An Exploration of Care Mapping Among Families of Children with Medical Complexity (CMC)

BACKGROUND: A care map is a visual diagram that illustrates all of the resources needed to support a child with medical complexity, providing a contextualized view of the child in a broader health network. It is believed that health care providers (HCPs) can utilize care maps to enable child and family centered care by helping families prioritize and coordinate their health needs. While the popularity of care maps has been growing, there is a paucity of research on their clinical usefulness.

OBJECTIVES: The objective of this study is to explore how care maps are constructed by parents, what they mean for parents and HCPs, and how they can be applied in a clinical setting.

DESIGN/METHODS: This is a qualitative study informed by a grounded theory approach. Theoretical sampling of parents and HCPs of CMC was utilized. Fifteen care map training sessions and forty-five semi-structured interviews with parents and HCPs of CMC were conducted. The data was coded and analyzed iteratively for predominant themes and emerging theory.

RESULTS: Both HCPs and parents strongly identified the care map [Figure 1] as a valuable tool in the care of CMC. Data analysis revealed key themes that demonstrated how and why care maps are useful. Care maps allow HCPs to recognize family experiences, identify parental goals of care and promote improved care coordination and communication. Parents described creating care maps as an empowering and therapeutic process that helped them to organize and communicate their complex interplay of supports. Both parents and HCPs acknowledged challenges associated with care mapping including the ability of parents to create a care map as well as the HCPs ability to independently interpret the care map’s meaning.

CONCLUSION: Care maps are a useful communication and coordination tool to demonstrate a contextualized view of a family’s narrative of their experience caring for a CMC. Findings may inform a model of how to utilize care maps in clinical practice.

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Paracellular transport through healthy and cystic fibrosis bronchial epithelial cell lines--do we have a proper model?

It has been reported recently that the cystic fibrosis transmembrane conductance regulator (CFTR) besides transcellular chloride transport, also controls the paracellular permeability of bronchial epithelium. The aim of this study was to test whether overexpressing wtCFTR solely regulates paracellular permeability of cell monolayers. To answer this question we used a CFBE41o- cell line transfected with wtCFTR or mutant F508del-CFTR and compered them with parental line and healthy 16HBE14o- cells. Transepithelial electrical resistance (TER) and paracellular fluorescein flux were measured under control and CFTR-stimulating conditions. CFTR stimulation significant decreased TER in 16HBE14o- and also in CFBE41o- cells transfected with wtCFTR. In contrast, TER increased upon stimulation in CFBE41o- cells and CFBE41o- cells transfected with F508del-CFTR. Under non-stimulated conditions, all four cell lines had similar paracellular fluorescein flux. Stimulation increased only the paracellular permeability of the 16HBE14o- cell monolayers. We observed that 16HBE14o- cells were significantly smaller and showed a different structure of cell-cell contacts than CFBE41o- and its overexpressing clones. Consequently, 16HBE14o- cells have about 80% more cell-cell contacts through which electrical current and solutes can leak. Also tight junction protein composition is different in 'healthy' 16HBE14o- cells compared to 'cystic fibrosis' CFBE41o- cells. We found that claudin-3 expression was considerably stronger in 16HBE14o- cells than in the three CFBE41o- cell clones and thus independent of the presence of functional CFTR. Together, CFBE41o- cell line transfection with wtCFTR modifies transcellular conductance, but not the paracellular permeability. We conclude that CFTR overexpression is not sufficient to fully reconstitute transport in CF bronchial epithelium. Hence, it is not recommended to use those cell lines to study CFTR-dependent epithelial transport.

Paracellular permeability of bronchial epithelium is controlled by CFTR

In normal airway epithelium, the cystic fibrosis transmembrane conductance regulator (CFTR) transports Cl(-) ions to the apical surface of the epithelium paralleled by the flow of water through transcellular and paracellular pathways. The hypothesis was tested whether CFTR not only regulates the transcellular but also the paracellular shunt pathway. Therefore, we performed measurements of transepithelial electrical resistance (TER) and paracellular (14)C-mannitol permeability in wtCFTR (16HBE14o(-)) and delF508-CFTR (CFBE41o(-)) expressing human bronchial epithelial cells. Under resting conditions, CFBE41o(-) cell monolayers exhibit a higher paracellular permeability and lower TER as compared to 16HBE14o(-) monolayers. Stimulation of CFTR by cAMP induces opposite effects in the two cell lines. 16HBE14o(-) monolayers show a sharp decrease of TER, in parallel with a concomitant increase of paracellular permeability. The change in paracellular permeability is mediated by a myosin II dependent mechanism because it can be blocked by the myosin light chain kinase inhibitor ML-7. In contrast, CFBE41o(-) cells respond to cAMP stimulation with a decrease of paracellular permeability, paralleled by slight increase of TER. We conclude that stimulation of wtCFTR increases vectorial transcellular salt transport and, simultaneously, the paracellular permeability allowing water to follow through the paracellular pathway. In contrast, in CF epithelium cAMP stimulation increases neither vectorial salt transport nor paracellular permeability which is likely to contribute to the CF pulmonary phenotype. Taken together, our results link CFTR dysfunction to an improper regulation of the paracellular transport route.

Medical problems of geriatric psychiatric patients and younger controls during electroconvulsive therapy

Medical problems occurring during electroconvulsive therapy were studied in a population of 293 psychiatric inpatients who received 2,809 treatments. Geriatric patients (N = 199) developed significantly more medical problems that required medical treatment or temporary discontinuation of electroconvulsive therapy than did younger controls (N = 94). The most important of these were cardiovascular in nature. Despite their increased frequency, the majority of medical problems that occurred were reversible. Electroconvulsive therapy therefore appeared to be a safe procedure for elderly psychiatric patients.