Palestinian nurses' lived experiences working in the occupied West Bank.

BACKGROUND: Since the construction of the separation wall between Israel and the West Bank, Palestinians living in occupied West Bank have endured intense conflict, and severe restrictions on people's movement, trade and healthcare access, all of which resulted in spiralling poverty. These issues have created challenges for nurses that, to date, have not been explored. AIM: To explore the lived experience of Palestinian nurses working in the occupied West Bank. METHODS: Qualitative phenomenological study using interviews with Palestinian nurses working in public hospitals in the West Bank. FINDINGS: Seventeen nurses were interviewed. Despite ongoing experiences of trauma and humiliation, personal/professional role conflicts, political workplace bias and blurred role boundaries, these nurses persevered because of their commitment to caring and sense of moral duty to 'the people of this land'. DISCUSSION: Nurses in conflict areas are subject to layers of trauma. Palestinian nurses in the West Bank not only experience ongoing personal trauma, loss and humiliation of living in a conflict zone but they also experience additional professional trauma. CONCLUSION: The findings provide first-person reports of the unique challenges of nurses working in the occupied West Bank. IMPLICATIONS FOR NURSING PRACTICE: Understanding the experiences of nurses working in occupied territories provides authentic information for local authorities and the global healthcare community. Practice improvements must be addressed and implemented. IMPLICATIONS FOR HEALTH POLICY: Local and global organizations that mobilize support, invest in human capital, and protect human rights in areas of conflict may benefit from understanding the experiences of nurses in this study.

Characterization of binding of leukotriene C4 by human multidrug resistance protein 1: evidence of differential interactions with NH2- and COOH-proximal halves of the protein.

Multidrug resistance protein 1 (MRP1) is capable of actively transporting a wide range of conjugated and unconjugated organic anions. The protein can also transport additional conjugated and unconjugated compounds in a GSH- or S-methyl GSH-stimulated manner. How MRP1 binds and transports such structurally diverse substrates is not known. We have used [(3)H]leukotriene C(4) (LTC(4)), a high affinity glutathione-conjugated physiological substrate, to photolabel intact MRP1, as well as fragments of the protein expressed in insect cells. These studies revealed that: (i) LTC(4) labels sites in the NH(2)- and COOH-proximal halves of MRP1, (ii) labeling of the NH(2)-half of MRP1 is localized to a region encompassing membrane-spanning domain (MSD) 2 and nucleotide binding domain (NBD) 1, (iii) labeling of this region is dependent on the presence of all or part of the cytoplasmic loop (CL3) linking MSD1 and MSD2, but not on the presence of MSD1, (iv) labeling of the NH(2)-proximal site is preferentially inhibited by S-methyl GSH, (v) labeling of the COOH-proximal half of the protein occurs in a region encompassing transmembrane helices 14-17 and appears not to require NBD2 or the cytoplasmic COOH-terminal region of the protein, (vi) labeling of intact MRP1 by LTC(4) is strongly attenuated in the presence of ATP and vanadate, and this decrease in labeling is attributable to a marked reduction in LTC(4) binding to the NH(2)-proximal site, and (vii) the attenuation of LTC(4) binding to the NH(2)-proximal site is a consequence of ATP hydrolysis and trapping of Vi-ADP exclusively at NBD2. These data suggest that MRP1-mediated transport involves a conformational change, driven by ATP hydrolysis at NBD2, that alters the affinity with which LTC(4) binds to one of two sites composed, at least in part, of elements in the NH(2)-proximal half of the protein.

Mutation of Trp1254 in the multispecific organic anion transporter, multidrug resistance protein 2 (MRP2) (ABCC2), alters substrate specificity and results in loss of methotrexate transport activity.

