Nurses' knowledge of and attitude toward postoperative patient-controlled analgesia (PCA) and the associated factors

BACKGROUND

Postoperative pain control is pivotal for surgical care; it facilitates patient recovery. Although patient-controlled analgesia (PCA) has been available for decades, inadequate pain control remains. Nurses' knowledge of and attitude toward PCA may influence the efficacy on clinic application.

PURPOSE

The purpose of this study is to evaluate nurses' knowledge of and attitude toward postoperative PCA and investigate the associated factors.

METHODS

This is a cross-sectional study. We enrolled registered nurses from a 2200-bed medical center in northern Taiwan within one year. The participants completed an anonymous self-reported PCA knowledge inventory and PCA attitude inventory. Data were analyzed descriptively and associated were tested using logistic regression.

RESULTS

With 303 participants enrolled, we discovered that nurses had limited knowledge of and a negative attitude toward PCA. Under half of the participants know how to set up a bolus dose and lockout intervals. The majority held misconceptions regarding side effect management for opioids. The minority agree to increase the dose when a patient experienced persistent pain or suggested the use of PCA. Surprisingly, participants with a bachelor's or master's degree had lower knowledge scores than those with a junior college degree. Those with 6-10 years of work experience also are lower than those with under 5 years of experience. However, the participants with experience of using PCA for patient care had higher knowledge scores and a more positive attitude.

CONCLUSIONS

Although postoperative PCA has been available for decades and education programs are routinely provided, nurses had limited knowledge of and a negative attitude toward PCA. A higher education level and longer work experience were not associated with more knowledge. The current education programs on PCA should be revised to enhance their efficacy in delivering up-to-date knowledge and situation training which may convey supportive attitude toward clinical application of PCA.

Factors Associated With Levels of Public Engagement in Protective Behaviors During the Early COVID-19 Pandemic: Causal-Comparative Study Based on the Health Belief Model

BACKGROUND

While the challenges of COVID-19 are still unfolding, the enhancement of protective behavior remains a top priority in global health care. However, current behavior-promoting strategies may be inefficient without first identifying the individuals with lower engagement in protective behavior and the associating factors.

OBJECTIVE

This study aimed to identify individuals with and potential contributing factors to low engagement in protective behavior during the COVID-19 pandemic.

METHODS

This is a causal-comparative study. A theory-based web-based survey was used to investigate individuals' protective behavior and potential associating factors. During June 2020, the distribution of the survey was targeted to 3 areas: Taiwan, Japan, and North America. Based on the theory of the health belief model (HBM), the survey collected participants' various perceptions toward COVID-19 and a collection of protective behaviors. In addition to the descriptive analysis, cluster analysis, ANOVA, and Fisher exact and chi-square tests were used.

RESULTS

A total of 384 responses were analyzed. More than half of the respondents lived in Taiwan, followed by Japan, then North America. The respondents were grouped into 3 clusters according to their engagement level in all protective behaviors. These 3 clusters were significantly different from each other in terms of the participants' sex, residency, perceived barriers, self-efficacy, and cues of action.

CONCLUSIONS

This study used an HBM-based questionnaire to assess protective behaviors against COVID-19 and the associated factors across multiple countries. The findings indicate significant differences in various HBM concepts among individuals with varying levels of behavioral engagement.

[Analysis of public health risks associated with pathogenic fungi in China]

At present, the public health risks caused by pathogenic fungi are greater in China and have attracted great attention from disease control departments. Due to the difficulty in diagnosing fungal infections, the public health risk of pathogenic fungi is currently hidden in the unexplained pneumonia/encephalitis/fever syndrome and is not effectively appreciated. From the public health perspective, the mainly focused fungal pathogens include highly pathogenic fungi (including dimorphic fungi and dematiaceous fungi), pathogenic fungi that cause regional aggregation infections, and drug-resistant pathogenic fungi. However, due to the lack of systematic monitoring data, the disease burden related to pathogenic fungi cannot be accurately quantified and evaluated. Therefore, to effectively reduce the serious harm of fungal infections to the public, systematic monitoring of pathogenic fungi should be carried out nationally.

Factors associated with walking performance among adolescents undergoing cancer treatment: A correlational study

This study aimed to describe and compare the differences in walking performance between adolescent patients in inpatient wards and outpatient units, and to identify factors that influence walking performance among adolescents receiving cancer treatment. The cross-sectional study with correlational research design recruited 32 adolescents with cancer between February 2015 and March 2017 in two teaching hospitals in Taiwan. Descriptive, bivariate, and multivariate regression analyses were used. Participants' age, treatment setting, and symptom distress were significantly associated with number of walking steps. All independent variables in the model together accounted for 82.1% of variance. This study addresses a gap in the existing literature to identify associated factors that affected walking performance among adolescents undergoing cancer treatment. Our findings represent a pathway toward generating knowledge to enhance well-being for this unique population.

[Progress of genomic mutation spectrum in biliary tract malignant tumors]

Biliary tract cancer is characterized by high invasiveness, occult early clinical manifestations and rapid progression. Surgical resection typically fails to achieve satisfactory outcomes. Biliary tract cancer exhibits low sensitivity to radiotherapy and chemotherapy. The prognosis of patients is extremely poor. Genomics research based on next-generation sequencing technology has made some advances. The gene mutation spectrum of biliary tract cancer has been preliminarily revealed, which lays a foundation for the study of molecular typing. This review summarizes the research progress and clinical application of gene mutation spectrum of biliary tract cancer in recent years, aiming to provide reference for the clinical diagnosis, treatment and basic research.

Pediatric palliative care utilization by decedent children: A nationwide population-based study, 2002-2017

PURPOSE

This study aimed (1) to describe how trends in pediatric palliative care (PPC) utilization changed from 2002 to 2017, and (2) to examine factors predicting PPC utilization among decedent children in Taiwan.

DESIGN

This retrospective, correlational study retrieved 2002-2017 data from three national claims databases in Taiwan.

METHODS

Children aged 1 through 18 years who died between January 2002 and December 2017 were included. Pediatric palliative care utilization was defined as PPC enrollment and PPC duration, with enrollment described by frequency (n) and percentage (%) and duration described by mean and standard deviation (SD). Logistic regression was used to examine the associations of various demographic characteristics with PPC enrollment; generalized linear regression was used to examine associations of the demographic characteristics with PPC duration.

FINDINGS

Across the 16-year study period, PPC enrollment increased sharply (15.49 times), while PPC duration decreased smoothly (by 29.41%). Cause of death was a continuous predictor of both PPC enrollment and PPC duration. The children less likely to be enrolled in PPC services were those aged 1 to 6 years, boys, living in poverty, living in rural areas, and diagnosed with life-threatening noncancer diseases.

CONCLUSION

This study used nationwide databases to investigate PPC enrollment and PPC duration among a large sample of deceased children from 2002 to 2017. The findings not only delineate trends and predictors of PPC enrollment and PPC duration but also highlight great progress in PPC as well as the areas still understudied and underserved. This information could help the pediatric healthcare system achieve the core value of family-centered care for children with life-threatening diseases and their families.

CLINICAL RELEVANCE

Pediatric palliative care should be widely and continuously implemented in routine pediatric clinical practice to enhance quality of life for children and their families at the end of life.

Examining the Role of Resilience, Posttraumatic Growth, and Quality of Life in Women with Breast Cancer: A Serial Multiple Mediator Model Approach

OBJECTIVES

It is unclear how resilience and posttraumatic growth help women with breast cancer face cancer-related symptom distress. This study included both resilience and posttraumatic growth as mediators in a serial multiple mediator model to examine changes in the relationship between symptom distress and quality of life among women with breast cancer.

DATA SOURCES

We conducted the descriptive, cross-sectional study in Taiwan. Data were collected using a survey that assessed symptom distress, resilience, posttraumatic growth, and quality of life. A serial multiple mediator model examined one direct and three specific indirect effects of symptom distress on quality of life through resilience and posttraumatic growth. All 91 participants reported the presence of symptom distress and moderate levels of resilience. Quality of life was significantly associated with symptom distress (b = -1.04), resilience (b = 0.18), and posttraumatic growth (b = 0.09). The indirect effect of symptom distress on quality of life through resilience alone was statistically significant (b = -0.23, 95% CI -0.44 to -0.07) and statistically greater than the specific indirect effect through resilience and posttraumatic growth combined (b = -0.21, 95% CI -0.40 to -0.05).

CONCLUSION

Resilience plays a unique role in reducing the impact of symptom distress on the quality of life among women with breast cancer.

IMPLICATIONS FOR NURSING PRACTICE

Given the importance of resilience to quality of life, oncology nurses can assess the resilience of women with breast cancer and help identify available internal, external, and existential resources to strengthen their resilience.

Scale Validation of the Mandarin-Language Supportive Care Needs Survey-Adolescent Form

OBJECTIVES

To (1) modify the Mandarin-language 34-item Supportive Care Needs Survey-Adult Form into the Adolescent Form and (2) examine the psychometric properties of the Adolescent Form.

DATA SOURCES

A multiphase, iterative scale validation process was used in this methodological study. Participants who were 13 to 18 years old and receiving cancer treatment in inpatient or outpatient settings, or receiving follow-up care in outpatient settings, were recruited using a convenience sampling method. Confirmatory factor analysis demonstrated good fitness of indices, and all factor loadings for the 18-item Adolescent Form were >0.50, which supported the scale's construct validity. The Adolescent Form score was significantly correlated with the symptom distress score (r = 0.56, P < .01) and quality of life score (r = -0.65, P < .01), which indicated the scale's convergent validity. The correlated item-total correlations (0.30-0.78), Cronbach's alpha (.93), and test-retest reliability coefficient (0.79) confirmed the scale's stability.

