Let's go outside: using photography to explore values and culture in mental health nursing

Creative and imaginative approaches to mental healthcare education are known to help students explore emotions, empathy and others' experiences, as well as address ambivalence and ambiguity. Very few studies in mental health nursing education specifically utilise photography as a participatory pedagogic tool, with even fewer utilising photography to explore understandings of culture, values and diversity. Photography makes visible complex, collaborative forms of learning and previously unidentified, unarticulated ideas about culture and values. Photography as a critical pedagogic method helps develop critical, politicized understandings of culture and values. Increasing culturally diverse populations means complex and conflicting values have become a common feature in mental health nursing. In education the need to critically examine such topics necessitates creative and engaging pedagogy, and visual methods are readily acknowledged as such. Yet while many studies advocate and demonstrate the value of art-based methods in student learning, very few studies in mental health nursing specifically utilize photography as a participatory pedagogic tool, and fewer still use photography to explore understandings of culture, values and diversity. In this paper, we discuss a qualitative study where mental health nursing students used photography to create images in order to explore their own and often dominant culture and attendant values. Findings suggest that photography makes visible situated, relational and collaborative learning, and surfaces previously unidentified, unarticulated ideas about culture and values. These practices mimic important processes central to mental health nursing practice and contemporaneous understandings of diverse cultures. We argue that photography provides an important resource with which to unearth subjugated knowledge, promote critical understandings of culture and values, and thereby help address inequalities in mental health care.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

A retrospective 15-year review: survival advantage after switching to sirolimus in hepatitis C virus infected liver graft recipients

BACKGROUND

The use of sirolimus-based immune suppression in liver transplantation, particularly in hepatitis C virus (HCV)-infected recipients, remains contentious. There is some evidence that sirolimus retards hepatic fibrosis, is renal sparing and may be of benefit in preventing hepatocellular carcinoma (HCC) recurrence. Sirolimus has not been adopted by many transplant centres because of persistent concerns regarding an increased risk of hepatic artery thrombosis, graft loss and death with de novo sirolimus.

AIM

To review the impact of switching to sirolimus monotherapy in HCV-infected liver recipients with respect to survival, graft loss and hepatic fibrosis.

METHODS

A retrospective review of 190 patients from a single centre undergoing first liver transplantation for HCV over 15 years. 113 patients were switched from calcineurin inhibitor (CNI)-based therapy to low-dose sirolimus monotherapy at a median of 15 months after transplantation for HCV-related fibrosis (72%), renal impairment (14%) or high-risk HCC (5%).

RESULTS

Patients switched to sirolimus had improved survival (P < 0.001) and slower progression to cirrhosis (P = 0.001). In patients with HCC (n = 91), sirolimus duration rather than strategy was an independent predictor of survival (P = 0.001) and extended time to HCC recurrence (33 vs. 16 months). Patients switched for renal dysfunction showed improvement in serum creatinine (140-108 μmol/L, P = 0.001). Those remaining on CNI-therapy were more likely to develop post-transplant diabetes (P = 0.03).

CONCLUSION

These data suggest selective switching to low-dose sirolimus monotherapy in HCV-positive liver recipients improves clinical outcome.

Cost-effectiveness analysis of preoperative transfusion in patients with sickle cell disease using evidence from the TAPS trial

The study's objective was to assess the cost-effectiveness of preoperative transfusion compared with no preoperative transfusion in patients with sickle cell disease undergoing low- or medium-risk surgery. Seventy patients with sickle cell disease (HbSS/Sß(0) thal genotypes) undergoing elective surgery participated in a multicentre randomised trial, Transfusion Alternatives Preoperatively in Sickle Cell Disease (TAPS). Here, a cost-effectiveness analysis based on evidence from that trial is presented. A decision-analytic model is used to incorporate long-term consequences of transfusions and acute chest syndrome. Costs and health benefits, expressed as quality-adjusted life years (QALYs), are reported from the 'within-trial' analysis and for the decision-analytic model. The probability of cost-effectiveness for each form of management is calculated taking into account the small sample size and other sources of uncertainty. In the range of scenarios considered in the analysis, preoperative transfusion was more effective, with the mean improvement in QALYs ranging from 0.018 to 0.206 per patient, and also less costly in all but one scenario, with the mean cost difference ranging from -£813 to £26. All scenarios suggested preoperative transfusion had a probability of cost-effectiveness >0.79 at a cost-effectiveness threshold of £20 000 per QALY.

