Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project.

OBJECTIVE: The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project. DESIGN: We enrolled dying patients, their families and 1-3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach. SETTING: 21-bed medical surgical ICU in a tertiary care, university-affiliated hospital. RESULTS: 33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1-3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection. CONCLUSIONS: For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings.

Residency time, migration route and survival of Atlantic salmon Salmo salar smolts in a Canadian fjord.

Atlantic salmon Salmo salar smolts (n = 181) from two rivers were surgically implanted with acoustic transmitters and released to determine migration route, residency time and survival in a 50 km long estuarine fjord located on the south coast of Newfoundland, Canada. Data obtained from automated receivers placed throughout the Bay d'Espoir fjord indicated that migrating smolts used different routes to reach the outer areas of the fjord. The duration of time that smolts spent in the immediate estuary zone also differed between the two localities (7 and 17 days) although the total time smolts were resident in the fjord was similar and extensive (40 days). Many smolts were resident for periods of 4-8 weeks moving back and forth in the outer part of the fjord where maximum water depths range from 300 to 700 m. Survival in the estuary zone was greater for smolts with prolonged residency in estuarine habitat. Overall smolt survival to the fjord exit was moderately high (54-85%), indicating that the initial phase of migration did not coincide with a period of unusually high mortality.

Myogenesis and muscle metabolism in juvenile Atlantic salmon (Salmo salar) made transgenic for growth hormone.

Atlantic salmon (Salmo salar) made transgenic for growth hormone (GH) and non-transgenic salmon were sampled at 4 and 7 months of age to estimate myogenic factors, satellite cell proliferation and metabolic enzyme activities. The growth rate of 4 month old transgenic salmon was higher than that of non-transgenic salmon. Myosatellite cell (MC) proliferation rates were higher in cells isolated from GH-transgenic salmon compared with cells from non-transgenic salmon of the same mass. Moreover, MCs extracted from non-transgenic salmon demonstrated a higher proliferation capacity when exposed in vitro to salmon GH. White muscle MyoD I mRNA content was higher in transgenic and non-transgenic salmon at 7 months compared with that at 4 months, indicating an effect of age on MyoD I mRNA expression. White muscle myogenin mRNA content varied with fish age and presence of the transgene, and was higher in transgenic fish at 7 months, suggesting a higher differentiation capacity. MyoD I, MyoD II and myogenin mRNA content was higher in red muscle of GH-transgenic fish at 7 months compared with non-transgenic salmon at 7 months. However, red muscle myogenic factor expression was not different between transgenic and non-transgenic fish of the same weight. Enzyme activities in white muscle and liver were highly affected by the presence of the transgene, although this effect was generally dependent on the age of the fish. Glycolytic and oxidative enzyme activities were increased in transgenic salmon liver, indicating a higher metabolic rate in transgenics. This study demonstrates that (1) the higher growth rate of transgenic salmon particularly at 4 months of age could be explained at least in part by higher numbers and proliferation rates of MCs, (2) GH can directly stimulate the proliferation of myosatellite cells extracted from salmon, indicating that GH is one possible factor involved in the higher myosatellite cell proliferation rates in transgenic salmon, (3) MyoD and myogenin mRNA expression are affected by fish age, and (4) metabolic enzyme activities are affected by the age of the fish at least in liver and white muscle, and any transgene effect is dependent upon the age of the fish.

Cardiorespiratory modifications, and limitations, in post-smolt growth hormone transgenic Atlantic salmon Salmo salar.

