'I couldn't even talk to the patient': barriers to communicating with cancer patients as perceived by nursing students

Communication is closely related to safe practice and patient outcomes. Given that most clinicians fall into routines when communicating with patients, it is important to address communication issues early. This study explores Taiwanese nursing students’ experiences of communication with patients with cancer and their families. Senior nursing students who had cared for cancer patients were recruited to participate in focus group interviews. These semi-structured interviews were recorded and transcribed for content analysis. Among the 45 participants, about 36% of them never received any communication training. Up to 76% of the participants stated that their communication with cancer patients was difficult and caused them emotional stress. Subsequent data analysis revealed four themes: dis-engagement, reluctance, regression, and transition. Students’ negative communication experiences were related to the patients’ terminally ill situation; the students’ lack of training, low self-efficacy and power status, poor emotional regulation, and cultural considerations. The findings of this study provide a deeper understanding of nursing students’ communication experiences in oncology settings within the cultural context. Early and appropriate communication training are necessary to help students regulate their emotions and establish effective communication skills. Further studies are needed to examine the relationship among students’ emotional labor, communication skills and outcomes

Helminth-induced Th2 cell dysfunction is distinct from exhaustion and is maintained in the absence of antigen

T cell-intrinsic regulation, such as anergy, adaptive tolerance and exhaustion, is central to immune regulation. In contrast to Type 1 and Type 17 settings, knowledge of the intrinsic fate and function of Th2 cells in chronic Type 2 immune responses is lacking. We previously showed that Th2 cells develop a PD-1/PD-L2-dependent intrinsically hypo-responsive phenotype during infection with the filarial nematode Litomosoides sigmodontis, denoted by impaired functionality and parasite killing. This study aimed to elucidate the transcriptional changes underlying Th2 cell-intrinsic hypo-responsiveness, and whether it represents a unique and stable state of Th2 cell differentiation. We demonstrated that intrinsically hypo-responsive Th2 cells isolated from L. sigmodontis infected mice stably retained their dysfunctional Th2 phenotype upon transfer to naïve recipients, and had a divergent transcriptional profile to classical Th2 cells isolated prior to hypo-responsiveness and from mice exposed to acute Type 2 stimuli. Hypo-responsive Th2 cells displayed a distinct transcriptional profile to exhausted CD4+ T cells, but upregulated Blimp-1 and the anergy/regulatory-associated transcription factors Egr2 and c-Maf, and shared characteristics with tolerised T cells. Hypo-responsive Th2 cells increased mRNA expression of the soluble regulatory factors Fgl2, Cd38, Spp1, Areg, Metrnl, Lgals3, and Csf1, and a subset developed a T-bet+IFN-γ+ Th2/Th1 hybrid phenotype, indicating that they were not functionally inert. Contrasting with their lost ability to produce Th2 cytokines, hypo-responsive Th2 cells gained IL-21 production and IL-21R blockade enhanced resistance to L. sigmodontis. IL-21R blockade also increased the proportion of CD19+PNA+ germinal centre B cells and serum levels of parasite specific IgG1. This indicates a novel regulatory role for IL-21 during filarial infection, both in controlling protection and B cell responses. Thus, Th2 cell-intrinsic hypo-responsiveness is a distinct and stable state of Th2 cell differentiation associated with a switch from a classically active IL-4+IL-5+ Th2 phenotype, to a non-classical dysfunctional and potentially regulatory IL-21+Egr2+c-Maf+Blimp-1+IL-4loIL-5loT-bet+IFN-γ+ Th2 phenotype. This divergence towards alternate Th2 phenotypes during chronicity has broad implications for the outcomes and treatment of chronic Type 2-related infections and diseases

Altered T Cell Memory and Effector Cell Development in Chronic Lymphatic Filarial Infection That Is Independent of Persistent Parasite Antigen

Chronic lymphatic filarial (LF) infection is associated with suppression of parasite-specific T cell responses that persist even following elimination of infection. While several mechanisms have been implicated in mediating this T cell specific downregulation, a role for alterations in the homeostasis of T effector and memory cell populations has not been explored. Using multiparameter flow cytometry, we investigated the role of persistent filarial infection on the maintenance of T cell memory in patients from the filarial-endemic Cook Islands. Compared to filarial-uninfected endemic normals (EN), microfilaria (mf) positive infected patients (Inf) had a reduced CD4 central memory (TCM) compartment. In addition, Inf patients tended to have more effector memory cells (TEM) and fewer effector cells (TEFF) than did ENs giving significantly smaller TEFF ∶ TEM ratios. These contracted TCM and TEFF populations were still evident in patients previously mf+ who had cleared their infection (CLInf). Moreover, the density of IL-7Rα, necessary for T memory cell maintenance (but decreased in T effector cells), was significantly higher on memory cells of Inf and CLInf patients, although there was no evidence for decreased IL-7 or increased soluble IL7-Rα, both possible mechanisms for signaling defects in memory cells. However, effector cells that were present in Inf and CLInf patients had lower percentages of HLA-DR suggesting impaired function. These changes in T cell populations appear to reflect chronicity of infection, as filarial-infected children, despite the presence of active infection, did not show alterations in the frequencies of these T cell phenotypes. These data indicate that filarial-infected patients have contracted TCM compartments and a defect in effector cell development, defects that persist even following clearance of infection. The fact that these global changes in memory and effector cell compartments do not yet occur in infected children makes early treatment of LF even more crucial