CONCLUSION

This study successfully modified the 34-item Adult Form into the 18-item Adolescent Form. Given its adequate psychometric properties, this concise scale has great promise as a useful, feasible, and age-appropriate tool for evaluating care needs among adolescents with cancer who speak Mandarin.

IMPLICATIONS FOR NURSING PRACTICE

This scale can screen for unmet care needs in busy pediatric oncology settings or large-scale clinical trials. It allows for cross-sectional comparison of unmet care needs between adolescent and adult populations and for longitudinal follow-up into how unmet care needs change from adolescence into adulthood.

[Relationship between carotid atherosclerotic plaque characteristics in magnetic resonance imaging and perioperative hemodynamic instability]

Objective: To analyze the relationship between carotid atherosclerotic plaque characteristics in magnetic resonance imaging (MRI) and perioperative hemodynamic instability in patients with severe carotid artery stenosis undergoing carotid artery stenting (CAS). Methods: A total of 89 patients with carotid artery stenosis who underwent CAS treatment at Beijing Tsinghua Changgung Hospital affiliated to Tsinghua University from January 1, 2017, to December 31, 2021, were prospectively included. Among them, 74 were male and 15 were female, with an age range of 43 to 87 years (mean age: 67.8±8.2 years). Preoperative examinations included carotid artery MRI vessel wall imaging to analyze the existence of large lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), and fibrous cap rupture in carotid artery plaques. Plaques without the above-mentioned risk factors were defined as stable plaque group (34 cases), while those with such risk factors were defined as vulnerable plaque group (55 cases). The number of risk factors present in each plaque was also calculated. Intraoperative changes in blood pressure and heart rate were recorded, and the use of dopamine postoperatively was noted. Using the risk factors that the plaque has as independent variables and the clinical outcomes as dependent variables, the RR values were calculated, and the differences in clinical outcomes of patients with different risk factors were compared. Results: The incidence rates of hypotension and bradycardia were higher in patients with vulnerable plaques than those with stable plaques (60.0% (33/55) vs 14.7%(5/34) and 38.2%(21/55) vs 14.7%(5/34), respectively; both P<0.05). Based on MRI imaging features, the large LRNC was present in 45 cases, with RR values for hypotension and bradycardia of 3.15 (1.69-5.87) and 2.20 (1.07-4.53), respectively; IPH was present in 37 cases, with RR values for hypotension and bradycardia of 2.70 (1.61-4.55) and 2.25 (1.15-4.39), respectively; and fibrous cap rupture was present in 29 cases, with RR values for hypotension and bradycardia of 1.50 (0.94-2.40) and 1.29 (0.67-2.49), respectively. The higher the number of risk factors in vulnerable plaques, the higher the incidence of intraoperative blood pressure and heart rate decrease: when the number of risk factors ranged from 0 to 3, the incidence of blood pressure decrease was 14.7% (5/34), 9/18, 11/18, and 13/19, respectively (P<0.001), and the incidence of heart rate decrease was 14.7% (5/34), 6/18, 7/18, and 8/19, respectively (P=0.022). There was no significant difference in the number of cases of dopamine use between the two groups (P>0.05). Conclusion: Patients with a higher number of risk factors for vulnerable carotid plaques, as indicated by carotid artery MRI vessel wall imaging, are at a higher risk of experiencing blood pressure and heart rate decrease during CAS surgery.

Medical clowning influences the emotions of parents of children undergoing cancer treatment: A quasi-experimental study

BACKGROUND

Medical clowning for children has been found to be effective at enhancing parents' psychological well-being during preoperative preparation, but has not been found during cancer treatment. This study aimed to examine whether and how medical clowning influenced the emotions of parents of children undergoing cancer treatment.

METHODS

In this quasi-experimental study, 96 parents of children receiving inpatient cancer treatment were recruited, from June 2018 through April 2020. A demographic questionnaire measuring characteristics of parent and dyadic child, Brief Symptom Rating Scale measuring psychological distress of the parent, and Mood Assessment Scale measuring emotional status of parent and child were administered 1 day before a clowning service. The day after the clowning service, the Mood Assessment Scale again collected emotional status for parent and child. Descriptive analysis, bivariate analysis, and structural equation modeling to fit the actor-partner, cross-lagged model were used.

FINDINGS

Parents experienced a low degree of psychological distress that called for emotional management. The indirect effect of medical clowning on parents' emotions through children's emotions was significant, as were the direct effect and total effect of medical clowning on parents' emotions.

DISCUSSION

Parents experienced psychological distress during their child's inpatient cancer treatment. Medical clowning can directly improve children's emotions and through this pathway indirectly improve their parents' emotions.

APPLICATION TO PRACTICE

There is need to monitor psychological distress and provide interventions for parents of children undergoing cancer treatment. Medical clowns should continue to serve parent-child dyads in pediatric oncology practice and become members of multidisciplinary health care teams.

The impacts of the scope of benefits expansion on hospice care among adult decedents: a nationwide longitudinal observational study

OBJECTIVES

Compared to aggressive treatment for patients at the end stage of life, hospice care might be more likely to satisfy such patients' need and benefits and improve their dignity and quality of life. Whether the reimbursement policy expansion affect the use of hospice care among various demographics characteristics and health status was unknown. Therefore, the purpose of this study was to explore the impacts of reimbursement policy expansion on hospice care use, and to investigate the effects on people with various demographics characteristics and health status.

METHODS

We used the 2001-2017 Taiwan NHI claims data, Death Registry, and Cancer Registry in this study, and we included people who died between 2002 and 2017. The study period was divided into 4 sub-periods. hospice care use and the initiation time of 1st hospice care use were used as dependent variables; demographic characteristics and health status were also collected.

RESULTS

There were 2,445,781 people who died in Taiwan during the study period. The results show that the trend of hospice care use increased over time, going steeply upward after the scope of benefits expansion, but the initiation time of 1st hospice care use did not increase after the scope of benefits expansion. The results also show that the effects of expansion varied among patients by demographic characteristics.

CONCLUSION

The scope of benefits expansion might induce people's needs in hospice care, but the effects varied by demographic characteristics. Understanding the reasons for the variations in all populations would be the next step for Taiwan's health authorities.

The Moderated Mediating Effects of Nutrition and Physical Activity Between Fatigue and Quality of Life in Childhood Cancer Survivors

PURPOSE

The aim of this study was to investigate the associations between nutrition, physical activity, fatigue, and quality of life (QoL) among childhood cancer survivors. The specific purpose was to examine whether nutrition mediated and physical activity moderated the relationship between fatigue and QoL in this population.

METHODS

A pooled sample of 120 childhood cancer survivors was recruited at pediatric oncology wards and ambulatory settings between August 2020 and May 2021. We collected data on participants' demographic characteristics, fatigue, nutritional status, physical activity, and QoL. We then adapted Hayes Process Macro to examine the mediating and moderating effects of nutrition and physical activity on the relationship between fatigue and QoL.

RESULTS

In models adjusted for age and sex, (1) the simple mediation analysis identified the mediating effect of nutrition on the relationship between fatigue and QoL; and (2) the mediation and moderation analysis identified that the direct effect of nutrition between fatigue and QoL was significant when adding (a) physical activity and (b) fatigue × physical activity. There were significantly decreasing trends in physical activity at 1 standard deviation below the mean and at the mean, but not at 1 standard deviation above the mean.

CONCLUSIONS

Our findings demonstrate that nutrition mediated and physical activity moderated the relationship between fatigue and QoL. This highlights an opportunity to enhance QoL among childhood cancer survivors through healthy lifestyle interventions. To ensure that future interventions address children's needs and promote the greatest impact, such interventions should include nutrition and physical activity components that involve nurses, pediatric oncology physicians, nutritionists, and physical therapists.

Sleep changes in Taiwanese first graders before and after school closure during the COVID-19 pandemic

PURPOSE

The objective of this study was (1) to examine sleep changes in first graders before and after school closure and (2) to examine the association between parental work rearrangement and children's sleep change during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN AND METHODS

This was an observational study. The children's sleep habit questionnaire was completed by 103 parents of first-graders before and after school closure. Paired t-test and the general linear model were applied to data analysis.

RESULTS

Children delayed their bedtime and rising time, but total sleep duration increased. Moreover, parents who rearranged their work during the pandemic perceived more child parasomnia symptoms (p = .029) and less delayed sleep-wake patterns in their children.

PRACTICAL IMPLICATION

Sleep is an indicator that reflects children's behavioral changes in response to the COVID-19 pandemic. As routine changes, parents should be aware of child's parasomnia symptoms. Nursing interventions could aim at promoting sufficient external cues in the daytime during home confinement.