In recent years, there has been a great deal of interest in how growth hormone (GH) transgenesis affects fish physiology. However, the results of these studies are often difficult to interpret because the transgenic and non-transgenic fish had very different environmental/rearing histories. This study used a stable line of size-matched GH Atlantic salmon (Salmo salar) that were reared in a shared tank with controls (at 10 degrees C, for approximately 9 months) to perform a comprehensive examination of the cardiorespiratory physiology of GH transgenic salmon, and serves as a novel test of the theory of symmorphosis. The GH transgenic salmon had a 3.6x faster growth rate, and 21 and 25% higher values for mass-specific routine and standard oxygen consumption (M(O(2))), respectively. However, there was no concurrent increase in their maximum M(O(2)), which resulted in them having an 18% lower metabolic scope and a 9% reduction in critical swimming speed. This decreased metabolic capacity/performance was surprising given that the transgenics had a 29% larger heart with an 18% greater mass-specific maximum in situ cardiac output, a 14% greater post-stress blood haemoglobin concentration, 5-10% higher red muscle and heart aerobic enzyme (citrate synthase or cytochrome oxidase) activities, and twofold higher resting and 1.7x higher post-stress, catecholamine levels. However, gill surface area was the only cardiorespiratory parameter that was not enhanced, and our data suggest that gill oxygen transfer may have been limiting. Overall, this research: (1) shows that there are significant metabolic costs associated with GH transgenesis in this line of Atlantic salmon; (2) provides the first direct evidence that cardiac function is enhanced by GH transgenesis; (3) shows that a universal upregulation of post-smolt (adult) GH transgenic salmon cardiorespiratory physiology, as suggested by symmorphosis, does not occur; and (4) supports the idea that whereas differences in arterial oxygen transport (i.e. cardiac output and blood oxygen carrying capacity) are important determinants of inter-specific differences in aerobicity, diffusion-limited processes must be enhanced to achieve substantial intra-specific improvements in metabolic and swimming performance.

Vitrification assays with embryos from a cold tolerant sub-arctic fish species.

Pseudopleuronectes americanus is a Northern teleost species that produces antifreeze proteins (AFPs) to protect them from freezing during the winter. These AFPs bind to ice crystals to inhibit their growth, and they also protect cell membranes at low temperatures. In this study, vitrification trials were done with fish embryos at three different developmental stages, using two different protocols for incorporating the vitrifying solutions. Toxicity of the cryoprotectants and permeability to dimethyl sulfoxide were analyzed. Embryos were vitrified in 0.5 ml straws by direct immersion in liquid nitrogen, and their morphology and development analyzed following thaw. The embryos responded well to vitrification as evidenced by the high percentage that exhibited good morphology following thaw. Although none of the embryos hatched, a small percentage (0.92%) of them showed active movements within the chorion and continued to develop for a number of days following thaw. This is the first record of post-thaw development of vitrified fish embryos.

Mental health nursing policy - an exploratory qualitative study of managers' opinions.

During the 1990s, much of the legislation and policy that pertains to mental health services has sought to direct them towards a virtually exclusive concern with the seriously mentally ill, typified by the following recommendation from a recent Department of Health review of mental health nursing that stated: 'The essential focus for the work of mental health nurses lies in working with people with serious or enduring mental illness'. On the other hand, pressure from the primary health care sector suggests the need for services to be provided for the less seriously mentally ill, particularly through the auspices of general practice fundholders. Following a review of the literature, a small-scale, exploratory study was initiated to seek answers to the following research question: How is the policy focus urging reorientation to the severely mentally ill viewed by nurse managers who have a responsibility through Mental Health Resource Centres and Community Mental Health Teams, to provide mental health services? The study was based within a Welsh National Health Service (NHS) Trust that employed six nurse managers of Community Mental Health Teams (CMHTs). Four of the managers additionally had responsibility for Community Mental Health Resource Centres (CMHRCs). Of the population of six managers, four composed the sample for the investigation. A qualitative research approach was employed, utilizing semistructured interviews as the data collection tool. Analysis of the data revealed that managers were finding creative solutions in order to meet the conflicting demands placed upon them. The research findings also indicated that many of the obstacles to providing a needs-led service were structural in origin, and could be resolved by central strategic intervention.

Liver-specific and seasonal expression of transgenic Atlantic salmon harboring the winter flounder antifreeze protein gene.

We have analyzed the inheritance and expression of a line of transgenic salmon harboring the antifreeze protein gene from the winter flounder. The genomic clone 2A-7 coding for a major liver-type antifreeze protein gene (wflAFP-6) was integrated into the salmon genome. From a transgenic founder (#1469), an F3 generation was produced. In this study, southern blot analysis showed that only one copy of the antifreeze protein transgene was integrated into a unique site in F3 transgenic fish. The integration site was cloned and characterized. Northern analysis indicated that the antifreeze protein mRNA was only expressed in the liver and showed seasonal variation. All of the F3 offspring contained similar levels of the antifreeze protein precursor protein in the sera and the sera of these offspring showed a characteristic hexagonal ice crystal pattern indicating the presence of antifreeze activity. In addition, the antifreeze protein precursor protein level was found to vary with the season, being highest in the month of November and lowest in May. This study had demonstrated a tissue-specific and stable expression of the antifreeze protein transgene in the F3 generation of the transgenic salmon 1469 line.