Regulatory T cell-derived extracellular vesicles modify dendritic cell function

Regulatory T cells (Treg) are a subpopulation of T cells that maintain tolerance to self and limit other immune responses. They achieve this through different mechanisms including the release of extracellular vesicles (EVs) such as exosomes as shown by us, and others. One of the ways that Treg derived EVs inhibit target cells such as effector T cells is via the transfer of miRNA. Another key target for the immunoregulatory function of Tregs is the dendritic cells (DCs). In this study we demonstrate directly, and for the first time, that miRNAs are transferred from Tregs to DCs via Treg derived EVs. In particular two miRNAs, namely miR-150-5p and miR-142-3p, were increased in DCs following their interaction with Tregs and Treg derived exosomes. One of the consequences for DCs following the acquisition of miRNAs contained in Treg derived EVs was the induction of a tolerogenic phenotype in these cells, with increased IL-10 and decreased IL-6 production being observed following LPS stimulation. Altogether our findings provide data to support the idea that intercellular transfer of miRNAs via EVs may be a novel mechanism by which Tregs regulate DC function and could represent a mechanism to inhibit immune reactions in tissues

Silence among Afro Caribbean men diagnosed with prostate cancer in Trinidad and Tobago : a grounded theory study.

Background: Prostate cancer (PCa) is the leading cause of death among Afro-Caribbean men in Trinidad and Tobago (TT). TT is listed as one among countries with the highest PCa mortality rates in the world (Hosein et al., 2016). A systematic review undertaken explored men’s cultural beliefs about prostate symptoms and help-seeking behaviours, which revealed a dearth of knowledge of Afro-Caribbean men and PCa (King-Okoye et al., 2017). This study aims to explore men and partners experiences along care pathways for PCa in TT, including the beliefs and meanings men associate with their illness and its presentation. Methods: Utilising Straussian grounded theory, semi-structured and focus-group interviews were conducted with men (n= 51) diagnosed with PCa and partners (n=16) at four (urology & oncology) centres throughout TT in 2015-2016. Results: Five categories: ‘Disrupting the Self’, ‘Disconnected to Health Services’, ‘The Silent Wall’, ‘Blame and Distrust’ and ‘Breaking the Silence’ and a core category, ‘Silence among Afro-Caribbean men’ (SAACM) were generated from the data. These connect with men’s late presentation of PCa at emergency services with severe and life-limiting symptoms associated with high mortality rates for this disease. The main reasons underlying men’s late presentation to health services with debilitating symptoms, concern masculinity norms, lack of awareness and knowledge of early stage PCa, cultural beliefs and practices and perceptions of an uncaring health system. These heavily influenced men’s ability to access care and move through routes to diagnosis for PCa in TT. Conclusion: The SAACM offers unique insight into identifying how men’s cultural beliefs, hegemonic masculinity and lack of knowledge and awareness of the prostate and PCa resulted in delays in help-seeking and subsequently late diagnosis. A better understanding of men and their partners’ experiences along routes to diagnosis for PCa can target specific public health messages to address barriers to early diagnosis for men. Key words: Trinidad and Tobago, experiences, beliefs, culture, silenc

“It stays with me”: The experiences of second- and third-year Student Nurses when caring for patients with cancer

Little is known about student nurses experiences of nursing patients with cancer in the UK. With the increasing survival of people with cancer and with cancer no longer seen as a terminal illness it is useful to understand student nurses clinical experience when nursing those with cancer. This study takes a phenomenological approach involving three focus group interviews with twenty student nurses from the second and third year of their course in one centre in the UK. All the students had experience of caring for patients with cancer. The key themes emerging from the study were: Communication, Impact on Self, Lack of Support and End-of-Life-Care. Students emphasized the need to have more knowledge and support in relation to cancer care. They describe how they lack communication skills and found it difficult to handle their emotions. A number of students found the whole experience of caring for patients with cancer emotionally distressing and draining and they describe avoiding contact with these patients by using distancing and avoidance strategies. Student nurses need additional support through demystifying cancer, using reflective practice and good mentoring in the clinical area to enable students to feel supported, and develop confidence in their capacity for care for people with cancer

Beliefs that contribute to delays in diagnosis of prostate cancer among Afro‐Caribbean men in Trinidad and Tobago

Objective: The aim of this study was to explore TT men’s pre-diagnosis experiences of prostate cancer (PCa). This study is part of a wider project that examined men and their partners’ experiences of routes to diagnosis for PCa in TT. Methods: Men (n=51) were voluntarily recruited to semi-structured interviews from four centres. Data were analysed following principles of Grounded Theory. Results: Major barriers to medical help-seeking were highlighted as lack of knowledge and awareness of the prostate gland and symptoms of PCa, the digital rectal exam (DRE), PSA, cultural and religious beliefs and hegemonic masculinity norms and non-reporting of bodily changes to GPs. Fear of DRE, distrust in providers and misinterpretation of bodily changes as related to ageing and diabetes mellitus also contributed to delays towards seeking medical help. Men’s interactions with pharmacists and traditional healers lengthened the time taken to consult with Health Care Providers for prostate concerns. Conclusions: TT men’s PCa pre-diagnosis experiences are important to unearth barriers and facilitators to care along routes to diagnosis for this disease. This can help target specific health promotion strategies to motivate men to seek medical care for symptoms in a timely manner.</p