The ATP-binding cassette (ABC) proteins comprise a large superfamily of transmembrane transporters that utilize the energy of ATP hydrolysis to translocate their substrates across biological membranes. Multidrug resistance protein (MRP) 2 (ABCC2) belongs to subfamily C of the ABC superfamily and, when overexpressed in tumor cells, confers resistance to a wide variety of anticancer chemotherapeutic agents. MRP2 is also an active transporter of organic anions such as methotrexate (MTX), estradiol glucuronide (E217betaG), and leukotriene C4 and is located on the apical membrane of polarized cells including hepatocytes where it acts as a biliary transporter. We recently identified a highly conserved tryptophan residue in the related MRP1 that is critical for the substrate specificity of this protein. In the present study, we have examined the effect of replacing the analogous tryptophan residue at position 1254 of MRP2. We found that only nonconservative substitutions (Ala and Cys) of Trp1254 eliminated [3H]E217betaG transport by MRP2, whereas more conservative substitutions (Phe and Tyr) had no effect. In addition, only the most conservatively substituted mutant (W1254Y) transported [3H]leukotriene C4, whereas all other substitutions eliminated transport of this substrate. On the other hand, all substitutions of Trp1254 eliminated transport of [3H]MTX. Finally, we found that sulfinpyrazone stimulated [3H]E217betaG transport by wild-type MRP2 4-fold, whereas transport by the Trp1254 substituted mutants was enhanced 6-10-fold. In contrast, sulfinpyrazone failed to stimulate [3H]MTX transport by either wild-type MRP2 or the MRP2-Trp1254 mutants. Taken together, our results demonstrate that Trp1254 plays an important role in the ability of MRP2 to transport conjugated organic anions and identify this amino acid in the putative last transmembrane segment (TM17) of this ABC protein as being critical for transport of MTX.

Educational needs of patients with advanced heart failure and their caregivers.

At the time of initial transplant evaluation, we evaluated the information and counseling needs of 82 outpatients with advanced heart failure and compared them with the needs of 74 of their caregivers. Both groups answered a 23-item questionnaire, which used a 5-point Likert scale to assess needs across 6 sub-scales specific to heart failure and the process of determining transplant eligibility. The 5 most important learning needs of patients and caregivers were similar, and we found significant differences only in the groups' responses to 3 individual questions. We conclude that nurses can meet the needs of patients and their caregivers by providing honest explanations, focusing on enhanced quality of life issues, and giving information for dealing with an emergency.

Role of spirituality in adjustment of patients with advanced heart failure.

Heart failure is a chronic and progressive disease often characterized by severe symptoms, frequent hospitalization, and poor prognosis. It may threaten the individual's sense of self and lead to questions related to spirituality. The purpose of this qualitative, phenomenologic study was to describe the role of spirituality in the adjustment of patients to advanced heart failure. Purposive sampling of all patients who presented to two university-affiliated, outpatient heart failure clinics was used. Eighty-seven patients were interviewed using a semistructured questionnaire. Data were subjected to content analysis and thematic coding. Patients described a three-step process where spirituality contributed to their adjustment to advanced heart failure: development of regret regarding past behaviors and lifestyles; the search for meaning within the present experience of heart failure; and the search for hope for the future and reclaiming of optimism. Assessment and interventions that include a spiritual dimension can facilitate the adjustment of patients to advanced heart failure.

Sexuality of patients with advanced heart failure and their spouses or partners.

BACKGROUND: Sexuality is an important aspect of quality of life for patients with advanced heart failure and their spouses or partners. Therefore, we conducted a study to determine the types of sexual problems and concerns of patients and their spouses/partners, their level of interest in receiving information on this topic, and the relationship between their need for information and the degree of sexual problems. METHODS: Sixty-three couples were recruited from a university-affiliated, outpatient, heart failure program during their initial visit. RESULTS: The most important sexual relationship issue of both patients and spouses/partners was related to decreased frequency in sexual relations. They reported the need to receive specific information about sexual activity as moderate to very high, but it was unrelated to the level of need for education and counseling. CONCLUSIONS: Nurses and physicians need to assume interest and provide instruction related to the sexual activity needs of patients and their spouses/partners.

Multidrug resistance protein. Identification of regions required for active transport of leukotriene C4.

Multidrug resistance protein (MRP) is a broad specificity, primary active transporter of organic anion conjugates that confers a multidrug resistance phenotype when transfected into drug-sensitive cells. The protein was the first example of a subgroup of the ATP-binding cassette superfamily whose members have three membrane-spanning domains (MSDs) and two nucleotide binding domains. The role(s) of the third MSD of MRP and its related transporters is not known. To begin to address this question, we examined the ability of various MRP fragments, expressed individually and in combination, to transport the MRP substrate, leukotriene C4 (LTC4). We found that elimination of the entire NH2-terminal MSD or just the first putative transmembrane helix, or substitution of the MSD with the comparable region of the functionally and structurally related transporter, the canalicular multispecific organic anion transporter (cMOAT/MRP2), had little effect on protein accumulation in the membrane. However, all three modifications decreased LTC4 transport activity by at least 90%. Transport activity could be reconstituted by co-expression of the NH2-terminal MSD with a fragment corresponding to the remainder of the MRP molecule, but this required both the region encoding the transmembrane helices of the NH2-terminal MSD and the cytoplasmic region linking it to the next MSD. In contrast, a major part of the cytoplasmic region linking the NH2-proximal nucleotide binding domain of the protein to the COOH-proximal MSD was not required for active transport of LTC4.