[Relationship between vitamin D receptor gene polymorphisms and gestational diabetes mellitus: a case-control study]

Objective: To investigate the relationship between vitamin D receptor (VDR) gene polymorphisms and gestational diabetes mellitus (GDM) and provide evidence for the study of the mechanism of GDM. Methods: A case-control study design was used to study pregnant women who delivered in the obstetrics department of the First Hospital of Shanxi Medical University from March 1, 2012 to July 30, 2014. Of these, 334 cases were diagnosed with GDM and were matched 1∶1 by age, gestation time and residence to corresponding healthy controls. DNA genotyping was performed for the study subjects, and those with genotyping deletions >10% were excluded. Finally 323 cases and 320 controls were included in the study. Under co-dominant, dominant, recessive, and allele genetic models, unconditional logistic regression analysis on the relationship between VDR gene locus polymorphism and GDM was conducted. And software Haploview was used to analyze the relationship between haplotype and GDM. Results: At the genetic level, VDR gene was associated with the risk of developing GDM (P<0.05). After adjusting for pre-pregnancy body mass index, family history of diabetes, it was found that rs7967152 loci was associated with an increased risk of developing GDM (AC vs. AA, OR=1.58, 95%CI: 1.13-2.21; AC+CC vs. AA, OR=1.58, 95%CI: 1.15-2.18; C vs. A, OR=1.41, 95%CI: 1.10-1.82) and rs2238140 loci was associated with an increased risk of developing GDM (AA vs. GG, OR=2.24, 95%CI: 1.19-4.20; GA+AA vs. GG, OR=1.48, 95%CI: 1.07-2.03; A vs. G, OR=1.43, 95%CI: 1.11-1.83). Carrying rs2853564 locus AG genotype and AG+GG genotype (OR=1.46, 95%CI: 1.04-2.05; OR=1.45, 95%CI: 1.05-2.00) compared with carrying AA genotype and carrying rs2853566 locus AG genotype and AG+GG genotype (OR=1.43, 95%CI: 1.03-2.00; OR=1.41, 95%CI: 1.02-1.94) compared with carrying AA genotype were risk factors for GDM. Haplotype block consisting of rs1544410, rs7967152 in the VDR gene with GC haplotype was a risk factor for GDM(OR=1.50, 95%CI: 1.15-1.97). Conclusions: VDR gene rs7967152, rs2238140, rs2853564, rs2853566 locus polymorphisms and block (rs1544410, rs7967152) GC haplotype were associated with an incrased risk of developing GDM.

Sleep pattern regularity and measures of infant weight and length during the first 6 months

PURPOSE

To examine the association between sleep pattern regularity and measures of weight and length in infants.

DESIGN AND METHODS

This was a prospective observational study conducted in a university-affiliated children's hospital in northern Taiwan. A total of 316 healthy infants recruited during their 6-month well-child checkups had their weight and recumbent length measured, and wore an actigraph on the ankle for a week. Based on average weekday, weekend, and all-week sleep durations, infants were categorized into 3 groups: regular sleep, weekend catch-up sleep, and weekend sleep curtailment. General linear model analyses were performed with the 3 sleep regularity groups as the primary predictor variable of interest and infant anthropometry as the dependent variable.

RESULTS

At risk of overweight, overweight, and obese was present in a total of 62 (19.6%) infants. In both unadjusted and adjusted models, infants in the weekend catch-up sleep group (30.4%) and those in the weekend sleep curtailment group (34.5%) had significantly higher weight-to-length ratios, body mass index, weight-for-age z-scores, and weight velocity of 6-month increments z-scores when compared with infants in the regular sleep group (35.1%, all p < 0.05).

CONCLUSIONS

Differences in weekday-weekend sleep exist as early as in the first 6 months of life, and both catch-up sleep and sleep curtailment over the weekend is associated with higher measures of weight and length in infants.

PRACTICE IMPLICATIONS

Sleep assessments in well-child checkups should include not only global assessments of average sleep duration but also address sleep patterns and their regularity.

Explore the correlation between cerebral vessel characteristics with cognitive impairment among elder individuals: a community study from China

Background

Brain Magnetic Resonance Imaging (MRI) examination of cerebral small vessel disease (CSVD) may help screen vascular cognitive impairment. A recently estimated CSVD score system was suggested to capture the overall CSVD burden. The study aimed to detect the association between systemic evaluation score of cerebral vascular imaging parameters with cognitive functions.

Methods

This was a cross-sectional study in community settings. From October 2017 to September 2018, elder (≧60) residents were recruited through on-site visit in 6 communities from Shanghai, China. The participants underwent brain MRI, carotid ultrasound, laboratory tests of blood and urine samples. Cognitive function was evaluated using Mini-Mental State Examination (MMSE). MRI score of CSVD was calculated according to the 2012 standard for the evaluation of statistical changes in imaging.

Results

Total 171 subjects completed survey and examinations. There were 55 participants diagnosed with cognitive impairment, with a total percentage of 32.2%. Participants with and without cognitive impairment showed significant differences in age, BMI and education level. Cognitive impaired participant had more disease history/comorbidity of hypertension and chronic renal insufficiency, higher level of creatinine, as well as lower level of full blood count (FBC) and alanine aminotransferase (ALT). A significant difference was detected in CSVD score between participants with and without cognitive impairment. Results of linear regression analysis showed significant negative correlations between MMSE score and both left and right carotid artery peak systolic velocity (PSV), however the CSVD score was only borderline (P = 0.0566) positively correlated with MMSE. Multivariate linear correlation analysis including all collected risk factor data showed that left carotid artery PSV score was among the independent negative correlated factors of MMSE. Multivariate binary logistic analysis showed that age, education and history of hypertension were the only statistically associated factors of cognitive impairment.

Conclusions

The current study identified high prevalence of cognitive impairment in a Chinese community. In addition, correlations between cerebral vascular disease imaging status and cognitive functions were confirmed although the sample size limited the possibility of screening cognitive impairment with imaging technique.

[More attention should be paid to the influence of malnutrition on chronic limb threatening ischemia]

Chronic limb threatening ischemia (CLTI) is a severe condition of peripheral artery disease with high amputation and mortality. Pain and infection cause insufficient nutrient intake and protein loss in CLTI patients,while malnutrition is very prevalent in patients with CLTI and associated with poor prognosis.More and more studies have shown that malnutrition increases the risk of amputation and mortality,delays the time of wound healing.Moderate and severe malnutrition are independent risk factors for amputation and mortality in CLTI patients undergoing surgical or endovascular revascularization.Nutritional screening tools such as Geriatric nutritional risk index,Mini Nutritional Assessment and Controlling nutritional status can help to stratify patients with nutritional risk.Identification of patients with nutritional risk and nutritional intervention can improve the prognosis of CLTI patients.

[Relationship between the pre-pregnancy BMI, gestational weight gain, and risk of preeclampsia and its subtypes]

Objective: To explore the effects of maternal pre-pregnancy body mass index (BMI) and gestational weight gain and its subtypes on the risk of preeclampsia. Methods: Pregnant women delivered in the Department of Obstetrics and Gynecology of the First Affiliated Hospital of Shanxi Medical University from March 2012 to September 2016 were selected as the research subjects. According to the inclusion and exclusion criteria, 9 274 pregnant women were included. 901 preeclampsia pregnant women were selected as the case group, and 8 373 non-preeclampsia pregnant women were selected as the control group. General demographic characteristics, pre-pregnancy weight, height, lifestyle during pregnancy, reproductive history, and disease history of pregnant women were collected, and pre-pregnancy BMI and gestational weight gain were calculated. Unconditional logistic regression was used to analyze the relationship between pre-pregnancy BMI and weight gain during pregnancy and PE and its clinical subtypes. Results: Among the 901 preeclampsia after inclusion and exclusion, 401 cases were diagnosed as early-onset PE (EOPE), 500 cases were late-onset PE (LOPE), 178 cases were Mild PE (MPE), and 723 cases were severe PE (SPE). There were statistically significant differences between PE and non-PE pregnant women in terms of maternal age, residence, parity, family history of gestational diabetes and hypertension (P<0.05). After adjusting for the above factors, the logistic regression analysis results showed that pre-pregnancy BMI<18.5 kg/m² and inadequate gestational weight gain were protective factors for PE (OR=0.74, 95%CI: 0.56-0.98; OR=0.78, 95%CI: 0.62-0.99), while pre-pregnancy BMI≥24.0 kg/m² and excessive gestational weight gain were risk factors for PE (OR=1.82, 95%CI: 1.54-2.14; OR=1.82, 95%CI: 1.54-2.15). After subtype analysis on PE, the results showed that pre-pregnancy BMI<18.5 kg/m² was a protective factor for EOPE and MPE (OR=0.52, 95%CI: 0.32-0.83; OR=0.47, 95%CI: 0.23-0.97), while pre-pregnancy BMI≥24.0 kg/m² and excessive gestational weight gain were risk factors for clinical subtypes of PE. After stratification according to pre-pregnancy BMI, excessive gestational weight gain was the risk factor for PE (OR=1.86, 95%CI: 1.51-2.30; OR=1.90, 95%CI: 1.39-2.60) in pregnant women 18.5 kg/m²≤BMI<24.0 kg/m² and ≥24.0 kg/m². Inadequate gestational weight gain (OR=0.55, 95%CI: 0.34-0.89) was a protective factor for PE in pregnant women with pre-pregnancy BMI≥24.0 kg/m². Excessive gestational weight gain (OR=4.05, 95%CI: 1.20-13.69) was a risk factor for EOPE in pregnant women with pre-pregnancy BMI<18.5 kg/m². Excessive gestational weight gain was a risk factor for the clinical subtype of PE in pregnant women 18.5 kg/m²≤BMI<24.0 kg/m² before pregnancy. Inadequate gestational weight gain was a protective factor for EOPE and MPE (OR=0.39, 95%CI: 0.19-0.80; OR=0.29, 95%CI: 0.11-0.77) in pregnant women with pre-pregnancy BMI≥24.0 kg/m². Excessive weight gain was a risk factor for EOPE, LOPE and SPE (OR=1.60, 95%CI: 1.06-2.42;OR=2.20, 95%CI: 1.44-3.37;OR=2.28, 95%CI: 1.58-3.29). Conclusions: Pre-pregnancy BMI and gestational weight gain affect the risk of preeclampsia and its clinical subtypes. In contrast, the influence of gestational weight gain on preeclampsia varies among different pre-pregnancy BMI groups. Therefore, it is recommended to pay attention to the changes in pre-pregnancy BMI and gestational weight gain simultaneously to reduce preeclampsia.