Site-specific water quality guidelines: 1. Derivation approaches based on physicochemical, ecotoxicological and ecological data

Generic water quality guidelines (WQGs) are developed by countries/regions as broad scale tools to assist with the protection of aquatic ecosystems from the impacts of toxicants. However, since generic WQGs cannot adequately account for the many environmental factors that may affect toxicity at a particular site, site-specific WQGs are often needed, especially for high environmental value ecosystems. The Australian and New Zealand Guidelines for Fresh and Marine Water Quality provide comprehensive guidance on methods for refining or deriving WQGs for site-specific purposes. This paper describes three such methods for deriving site-specific WQGs, namely: (1) using local reference water quality data, (2) using biological effects data from laboratory-based toxicity testing, and (3) using biological effects data from field surveys. Two case studies related to the assessment of impacts arising from mining operations in northern Australia are used to illustrate the application of these methods. Finally, the potential of several emerging methods designed to assess thresholds of ecological change from field data for deriving site-specific WQGs is discussed. Ideally, multiple lines of evidence approaches, integrating both laboratory and field data, are recommended for deriving site-specific WQGs.

Changes in plasma amino acids during conditioning therapy prior to bone marrow transplantation: Their relevance to antioxidant status

Bone marrow transplant (BMT) recipients undergo a bimodal regimen of conditioning therapy, the precise prescription being dependent upon the primary disease of the individual patient. Generally, this treatment consists of chemotherapy and total body irradiation prior to transplantation, although the latter may or may not be included in the regimen. We have investigated amino acid metabolism and oxidant status in in a small series of BMT recipients before and after conditioning therapy.Plasma amino acids were measured by HPLC on 10 BMT recipients prior to commencing conditioning therapy, and again one week later before transplantation. In addition some general nutritional parameters and antioxidant components were measured. A marked decrease in the plasma concentration of a number of amino acids, especially those concerned with antioxidants, was observed over the 7 days of conditioning therapy.There is also a significant reduction in antioxidant capability, as reflected by measurements of glutathione and erythrocyte glutathione peroxidase (GSHPx), which may have an influence upon post-transplant recovery and graft function. Such a reduction in antioxidant concentrations may also have an influence upon the erythrocyte and platelet support required post-grafting.The data presented in this paper adds to the evidence for the conditional essentiality of some amino acids such as taurine and glutamine, and may support the case for specific antioxidant intervention treatment prior to, and/or after conditioning therapy together with monitoring antioxidant status during the post-grafting period.

Multispecies coexistence of trees in tropical forests: spatial signals of topographic niche differentiation increase with environmental heterogeneity

Neutral and niche theories give contrasting explanations for the maintenance of tropical tree species diversity. Both have some empirical support, but methods to disentangle their effects have not yet been developed. We applied a statistical measure of spatial structure to data from 14 large tropical forest plots to test a prediction of niche theory that is incompatible with neutral theory: that species in heterogeneous environments should separate out in space according to their niche preferences. We chose plots across a range of topographic heterogeneity, and tested whether pairwise spatial associations among species were more variable in more heterogeneous sites. We found strong support for this prediction, based on a strong positive relationship between variance in the spatial structure of species pairs and topographic heterogeneity across sites. We interpret this pattern as evidence of pervasive niche differentiation, which increases in importance with increasing environmental heterogeneity.