Growth enhancement in transgenic Atlantic salmon by the use of an "all fish" chimeric growth hormone gene construct.

We have developed an "all fish" growth hormone (GH) chimeric gene construct by using an antifreeze protein gene (AFP) promoter from ocean pout linked to a chinook salmon GH cDNA clone. After microinjection into fertilized, nonactivated Atlantic salmon eggs via the micropyle, transgenic Atlantic salmon were generated. The presence of the transgene was detected by polymerase chain reaction (PCR) using specific oligonucleotide primers. A number of these transgenic fish showed dramatic increases in their growth rate. At one year old, the average increase of the transgenic fish was 2 to 6 fold and the largest transgenic fish was 13 times that of the average non-transgenic control.

Antifreeze proteins in the urine of marine fish.

Several species of marine teleosts have evolved blood plasma antifreeze polypeptides which enable them to survive in ice-laden seawater. Four distinct antifreeze protein classes differing in carbohydrate content, amino acid composition, protein sequence and secondary structure are currently known. Although all of these antifreezes are relatively small (2.6-33 kd) it was generally thought that they were excluded from the urine by a variety of glomerular mechanisms. In the present study antifreeze polypeptides were found in the bladder urine of winter flounder (Pseudopleuronectes americanus), sea raven (Hemitripterus americanus), ocean pout (Macrozoarces americanus) and Atlantic cod (Gadus morhua). Since the plasma of each of these fish contains a different antifreeze class it would appear that all four classes of antifreeze can enter the urine. The major antifreeze components in the urine of winter flounder were found to be identical to the major plasma components in terms of high performance liquid chromatography retention times and amino acid composition. It is concluded that plasma antifreeze peptides need not be chemically modified before they can enter the urine.

Structural variations in the alanine-rich antifreeze proteins of the pleuronectinae.

The sequence and activity of antifreeze proteins from two right eye flounder species were compared to assess the influence of structural variations on antifreeze capacity. The cDNA encoding the major serum antifreeze protein in the yellowtail flounder (Limanda ferruginea) was cloned from liver tissue. Its DNA sequence shows that the precursor to the antifreeze is a 97-residue preproportion. Edman degradation identified the N-terminus of the 48-amino-acid mature serum antifreeze protein and confirmed the sequence of the first 36 residues. A comparison with the previously determined winter flounder antifreeze protein and mRNA sequences shows strong homology through the 5' and 3' untranslated regions and in the peptide region. The mature protein section has the greatest sequence variation. Specifically, the yellowtail antifreeze protein, in contrast to that of the winter flounder, contains a fourth 11-amino-acid repeat and lacks several of the hydrophilic residues that have been postulated to aid in the binding of the protein to ice crystals. Intramolecular salt bridges are present in the antifreeze proteins from both species but in different registries with respect to the 11-amino-acid repeats. On a mass basis the yellowtail flounder antifreeze, though longer than that of the winter flounder, is only 80% as effective at depressing the freezing temperature of aqueous solutions. This lower activity might be due to the reduced number of hydrophilic ice-binding residues per molecule.

The binding of zinc to the soluble proteins of intestinal mucosa in winter flounder (Pseudopleuronectes americanus).

1. The binding of Zn2+ to soluble proteins of intestinal mucosa of winter flounder was examined using an equilibrium dialysis technique. 2. There appeared to be more than one binding system present for Zn2+ in the mucosal cytosol. 3. It required four times the normal endogenous Zn2+ level found in the mucosal cytosol to saturate the highest affinity (K1 = 2.42 x 10(7] binding system. 4. Of 10 metals tested Cu2+ was the only one which interfered with Zn2+ binding to the mucosal cytosol proteins. 5. It is postulated that binding proteins in the mucosal cytosol of winter flounder may play a role in the transport of Zn2+.