promulgated by the JCAHO provide an important opportunity for nurses to create mechanisms to assure that diverse religious, cultural, and ethical beliefs of nurses are respected and upheld.

Ethical issues in caring for the patient with advanced cancer.

The patient in the advanced stages of cancer presents many challenges for the nurse caregiver. To care for the patient effectively as the end of life approaches requires a shift in focus from cure or treatment of the disease to the management of the associated symptoms. This is the primary goal of palliative care, a unique approach to meeting the needs of this vulnerable patient group. The clinical issues that are common in the care of the patient with advanced cancer may raise specific ethical concerns for the nurse. Managing the symptoms with the goal of palliative care in mind will help to frame these concerns more clearly. Communicating with patients and families on an ongoing basis in a clear and sensitive manner will help to ensure that patients' decisions are known and respected. Nurses need to be prepared to assist in these difficult situations. A nursing ethics group is one method that has been found to be effective in developing nurses' expertise in this area.

A road map for navigating end-of-life care.

As nurses begin to develop the sensitivities and skills necessary to preserve the integrity of clinical care and professional life, they must recognize the legitimacy of their perspectives and the value and consequences they have for the well-being of patient and family care. Nurses have much to contribute to the development of ethical practice environments for patients, families, multidisciplinary team members, and themselves. The frenzied, and at times anesthetized, culture of clinical settings can mitigate against the kind of deliberate reflection that is necessary if nurses are to act with ethical integrity. Knowing the rules of the road for end-of-life care and being attentive to common warning signs and addressing them proactively, enables nurses to provide patients and families with the highest quality care at the end of life.