The effectiveness of a medical clowning program on improving emotional status among hospitalized children undergoing cancer treatment: A quasi-experimental study

PURPOSE

To examine the effectiveness of one-time medical clowning on improving short-term positive emotions among hospitalized children undergoing cancer treatment, and to analyze whether age moderates this effect.

DESIGN

In this quasi-experimental research study, we recruited a pooled sample of 96 children who were undergoing cancer treatment in pediatric oncology/hematology wards at three university-affiliated medical centers in Taiwan from June 2018 through April 2020.

METHODS

Children's demographic characteristics, symptom distress, quality of life, and pretest emotional status were collected at T1. At T2, we collected only posttest emotional status. We adapted generalized estimating equation models to evaluate the effectiveness of medical clowning on enhancing positive emotions.

FINDINGS

Changes in the probabilities of positive emotion were significantly different across groups (51.84% for the experimental group, 15.76% for the control group; Δ = 36.08, p = 0.001), and the change was more than two times larger for the experimental group (effect ratio = 3.28, p < 0.05) than for the control group. When evaluating the moderating effect of age on the intervention, none of the coefficients reached the significant (p < 0.05) levels, suggesting that age may not moderate the intervention effect.

CONCLUSION

This study demonstrates the core value of medical clowning in child-friendly health care. Our findings clearly support the benefit of the one-time medical clowning program on enhancing short-term emotional well-being across age groups of children. Medical clowning programs should be strongly encouraged and supported in pediatric oncology wards.

CLINICAL RELEVANCE

Medical clowning programs should be widely and continuously implemented in pediatric oncology wards as a routine clinical practice for enhancing emotional well-being among children receiving cancer treatment. Nurses need to be aware of medical clowning's equal effectiveness across age groups, not only or better for younger children.

Factors influencing the protective behavior of individuals during COVID-19: a transnational survey

To slow the spread of infectious disease, it is crucial to understand the engagement of protective behavior among individuals. The purpose of this study was to systematically examine individuals' protective behaviors and the associated factors across countries during COVID-19. This causal-comparative study used a self-developed online survey to assess individuals' level of engagement with six protective behaviors. Analysis of variance and McNemar's test were employed for data analysis. Three hundred and eighty-four responses were analyzed. The majority of participants lived in three areas: Taiwan, Japan, and North America. Overall, the participants reported a high level of engagement in protective behaviors. However, engagement levels varied according to several demographic variables. Hand hygiene and cleaning/ventilation are two independent behaviors that differ from almost all other protective behaviors. There is a need to target the population at risk, which demonstrates low compliance. Different strategies are needed to promote specific protective behaviors.

Leukoaraiosis is associated with clinical symptom severity, poor neurological function prognosis and stroke recurrence in mild intracerebral hemorrhage: a prospective multi-center cohort study

Leukoaraiosis (LA) results from ischemic injury in small cerebral vessels, which may be attributable to decreased vascular density, reduced cerebrovascular angiogenesis, decreased cerebral blood flow, or microcirculatory dysfunction in the brain. In this study, we enrolled 357 patients with mild intracerebral hemorrhage (ICH) from five hospitals in China and analyzed the relationships between LA and clinical symptom severity at admission, neurological function prognosis at 3 months, and 1-year stroke recurrence. Patients were divided into groups based on Fazekas scale scores: no LA (n = 83), mild LA (n = 64), moderate LA (n = 98) and severe LA (n = 112). More severe LA, larger hematoma volume, and higher blood glucose level at admission were associated with more severe neurological deficit. More severe LA, older age and larger hematoma volume were associated with worse neurological function prognosis at 3 months. In addition, moderate-to-severe LA, admission glucose and symptom-free cerebral infarction were associated with 1-year stroke recurrence. These findings suggest that LA severity may be a potential marker of individual ICH vulnerability, which can be characterized by poor tolerance to intracerebral attack or poor recovery ability after ICH. Evaluating LA severity in patients with mild ICH may help neurologists to optimize treatment protocols. This study was approved by the Ethics Committee of Ruijin Hospital Affiliated to Shanghai Jiao Tong University (approval No. 12) on March 10, 2011.

[Folic acid supplementation before and during pregnancy and the risk of preeclampsia]

Objective: To investigate the relationship between folic acid supplementation and the risk of preeclampsia (PE). Methods: A total of 9 048 pregnant women were selected from the First Hospital of Shanxi Medical University in Taiyuan from March 2012 to September 2016. Among them, 882 pregnant women with PE were divided into case group, and 8 166 pregnant women without PE were divided into control group. Information on demographic characteristics, folic acid supplementation, maternal complications, and other factors were collected by face-to-face interviews after child birth in the hospital. Unconditional logistic regression analyses were used to investigate the relationship between folic acid supplementation and the risk of PE and the effects of pre-pregnancy BMI on the relationship of folic acid supplementation with the risk of PE. Results: Compared with nonusers, folic acid supplement users had reduced risk of PE (OR=0.79, 95%CI: 0.64-0.96). Folic acid supplementation before and during pregnancy were negatively related with the risk of PE (OR=0.63, 95%CI: 0.49-0.81). Pregnant women who used folic acid tablets only or used both folic acid tablets and multivitamin containing folic acid had reduced risk of PE (OR=0.81, 95%CI: 0.66-0.99; OR=0.64, 95%CI: 0.49-0.85). No significant relationship was observed in the multivitamin group. Supplemental folic acid doses of <400, 400, and >400 μg/d were related with reduced risk of PE (OR=0.62, 95%CI: 0.42-0.91; OR=0.81, 95%CI: 0.66-0.99; OR=0.68, 95%CI: 0.49-0.94). After stratified by pre-pregnancy BMI, pregnant women who used folic acid supplementation, those with pre-pregnancy BMI<24.0 kg/m(2) had reduced risk of PE (OR=0.75, 95%CI: 0.59-0.96). However, no significant relationship was observed in women with pre-pregnancy BMI≥24.0 kg/m(2). Conclusions: Folic acid supplementation before and during pregnancy were related with reduced risk of PE. Pre-pregnancy BMI might affect the relationship between folic acid supplementation and the risk of PE. Appropriate folic acid supplementation should be recommend for women with different pre-pregnancy BMI.

[The effect of peripheral blood cell score on the prognosis of multiple myeloma patients treated with bortezomib]

目的

评估外周血细胞检测结果在以硼替佐米为一线治疗的多发性骨髓瘤（MM）患者中的预后作用。

方法

回顾性分析2014年1月至2016年12月浙江大学医学院附属第一医院和浙江省舟山医院收治的155例初诊MM患者的临床数据，患者均一线接受以硼替佐米为基础方案的治疗。分析外周血细胞检测结果，包括ANC、单核细胞计数（AMC）、HGB、红细胞平均体积（MCV）、PLT以及其他临床特征对MM患者的预后评估作用。

结果

AMC（>0.6×10⁹/L）、MCV（>99.1fl）以及PLT（<150×10⁹/L）明显影响MM患者无进展生存（PFS）和总生存（OS），以上3个因子分别赋值1分，形成血细胞积分。结果显示，64例（41.3％）积分0，57例（36.8％）积分1，32例（20.6％）积分2，2例（1.3％）积分3，4组患者中位PFS时间分别为42.8、26.5、15.8、6.4个月（P<0.001），中位OS时间分别为未达到和48.2、31.1、31.4个月（P＝0.001）。多因素分析提示，血细胞积分（2～3对0～1）和骨髓浆细胞比例（>30％对≤30％）为PFS的独立预后因素（HR分别为1.95和1.76），而患者年龄（>65岁对≤65岁）、R-ISS分期（Ⅲ期对Ⅰ～Ⅱ期）和血细胞积分（2～3对0～1）是OS的独立预后因素（HR分别为2.08、2.13和2.12）。

结论

血细胞积分简单易得，可用于新药时代初治MM患者的预后评估，但仍需扩大病例并进行前瞻性研究进一步明确。

[Safety of laparoscopic cholecystectomy for gallbladder cancer: a meta-analysis]

Objective: To evaluate the effect and safety of laparoscopic cholecystectomy (LC) on the treatment of patients with gallbladder cancer (GBC), compared with patients undergoing open cholecystectomy (OC). Methods: PubMed, EMBASE, Web of Science, CNKI, CQVIP and WANFANG DATA and the Cochrane Library were searched for all Chinese and English literatures of randomized or non-randomized concurrent controlled trials of OC and LC treatment of GBC from the database establishment to March 2020. Two reviewers selected the studies according to inclusion and exclusion criteria, extracted the data, and then a meta-analysis was subsequently performed by the RevMan 5.3 software provided by the Cochrane Library. Results: A total of 15 studies (1 074 patients) including 14 retrospective studies and 1 prospective study met the inclusion criteria. The meta-analysis showed that compared with OC, LC has significant short-term efficacy in the treatment of patients with gallbladder cancer, including shorter operation time (mean difference (MD) =-18.78, 95% confidence interval (CI) : -36.68-0.88; P=0.04), less intraoperative blood loss (MD=-166.57, 95%CI: -248.51--84.63; P<0.000 1), shorter post-operative hospital stays (MD=-5.00, 95%CI: -6.43--3.57; P<0.000 1), less complication rate (OR=0.47, 95%CI: 0.28-0.79; P=0.004), but there was no significant difference on the aspects of recurrence rate (OR=0.48, 95%CI: 0.21-1.11; P=0.09), 5-year overall survival (HR=0.93, 95%CI: 0.54-1.61, I²=33.5%, P=0.198) and long-term survival. Conclusion: Whether it is radical cholecystectomy (RC) or simple cholecystectomy (SC), the short-term efficacy of LC is more significant than that of OC, and the long-term survival rate has no significant statistical difference. Limited by the quality of literature and experiments, the above conclusions still need to be supported by higher quality research.