Commitment to function: microsurgical flaps.

Microsurgical procedures facilitate the optimal function of patients and provide for an enhanced quality of life. The contribution of this procedure to the eventual positive outcome of multiple patient populations is clear. Therefore, competence in the care of this emerging patient population is essential for the plastic surgical nurse. This article has outlined the history of free flaps, flap anatomy and physiology, evaluation of flap vascularity, and postoperative nursing care. Further work needs to be performed in order to definitively describe nursing and medical interventions, delineate effective wound management techniques, and develop monitoring devices that will augment the success of the free flap procedure.

Cardiovascular effects of recreational cocaine abuse.

Deaths related to the recreational use of cocaine in the United States have increased to epidemic proportions within the last decade. Frequently, persons with cocaine toxicity present to the emergency room, require critical care nursing, and are admitted to the intensive care unit. This article outlines the cardiovascular effects of recreational cocaine abuse. Initially, the historical perspective of the drug is outlined. The mechanism of action, administration, absorption, and excretion are discussed. Details regarding the cardiovascular effects of cocaine are described. Although no uniform treatment plan has been developed for every complication of cocaine overdose, the current therapeutic modalities are outlined. Finally, the clinical implications for clinical practice are addressed. The recreational abuse of cocaine presents new patient care challenges for the critical care nurse. With increased knowledge, the health care provider may assist in meeting the clinical needs of this emerging patient population.

Randomized study of high dose oral cyclosporine therapy for mild acute cardiac rejection.

Mild acute rejection progresses to moderate rejection in approximately one third of the cases. Standard rejection therapy would then be instituted with the attendant risk of infection and other side effects. We randomized 40 episodes of mild acute rejection (20 episodes in each group) to receive no additional therapy or to have the oral cyclosporine dose increased for 7 to 10 days with repeat endomyocardial biopsy performed. In the group with no additional therapy 30% progressed to moderate rejection, whereas in the group with increased doses of oral cyclosporine, 10% progressed to moderate rejection (p = 0.10). As the purpose of our study was to assess the efficacy of increased cyclosporine levels for preventing progression from mild to moderate rejection, the treated group was redefined according to whether the cyclosporine level increased by greater than or equal to 50% during the study. In this treated group average cyclosporine levels increased from 169 +/- 78 to 413 +/- 267 ng/ml. Progression to moderate rejection occurred in one of 21 cases (5%) compared with seven of 19 cases (37%) in the group without an increase in cyclosporine level (p less than 0.05). The transient increase in cyclosporine levels was well tolerated. This study demonstrates that the use of high dose oral cyclosporine to treat mild acute rejection is well tolerated and may reduce progression to moderate rejection when a significant increase in cyclosporine level is achieved.

Appendicectomy and dietary fibre.

The hypothesis that dietary fibre protects against appendicitis was tested. One thousand seven hundred subjects, involved in another enquiry, were sent a questionnaire asking about their intake of cereal fibre and other foodstuffs, and whether or not they had had an appendectomy. The respondents, who represented 92 per cent of the sample, were divided into those who ate wholemeal bread daily and those who ate wholemeal bread rarely or never. These groups appeared to be very similar with respect to age, sex, smoking habit, alcohol intake and various other factors. Comparison of appendicectomy rates between those who ate wholemeal bread and those who did not showed a deficit among the former, which is consistent with a protective effect of cereal fibre, but the difference was not statistically significant.

Dietary potassium deficiency in the elderly: a controlled trial.

A controlled cross-over trial of supplementary potassium was conducted in 46 elderly people whose dietary intake of potassium appeared to be no more than 45 mEq per day. Their grip strength and mental function were no better after two weeks' treatment with 48 mEq than when they received placebo tablets. It was concluded that the possible benefits of widespread potassium supplementation do not justify the risks which would be incurred.