[Analysis of treatment modalities and prognosis of patients with gallbladder cancer in China from 2010 to 2017]

Objective: To evaluate the clinical characteristics and prognosis of gallbladder cancer (GBC) patients in China. Methods: This retrospective multicenter cohort study enrolled 3 528 consecutive GBC patients diagnosed between January 2010 to December 2017 in 15 hospitals from 10 provinces. There were 1 345 (38.12%) males and 2 183 (61.88%) females.The age of diagnosis was (63.7±10.8) years old (range: 26 to 99 years old) .There were 213 patients (6.04%) in stage 0 to Ⅰ, whereas 1 059 (30.02%) in stage Ⅱ to Ⅲ, 1 874 (53.12%) in stage Ⅳ, and 382 (10.83%) unavailable. Surgery was performed on 2 255 patients (63.92%) . Three hundred and thirty-six patients received chemotherapy or radiotherapy (9.52%; of which 172 were palliative); 1 101 (31.21%) received only supportive treatment.The patient source, treatment and surgery, pathology, concomitant gallstone, and prognosis were analyzed. Results: Among the 3 528 GBC patients, 959 (27.18%) were from East China, 603 (17.09%) from East-North China, 1 533 (43.45%) from Central China, and 433(12.27%) from West China. Among the 1 578 resectable tumor, 665 (42.14%) underwent radical surgery, 913 (57.86%) underwent surgery that failed to follow the guidelines.Eight hundred and ninety-one (56.46%) patients were diagnosed before surgery, 254 (16.10%) during surgery, and 381 (24.14%) after surgery (time point of diagnosis couldn't be determined in 52 patients) .Among the 1 578 patients with resectable tumor, 759 (48.10%) had concomitant gallstone.Among the 665 patients underwent radical surgery, 69 (10.4%) showed positive resection margin, 510 (76.7%) showed negative resection margin, and 86 (12.9%) unreported margin status.The 5-year overall survival rate (5yOS) for the 3 528-patient cohort was 23.0%.The 5yOS for patients with resectable tumor was 39.6%, for patients with stage ⅣB tumor without surgery was 5.4%, and for patients with stage ⅣB tumor underwent palliative surgery was 4.7%. Conclusions: More than half GBC patients in China are diagnosed in stage Ⅳ.Curative intent surgery is valuable in improving prognosis of resectable GBC.The treatment of GBC needs further standardization.Effective comprehensive treatment for GBC is in urgent need.

[Effects of two dimensional gray-scale blood flow imaging combined with color Doppler flow imaging in guiding arterial puncture and catheterization through wounds in patients with large burns]

Objective: To explore the effects of two dimensional gray-scale blood flow imaging (hereinafter referred to as " B-flow" ) combined with color Doppler flow imaging (CDFI) in guiding arterial puncture and catheterization through wounds in patients with large burns. Methods: Sixty-seven patients with large burns who met the inclusion criteria and hospitalized in the First Hospital of Jilin University from January 2017 to January 2019 were enrolled in the prospectively randomized control study. According to the random number table, CDFI alone group was allocated with 35 patients (23 males and 12 females) and B-flow+ CDFI group with 32 patients (22 males and 10 females), aged 19-60 and 18-58 years, respectively. According to the progress of the disease, arterial puncture and catheterization were performed in the right time. During the operation, CDFI was used alone for guidance in patients of CDFI alone group, while B-flow and CDFI were used together for guidance in patients of B-flow+ CDIF group. Based on the first time of catheterization, the catheterization location, one-time catheterization success rate, post-back stitching re-catheterization success rate, catheterization failure rate, catheterization duration, and incidences of wound sepsis, catheter-related bloodstream infection, and arterial thrombosis within post catheterization day (PCD) 3 of patients in the two groups were recorded. Data were statistically analyzed with the independent-sample t test, chi-square test or Fisher's exact probability test. Results: (1) All the patients underwent catheterization through wounds, and there was no statistically significant difference in catheterization location of patients between the two groups (χ(2)=0.574, P>0.05). The one-time catheterization success rate of patients in B-flow+ CDFI group was 81.25% (26/32), which was obviously higher than 51.43% (18/35) in CDFI alone group (χ(2)=6.594, P<0.05). The catheterization failure rate of patients in B-flow+ CDFI group was 3.12% (1/32), which was obviously lower than 20.00% (7/35) in CDFI alone group (P<0.05). The post-back stitching re-catheterization success rate of patients was similar between the two groups (χ(2)=1.029, P>0.05). (3) The catheterization duration of patients was (15.7±1.1) min in B-flow+ CDFI group, which was obviously shorter than (17.1±2.2) min in CDFI alone group (t=11.316, P<0.01). (4) Within PCD 3, the incidences of wound sepsis and catheter-related bloodstream infection of patients in CDFI alone group were 2.86% (1/35) and 0, close to 0 and 3.12% (1/32) in B-flow+ CDFI group (P>0.05); the incidence of arterial thrombosis of patients in B-flow+ CDFI group was 0, which was obviously lower than 20.00% (7/35) in CDFI alone group (P<0.05). Conclusions: Compared with CDFI alone, B-flow combined with CDFI can improve the success rate of arterial puncture and catheterization through wounds in large area burn patients, shorten the catheterization duration, and effectively reduce the incidence of arterial thrombosis after catheterization, with a good clinical application value.

Reduction of fibrillar strain-rate sensitivity in steroid-induced osteoporosis linked to changes in mineralized fibrillar nanostructure

As bone is used in a dynamic mechanical environment, understanding the structural origins of its time-dependent mechanical behaviour - and the alterations in metabolic bone disease - is of interest. However, at the scale of the mineralized fibrillar matrix (nanometre-level), the nature of the strain-rate dependent mechanics is incompletely understood. Here, we investigate the fibrillar- and mineral-deformation behaviour in a murine model of Cushing's syndrome, used to understand steroid induced osteoporosis, using synchrotron small- and wide-angle scattering/diffraction combined with in situ tensile testing at three strain rates ranging from 10-4 to 10-1 s-1. We find that the effective fibril- and mineral-modulus and fibrillar-reorientation show no significant increase with strain-rate in osteoporotic bone, but increase significantly in normal (wild-type) bone. By applying a fibril-lamellar two-level structural model of bone matrix deformation to fit the results, we obtain indications that altered collagen-mineral interactions at the nanoscale - along with altered fibrillar orientation distributions - may be the underlying reason for this altered strain-rate sensitivity. Our results suggest that an altered strain-rate sensitivity of the bone matrix in osteoporosis may be one of the contributing factors to reduced mechanical competence in such metabolic bone disorders, and that increasing this sensitivity may improve biomechanical performance.

[Advances in the research of pain assessment and non-drug intervention in burn children]

Children are a high-risk group of burn, and burn pain is a special type of pain. Because children of different ages have different cognitive ability and behavioral response to pain, thus it is particularly difficult to effectively evaluate the pain. It is very important for medical staff to understand the pain of children, to define the adverse reactions of pain, to evaluate and take appropriate pain intervention measures in time and effectively. In this paper, different evaluation methods of burn pain in children and non-drug intervention related measures were reviewed in order to provide references for clinical practice.

[Association between maternal dietary intake and the incidence of babies with small for gestational age]

Objective: To investigate the relations between dietary intake during pregnancy and the incidence of their babies with small for gestational age (SGA). Methods: Data on demographics, dietary intake of protein, fat, and carbohydrates of the pregnant mothers during the first, second and third trimester, were collected. Information related to birth weight and gestational age of the infants were also gathered. A total of 8 102 women, who delivered their babies at the First Affiliated Hospital of Shanxi Medical University from March 2012 to September 2016, were enrolled in this project. Among them, 961 mothers had infants with SGA but the other 7 141 of them having normal infants. Unconditional logistic regression model was used to analyze the effect of dietary nutrient intake on SGA the first, second and third trimester. Results: We found that low dietary intake of protein during the first trimester and following trimesters during pregnancy were positively associated with higher risk of SGA (OR=1.534, 95%CI: 1.217-1.934; OR=1.268, 95%CI: 1.005-1.599; OR=1.310, 95%CI: 1.036-1.655). When adjusting for maternal pre-pregnancy BMI, we found that when mothers were with a pre-pregnancy BMI less than 18.5 or with low maternal intake of protein during the first trimester, positive association with higher risk of SGA (OR=1.872, 95%CI: 1.033-3.395; OR=1.754, 95%CI: 1.125-2.734), was noticed. However, for mothers with a pre-pregnancy BMI between 18.5 and 24.0 or with low protein intake during the first trimester, significant association with higher risk of SGA (OR=1.465, 95%CI: 1.089-1.972) was found. Conclusions: Through our observation, maternal dietary intake during pregnancy seemed to be associated with the risk of SGA but the effects of dietary intake were different, according to the BMI of pre-pregnancy population. Early pregnancy appeares as the key period for dietary intake which may influence the SGA.

Physical activity self-efficacy mediates the effect of symptom distress on exercise involvement among adolescents undergoing cancer treatment

The objective of this study was to examine whether physical activity self-efficacy mediated the adverse effect of symptom distress on exercise involvement among adolescents undergoing cancer treatment. A secondary data analysis approach was used to analyse a pooled sample of 97 adolescents who were undergoing cancer treatment in paediatric oncology/haematology wards and ambulatory settings in northern Taiwan. Mediation analysis was performed to examine the mediation relationship among physical activity self-efficacy, symptom distress and exercise involvement. The total effect (path c) (p < 0.001), the indirect effect (paths a and b) (p < 0.05 and p < 0.01) and the direct effect (path c') (p < 0.001) were significant. The bootstrapping test was significant (95% CI: -0.356 to -0.016), indicating that physical activity self-efficacy partially mediated the adverse effect of symptom distress on exercise involvement after adjusting for age, gender and cancer diagnosis. Physical activity self-efficacy partially mediates the relationship between symptom distress and exercise involvement for adolescents undergoing cancer treatment. There is an imperative need for healthcare professionals to design interventions to enhance these adolescents' physical activity self-efficacy, increase their exercise involvement and thus improve their quality of life.

[The role of anatomical hepatectomy in the treatment of intrahepatic cholangiocarcinoma]

Objective: To evaluate the role of anatomical hepatectomy in the treatment of intrahepatic cholangiocarcinoma. Methods: The cases of intrahepatic cholangiocarcinoma who received curative surgery in two hospitals from 2010 to 2015 were analyzed retrospectively. Among the 98 patients enrolled in this study, 55 were male and 43 were female. The median age was 61 years. According to receiving anatomical hepatectomy or not, the 98 cases were divided into two groups: non-anatomical hepatectomy(n=30) and anatomical hepatectomy(n=68). The surgical results were compared between the two groups.Survival curves were plotted by the Kaplan-Meier method and compared by the log-rank test. The influence of each prognostic factor identified by univariate analysis was multivariate analysis by Cox's proportional hazard regression. Results: The duration of surgery was significantly prolonged in the anatomical hepatectomy group((196.4±94.9)minutes vs. (166.2±65.7)minutes, P=0.027), while there was no significant difference in terms of other surgical results such as intraoperative blood transfusion, postoperative morbidity and mortality rate. Compared to non-anatomical hepatectomy, anatomical hepatectomy significantly improved long-term survival results(14 months vs. 11 months)(χ²=4.641, P=0.031). Single variable analysis indicated that tumor differentiation, tumor numbers, T stage, N stage, anatomical hepatectomy and adjuvant therapy significantly affected overall survival. Multivariate analysis demonstrated that tumor numbers(HR=0.522, 95% CI: 0.259-0.974, P=0.042) and anatomical hepatectomy(HR=1.858, 95%CI: 1.092-3.161, P=0.022) were two independent prognostic factors for overall survival. Conclusion: Compared to non-anatomical hepatectomy, anatomical hepatectomy performed for intrahepatic cholangiocarcinoma is not only safe but also beneficial for long-term survival.

[The Long-Term Care Experiences and Care Needs of Parents Caring for Children With Adrenoleukodystrophy]

BACKGROUND

Children suffering from adrenoleukodystrophy (ALD) requires life-long care. Little is known about the care needs of parents of ALD children at different stages of their disease.

PURPOSE

The purpose of this study was to understand the long-term care experiences and care needs of parents caring for their ALD children.

METHODS

A descriptive qualitative study with 7 in-depth interviews was conducted with parents.

RESULTS

The results of these care experiences were distinguished into three phases: "pathogenesis to diagnosis", "rapid deterioration of physiological functions", and "bedridden until the death". The long-term care experiences revealed five themes, including "chaos and helplessness to seek medical attention then being forced to accept", "self-accusation and guilt", "strengthening parents' toughness", "seizing the moment and facing the future", and "accompanying children through life without pain". Within the three phases, the care needs comprised the three themes of "integrating resources and providing immediate care", "obtaining information and support regarding ALD rapidly", and "establishing individualized long-term care".

CONCLUSIONS / IMPLICATIONS FOR PRACTICE

This study revealed the long-term care experiences and care needs of the parents of ALD children. Providing individualized care, nursing instruction, and telephone consultation as well as connecting case managers with the hospice-care team will help facilitate and meet the care needs of these parents.

[A preliminary prospective study on the efficacy and safety of ultrasound-guided percutaneous lauromacrogol sclerotherapy in benign cystic or predominantly cystic thyroid nodules]

Objective: To investigate the efficacy and safety of percutaneous lauromacrogol injection (PLI) in treatment of cystic or predominantly cystic thyroid nodules. Methods: A total of 114 cystic thyroid nodules and 61 predominantly cystic thyroid nodules with pain or uncomfort or aesthetic complaints were offered PLI. Therapeutic success rates and side effects were evaluated. From October 2012 to December 2015,114 patients with cystic thyroid nodules and 61 with predominantly cystic thyroid nodules with pain or uncomfortable or aesthetic complaints at the outpatient clinic of the First Affiliated Hospital of Wenzhou Medical University were offered percutaneous lauromacrogol sclerotherapy. Cytological results were benign. This study was a prospective trial. Ultrasonography sound examination was performed in all patients before treatment. The baseline data of all the patients and the data of the patients examined at the follow-up of 1, 3, 6 and 12 months were analyzed. Therapeutic success rate (nodule volume reduction >50%) and safety were observed. The data of nodule volume reduction ratio and the function of thyroid were normal distribution and analyzed by Mann-Whitney test and t test. The data of nodule volume, symptoms score and cosmetic score were skewed distribution, which were indicated with median and analyzed by nonparamentic test. Results: The mean volume of the cystic thyroid nodules was reduced from 12.5 cm(3) before PLI to 0.2 cm(3) at 12 months after PLI (χ(2)=266.175, P<0.001), with a therapeutic success rate of 100%, and the mean volume of the predominantly cystic thyroid nodules was reduced from 10.5 cm(3) before PLI to 2.0 cm(3) at 12 months after PLI (χ(2)=203.122, P<0.001) with a therapeutic success rate of 93.4%(57/61). Pressure symptom score and cosmetic grade were significantly improved at 12 months after PLI in patients with cystic or predominantly cystic thyroid nodules. Pressure symptom score and cosmetic grade in patients with cystic thyroid nodules were Z=-6.126 and Z=-13.735, respectively; pressure symptom score and cosmetic grade in patients with predominantly cystic thyroid nodules were Z=-3.126 and Z=-7.212, respectively (all P<0.001) . There no significant difference in the thyroid functions before and after PLI in two groups of patients (all P>0.05) . The side effects of PLI were mild. Conclusion: PLI is a safe and effective alternative to treat benign cystic or predominantly cystic thyroid nodules.

[Reconsideration of pancreatic reconstruction after pancreatoduodenectomy]

Pancreatic fistula is one of the most common and serious complications after digestive tract reconstruction.Grade A pancreatic fistula is defined as biochemical fistula only when the drainage fluid amylase level is elevated without affecting clinical decision-making.It is not a true pancreatic fistula, or a real surgical complication.Surgeons should pay more attention to the diagnosis and treatment of B and C pancreatic fistula, and it is more valuable to reduce the occurrence of B and C pancreatic fistula.Pancreatic fistula is not a purely surgical technical problem, but the quality of surgical reconstruction is very important.For pancreatic surgeons, the reconstruction of the pancreatic stump digestive tract after pancreaticoduodenectomy is accompanied by both opportunities and challenges.

[Endoscopicretrograde cholangio-pancreatography management of long-term complications after pancreaticoduodenectomy]

Objective: To investigate the feasibility and effectiveness of endoscopicretrograde cholangio-pancreatography(ERCP)in the management of long-term complications after pancreaticoduodenectomy. Methods: From January 2009 to July 2018, the clinical data of 62 patients with biliary or pancreatic long-term complications after pancreatoduodenectomy were reviewed at Department of General Surgery, and the corresponding ERCP were carried out in the multi-disciplinary cooperation.There were 39 males and 24 females.The age was 56.5 years(aging from 13 to 76 years). The time of treatment was 3 months to 20 years after pancreatoduodenectomy.The long-term biliopancreatic complications after pancreatoduodenectomy included 51 cases of biliary calculi, 42 cases of bilioenteric anastomotic stenosis with proximal bile duct dilatation, and 11 cases of pancreaticointestinal anastomosis stenosis with distal pancreatic duct dilatation.All patients received conventional duodenoscopy or single-balloon enteroscopy assisted ERCP under general anesthesia. Results: A total of 95 ERCP were performed in 62 patients, averaging 1.5 times per case.The long-term complications of cholangiopancreatic after pancreatoduodenectomy(ERCP indications) included 56 times of bile duct stones(58.9%), 45 times of bilioenteric anastomatic stricture(47.4%), 11 times of recurrent pancreatitis(11.6%), 6 cases(6.3%) of bilioenteric anastomatic foreign body, 3 times of intrahepatic bile duct stenosis(3.2%). Among the 95 times, 82 times(86.3%) achieved endoscopic endoscopy, 76 times(80.0%) were diagnosed successfully, and 72 times(75.8%) were successfully treated with ERCP.Small intestinal perforation occurred in 1 patient undergoing duodenoscopy, and then healed by surgical repair. Conclusion: Multi-disciplinary collaboration of ERCP is safe and effective in the treatment of long-term complications after pancreaticoduodenectomy, but the long-term effect still needs further clinical follow-up.

[Clinical cohort study of imaging evaluation and postoperative pathology of carotid vulnerable plaque]

Objective: To evaluate the accuracy of contrast-enhanced ultrasound(CEUS) scanning in identifying vulnerable plaque in carotid artery. Methods: The study included a total of 25 patients who suffered from carotid artery stenosis and underwent carotid endarterectomy from January 2016 to December 2017 in Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University. Preoperative carotid artery contrast enhanced ultrasound and High-resolution MRI were performed to all patients to determine whether the plaques were stable. All patients then underwent carotid endarterectomy, during which, plaques were completely removed. Biopsies were performed using HE staining and CD31, CD34 and SMA immunohistochemistry was used to identify the plaques properties, including the thickness and integrity of the fiber cap, neovascular endothelium, hemorrhage, and inflammatory cells in the removed plaques.The results of these tests were compared with the diagnosis through the pre-operative imaging. Results: Among twenty-five cases, the pre-operative CEUS revealed sixteen with unstable plaques and nine with stable plaques. Meanwhile the post-operation pathology confirmed seventeen cases with unstable plaque components. The sensitivity of CEUS in the identification of carotid vulnerable plaque was 88.2%(15/17), the specificity was 87.5%(7/8), and the overall diagnostic accuracy was 88%(22/25). The sensitivity, specificity and overall diagnostic accuracy of high resolution MR for vulnerable plaque identification were 83.3%(10/12), 71.4%(5/7), 78.9%(15/19), respectively. There were no significant difference between two groups(χ(2)=0.003, P>0.05). Conclusions: The sensitivity, specificity and overall diagnostic accuracy of the CEUS for vulnerable plaque identification are high.Therefore, CEUS is recommended as one of the pre-operative diagnostic method for unstable plaque in carotid stenosis.

Glenoid Bone Reaction to All-Soft Suture Anchors Used for Shoulder Labral Repairs

BACKGROUND

All-soft suture anchors (ASSAs) are commonly used for shoulder labral repair and capsulorrhaphy in patients with shoulder instability. While these anchors may have some specific advantages over other types of suture anchors, little is known about the prevalence and time-dependence of bone cyst formation and tunnel expansion after implantation of ASSAs. The aim of this study was to quantify the proportions of cyst formation and tunnel expansion around ASSAs and to characterize and test for differences in abnormalities observed at different postoperative time points.

METHODS

Thirty patients who were treated with arthroscopic shoulder stabilization surgery with ASSAs (1.4 mm; JuggerKnot, Biomet) underwent a computed tomography (CT) scan of the operatively treated shoulder at 1 month (10 patients), 6 months (10 patients), or 12 months (10 patients) postoperatively. Demographic and operative data were collected, and CT scans were evaluated for cyst formation, tunnel expansion, and tunnel volume measured in cubic millimeters. Statistical analyses were performed to detect differences in these outcomes among the follow-up groups. All shoulders were stable at all time points of the study, and there were no incidents of recurrent instability during the study period.

RESULTS

Ninety-one suture anchors were evaluated in 30 patients. Tunnel expansion was identified in the large majority of patients in the 6-month and 12-month follow-up groups, with a significant increase in these proportions compared with the 1-month follow-up group (p = 0.002). Mean tunnel volumes also significantly increased over the study period (p < 0.001). The presence of cyst formation was negligible in all 3 follow-up cohorts.

CONCLUSIONS

This study demonstrated low rates of cyst formation but a significantly increased tunnel volume 6 and 12 months after shoulder labral surgery with ASSAs. There was no association with the initial tunnel location. Additional well-controlled studies with longer follow-up are needed to identify potential associations among tunnel expansion, intraoperative technique, and clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Caring for patients with oral cancer in Taiwan: The challenges faced by family caregivers

Family caregivers face multiple challenges when caring for patients with oral cancer at home. Understanding the difficulties they face may assist health professionals to better organise and provide support for family caregivers of oral cancer patients. The aim of this study was to describe the caregivers' primary tasks and the difficulties they encounter when caring for a family member with oral cancer. This qualitative study included a purposeful sample of 22 primary family caregivers ranging in age from 25 to 71 years old. The researchers used face-to-face, semi-structured and tape-recorded interviews to collect data and employed qualitative content analysis to elicit caregiving-related themes. Six task-related themes and associated challenges were identified. These included managing the patient's nutritional issues, investigating and making decisions about patient care, managing sudden and unpredictable changes in the patient's condition, managing emotional distress, adjusting their attitudes towards patient care, and seeking resources. Family caregivers handle such essential tasks when they care for patients in home settings and they face specific challenges related to them. This study identified several challenges related to each task. From the outset, healthcare providers should actively offer caregiving information and strategies. Health professionals can incorporate strategies for supporting caregivers' ability to carry out these tasks into their treatment model and can help caregivers manage difficulties that can impede them from doing so.

Development and feasibility of Mandarin-language bone health scales for adolescents with cancer in Taiwan

Cancer during adolescence increases the risk for bone mass deficiency later in life. Adolescents with cancer must learn to improve their bone health to avoid osteoporosis. In the present cross-sectional study, we developed and tested scales to assess the bone health self-efficacy and beliefs of adolescents with cancer in Taiwan. Test development followed three stages: item generation and scale formatting, examination of content validity, and validation of psychometric properties with a sample of 100 adolescents with cancer. Through the validation process, this research generated the seven-item Bone Health Self-Efficacy Scale and the 13-item Bone Health Belief Scale. Multiple indices demonstrated construct validity. Cronbach's alphas (0.809 and 0.705) demonstrated internal consistency. No items caused a drop in Cronbach's alpha of 10%, all inter-item correlations were <0.800, and the factor loadings for all items reached 0.400, demonstrating item appropriateness. The present study provides initial evidence of the scales' accessibility and feasibility for adolescents with cancer who speak Mandarin. These scales might also help clinical nurses evaluate the effectiveness of bone health education provided to adolescents with cancer.

Resilience and Coping Strategies Influencing the Quality of Life in Patients With Brain Tumor

The study purpose was to evaluate how much of the variance in quality of life (QOL) among Taiwanese patients with brain tumor could be accounted for by resilience and coping strategy. This cross-sectional study included 95 patients who had undergone a treatment of operations or chemotherapy or radiotherapy relevant to brain tumor after at least 1 month and completed the European Organization for Research and Treatment of Cancer QOL Questionnaire-Brain Cancer Module (EORTC QLQ-BN20), Resilience Scale (RS), and Ways of Coping Checklist-Revised (WCC-R). There was a significant negative correlation between resilience and future uncertainty QOL and motor dysfunction QOL. In addition, there was a significant positive correlation between the emotion-focused coping and future uncertainty QOL, as well as a significant negative correlation between problem-focused coping and motor dysfunction QOL. Resilience accounted for 4.8% and the emotion-focused coping accounted for 10.20% of the variance in separately predicting the future uncertainty QOL. This study highlights the potential importance of resilience and coping strategies in patients' QOL, which is relevant to brain tumor treatment.

Polarization resolved second harmonic microscopy

Second harmonic (SH) microscopy has proven to be a powerful imaging modality over the past years due to its intrinsic advantages as a multiphoton process with endogenous contrast specificity, which allows pinhole-less optical sectioning, non-invasive observation, deep tissue penetration, and the possibility of easier signal detection at visible wavelengths. Depending on the relative orientation between the polarization of the incoming light and the second-order susceptibility of non-centrosymmetric structures, SH microscopy provides the unique capacity to probe the absolute molecular structure of a broad variety of biological tissues without the necessity for additional labeling. In addition, SH microscopy, when working with polarimetry, provides clear and in-depth insights on the details of molecular orientation and structural symmetry. In this review, the working principles of the polarization resolving techniques and the corresponding implements of SH microscopy are elucidated, with focus on Stokes vector based polarimetry. An overview of the advancements on SH anisotropy measurements are also presented. Specifically, the recent progresses on the following three topics in polarization resolved SH microscopy will be elucidated, which include Stokes vector resolving for imaging molecular structure and orientation, 3-D structural chirality by SH circular dichroism, and correlation with fluorescence lifetime imaging (FLIM) for in vivo wound healing diagnosis. The potentials and challenges for future researches in exploring complex biological tissues are also discussed.

Comparative study of 13 candidate genes applying multi-reference normalization to detect the expression of different fineness in skin tissues of wool sheep

Fiber diameter is a useful indicator of wool traits and it is the main determinant of wool quality and value. A comparative study was conducted to analyze the abundance and expression of 13 candidate genes using expression profile microarray analysis and to identify novel molecular markers associated with wool traits to provide a molecular basis for improving wool quality in sheep. Genes associated with fineness of skin tissue were identified using a real-time reverse transcriptase-polymerase chain reaction method with 18SrRNA, β-Actin, and GAPDH used for multi-reference normalization. The results indicated that the expression levels of TXNIP, TFDP1, and FAIM genes in super-fine type wool sheep were higher than those in fine-type wool sheep; the corresponding expression ratios of super-fine to fine wool sheep were 1.45, 1.57, and 2.55, respectively. The expression levels of PIK3CA, ADAM9, and FZD3 genes were lower in super-fine wool sheep compared with fine-type wool sheep; the corresponding expression ratios were 0.61, 0.65, and 0.52, respectively. The other genes tested (RPS6KA, ABCG2, GSTA1, PTPN13, GJB3, PPARD, and LAMB1) were similarly expressed in both types of wool sheep. These results infer that lower expression of PIK3CA, ADAM9, and FZD3 genes was associated with lower fiber diameter, whereas lower expression of TXNIP, TFDP1, and FAIM genes was associated with higher fiber diameter.

[A meta-analysis of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair]

Objective: This study was aim to compare the efficacy and safety of percutaneous access and open femoral exposure for endovascular aortic aneurysm repair. Methods: Eligible studies were searched from PubMed, Embase, and Corchrane databases published in English from January 1999 to December 2015. Data extracted from each study were synthesized into overall odds ratios (OR) for technical success rates and complications. The outcomes on technical success rates and complications of both totally percutaneous access and open femoral exposure group were compared. Results: After a systematic review of English language articles, ten studies including 1 504 patients were eligible for the Meta-analysis. The technical success rates of the percutaneous endovascular aortic aneurysm repair (PEVAR) group was 95.1%, close to that of femoral exposure (FE) group (97.5%). The difference did not show significantly (OR=0.57, 95% CI: 0.31-1.04, P>0.05). However, the incidence of total postoperative complications in PEVAR group was 8%, significantly lower than that in FE group (15.9%) (OR=0.52, 95% CI: 0.37-0.42, P<0.01). Conclusion: PEVAR is associated with a similar technical success rate and lower complication incidence rate comparing with FE. Therefore, it could be as a preferred approach of endovascular aortic aneurysm repair.

The experiences of adolescents with osteosarcoma during the one-year of treatment in Taiwan

Osteosarcoma (OS) typically occurs during puberty. The one-year treatment for OS can be very challenging. However, little empirical research has explored the experiences of adolescents with OS. This research explored the experiences of Taiwanese adolescents with OS, utilizing a qualitative inductive content analysis with in-depth interviews and field notes that captured interviewer observations. In total, 20 participants-aged between 10 and 19 years and being treated for OS-were recruited. Ten categories were extracted: disbelief, hope for recovery and maintaining body integrity, experience with physical symptoms, inappropriate sleep hygiene, experience of psychosocial distress, use of spirituality to recover from misfortune, information acquisition, preparation to return to school, interdependence, and dedication to hope of recovery. This is the first empirical qualitative study to explore the experiences of Taiwanese adolescents with OS during treatment since being diagnosed. Close surveillance of the compliance in rehabilitation and physical function is needed. Providing age-appropriate and culture-oriented support systems would be helpful for addressing their psychosocial difficulties. Social networking sites closely moderated by health professionals may be a feasible way enhancing psychosocial well-being. Conducting a descriptive exploratory qualitative study for further development of psychosocial supportive care interventions is recommended.

[The Mediating Role of Parenting Self-Efficacy on Parenting Stress and Quality of Life in Parents of Young Children With Developmental Delay]

BACKGROUND

Previous studies indicate that parents of developmentally delayed children have higher parenting stress (PS) and lower quality of life (QoL) than parents of healthy children. Parenting self-efficacy (PSE) may mediate the effects of PS on the QoL of parents.

PURPOSE

The present study explores the mediating role of PSE between PS and the QoL of parents of developmentally delayed children and compares the differences in several variables between fathers and mothers.

METHODS

A cross-sectional research design was used to study a sample of 70 parent dyads. Instruments used were the Basic Information Form, Parenting Stress Index Short Form (PSI-SF), Parenting Self-efficacy Scale (PSE Scale), and World Health Organization Quality of Life-BREF Taiwan version (WHOQOL-BREF).

RESULTS

(1) Participants had a moderate level of QoL, PS, and PSE. (2) The PS of participants was significantly and negatively correlated with both QoL and PSE while their PSE was significantly and positively correlated with QoL. (3) The PSE of the fathers completely mediated the effects of PS on their QoL (p < .001), accounting for 62.2% of observed variation, while the PSE of the mothers partially mediated the effects of PS on their QoL (p < .05), accounting for 59.5% of observed variation.

CONCLUSIONS / IMPLICATIONS FOR PRACTICE

PSE was identified as the mediator between PS and QoL in both fathers and mothers. The PSE of the fathers completely mediated the effect of PS on QoL, while the PSE of the mothers partially mediated the effect of PS on QoL. Further research that explores the factors that affect the QoL of parents and then uses the results to develop interventions to enhance the PSE of parents, especially fathers, is recommended.

A solid-state cation exchange reaction to form multiple metal oxide heterostructure nanowires

Metal oxide nanostructures have been investigated extensively due to their wide range of physical properties; zinc oxide is one of the most promising materials. It exhibits fascinating functional properties and various types of morphologies. In particular, ZnO heterostructures have attracted great attention because their performance can be modified and further improved by the addition of other materials. In this study, we successfully transformed ZnO nanowires (NWs) into multiple ZnO/Al₂O₃ heterostructure NWs via a solid-state cation exchange reaction. The experiment was carried out in situ via an ultrahigh vacuum transmission electron microscope (UHV-TEM), which was equipped with a video recorder. Moreover, we analyzed the structure and composition of the heterostructure NWs by Cs-corrected STEM equipped with EDS. Based on these experimental results, we inferred a cation exchange reaction ion path model. Additionally, we investigated the defects that appeared after the cation reaction, which resulted from the remaining zinc ions. These multiple heterostructure ZnO/Al₂O₃ NWs exhibited excellent UV sensing sensitivity and efficiency.

Dynamics of monocyte surface receptors after burns: a pilot study

Previous studies suggested that monocytes may play a vital role in infection and sepsis following burn injury. The aim of this study was to determine whether burn injury had any effect on the levels of expression of monocyte cell-surface receptors at different phases post burn injury. Ten adult burn victims with burns of >25% of the total body surface area were included in this study. Blood samples were collected on the first, third and seventh day post burn injury. The peripheral blood mononuclear cells were extracted, with or without lipopolysaccharide stimulation. The monocyte phenotypes of CD14, CD16, HLA-DR, CD163, TLR2 and TLR4 were characterized by flow cytometry. Six healthy volunteers were recruited as controls. The percentage of expressed CD14+ monocytes increased during the first day, and then decreased on the third and seventh day after burn injury. The percentages of CD14+ cells expressing CD16 and HLA-DR decreased on the first day, followed by an increase on the third and seventh day post burn. In comparison, the percentage of CD14+ monocytes expressing TLR2 and TLR4 was higher on the first day in burn patients than that of control participants, followed by no change on the third and seventh day post burn injury. There was no significant difference in the percentages of CD14+ expressing CD163 between the two groups. This study showed that the expression of the specific receptors on the surface of monocyte is affected by burn injury. The changes in the expression levels of these receptors may contribute to burn-induced infection susceptibility.

Sleep Disturbances and Symptoms of Depression and Daytime Sleepiness in Pregnant Women

BACKGROUND

Sleep disturbance, depression, and daytime sleepiness are among the most prevalent symptoms reported by women during pregnancy. However, available data on the association between sleep disturbances and symptoms of depression and daytime sleepiness in pregnant women are sparse and methodological limitations have been acknowledged. The purpose of the study was to examine objective and self-reported sleep disturbances and symptoms of depression and daytime sleepiness in a group of healthy pregnant women.

METHODS

A total of 274 third-trimester pregnant women wore a wrist actigraph continuously for 7 days to assess objective sleep quality and quantity. Self-reported sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI), with self-reported poor sleep quality defined as a PSQI score more than 5. The Center for Epidemiologic Studies-Depression Scale (CES-D) and Epworth Sleepiness Scale were used to evaluate symptoms of depression and daytime sleepiness, respectively.

RESULTS

Sixty-four (23.4%) women were at risk for clinical depression and 69 (25.2%) had daytime sleepiness. Risk of clinically meaningful depressive symptomatology was significantly increased in women with objective total nighttime sleep less than 6 hours (OR 2.53 [95% CI 1.26-5.08]) and self-reported poor sleep quality (OR 3.31 [95% CI 1.74-6.30]), even after multiple adjustment. Neither objective nor self-reported sleep disturbances increased daytime sleepiness in this group of pregnant women.

DISCUSSION

Both objective nighttime sleep less than 6 hours and self-reported poor sleep quality in healthy third-trimester pregnant women is associated with significant risks for clinical depression. Improving sleep would likely be associated with a reduction in depression symptom severity and an attenuation of the prevalence of depression in pregnant women.

The lived experiences of aboriginal adolescent survivors of childhood cancer during the recovering process in Taiwan: A descriptive qualitative research

PURPOSE

The purpose of this study was to understand the experiences of Taiwanese aboriginal adolescent survivors of childhood cancer during the process of recovery.

METHOD

A snowball sampling strategy was used to recruit participants from the pediatrics unit of a medical center in the eastern region of Taiwan. In-depth interviews were conducted with 11 aboriginal adolescent childhood cancer survivors. The data were analyzed using content analysis.

RESULTS

The results revealed three major themes with subthemes within each theme. The three major themes are: roots of resilience, transformation and growth, and meaning of traditional rituals for resilience. The three subthemes within "roots of resilience" include: "feeling secure through company of family, care and financial support", "receiving support from the important others and religion" and "learning to self-adjust". The three subthemes revealed within "transformation and growth" are: restructuring the relationship with peers, "appreciating parents' hard work", and "learning to seize the moment". The two subthemes within "meaning of traditional rituals to resilience" include: "feeling blessed with the power of ancestral spirits" and "strengthening ethnic identity".

CONCLUSION

This study provided insight into the experiences of aboriginal adolescents as they recovered from childhood cancer. The experiences made positive impacts by inspiring growth in maturity and consolidating aboriginal ethnic identity. The adolescents were empowered by support from family, friends and clansmen, and by their participation in aboriginal rituals. As healthcare professionals care for the aboriginal adolescents, it is critical to consider this culturally and ethnically specific knowledge/experience of surviving cancer to improve quality of care.