The use of decision analysis to examine ethical decision making by critical care nurses.

OBJECTIVE: To examine the extent to which critical care staff nurses make ethical decisions that coincide with those recommended by a decision analytic model. DESIGN: Nonexperimental, ex post facto. SETTING: Midwestern university-affiliated 500 bed tertiary care medical center. SUBJECTS: One hundred critical care staff nurses randomly selected from seven critical care units. Complete responses were obtained from 82 nurses (for a final response rate of 82%). MEASURES: The dependent variable--consistent decision making--was measured as staff nurses' abilities to make ethical decisions that coincided with those prescribed by the decision model. Subjects completed two instruments, the Ethical Decision Analytic Model, a computer-administered instrument designed to measure staff nurses' abilities to make consistent decisions about a chemically-impaired colleague; and a Background Inventory. RESULTS: The results indicate marked consensus among nurses when informal methods were used. However, there was little consistency between the nurses' informal decisions and those recommended by the decision analytic model. Although 50% (n = 41) of all nurses chose a course of action that coincided with the model's least optimal alternative, few nurses agreed with the model as to the most optimal course of action. The findings also suggest that consistency was unrelated (p > 0.05) to the nurses' educational background or years of clinical experience; that most subjects reported receiving little or no education in decision making during their basic nursing education programs; but that exposure to decision-making strategies was related to years of nursing experience (p < 0.05). CONCLUSIONS: The findings differ from related studies that have found a moderate degree of consistency between nurses and decision analytic models for strictly clinical decision tasks, especially when those tasks were less complex. However, the findings partially coincide with other findings that decision analysis may not be particularly well-suited to the critical care environment. Additional research is needed to determine whether critical care nurses use the same decision-making methods as do other nurses; and to clarify the effects of decision task (clinical versus ethical) on nurses' decision making. It should not be assumed that methods used to study nurses' clinical decision making are applicable for all nurses or all types of decisions, including ethical decisions.

[PCR analysis of DNA in paraffin sections of malignant lymphomas]. / Analýza DNA z parafínových rezu pomocí metody PCR u maligních lymfomu.

The polymerase chain reaction was used to detect the clonal rearrangement of immunoglobulin heavy chain gene in paraffin embedded samples of human lymph nodes. We developed a sensitive and reliable method of the DNA isolation from 4-5 tissue sections, which enabled us to perform 50-100 PCR reactions. We compared the reactive lymph nodes and non-Hodgkin's malignant lymphomas using framework 3 and J region primers. PCR products were examined by agarose gel electrophoresis. The dominant 80-120 bp amplification product was found in all lymphoma samples. The samples of reactive nodes were negative.

Ethical dilemmas in the lived experience of nursing practice.

Through a series of semistructured interviews with 12 nurses delivering direct patient care in acute, long-term and home care settings, information was sought regarding the ethical concerns of practicing nurses. Although these nurses frequently did not specifically identify the areas of expressed concern as ethical in nature, thematic analysis of the transcribed interviews uncovered four major ethical areas of concern common to these 12 nurses. These areas are: (1) Withholding of information and truth-telling; (2) Unequal access or inequalities in care; (3) Differences between business and professional values; (4) Breaking and reporting broken rules. Several reasons are offered to explain the failure of nurses accurately to identify specific practice dilemmas as ethical in nature and the sequelae of these failures. Possibilities involving ongoing education and mentored experiences in practice areas are reported.

A survey of BSN curricula: research content.

The purpose in this study was to survey educators in National League for Nursing (NLN)-accredited programs regarding the goals in the research component. The 21-item survey instrument was sent to 200 randomly selected schools, of whom 165 (83%) responded. The responses fell into two classes: cognitive goals, i.e., critical thinking and theory/practice; and professional skills, i.e., research utilization and clinical judgment. While a number of variables were analyzed, no significant findings were observed.

Contribution of radiotherapy to the management of malignant melanoma. A ten year experience at the University of Illinois Hospital in Chicago.

Fraction size in radiotherapy of malignant melanoma remains a point of controversy. Among 139 patients treated at the University of Illinois Hospital in 1979-1988, 36 were considered potentially curable (not counting ocular melanomas); 20 were treated by the Princess Margaret Hospital (PMH) hypofractionated schedule using 800 cGy per fraction and achieved a permanency of local control lasting > 6 months since the beginning of radiotherapy in 10/22 (45.5%) courses. Comparable results were obtained in 11 patients treated by standard fractionation to at least threshold curative levels. A modification of PMH regimen in 5 patients (but with 13 courses) by decreasing fraction size to 400 cGy while keeping total dose and course duration unchanged, resulted in a 100% loss of focal control within 6 months. Patients considered incurable and irradiated by PMH schedule responded in 83% of courses compared to 51.4% response rate in patients irradiated with other schedules (except modified PMH regimen). Other aspects of melanoma management are analyzed.

Health systems and policy in the USA and in the United Kingdom: an overseas programme.

An international programme, especially in a developed country, dramatically increases a student's understanding of health care systems. Students from a university programme in the USA learn about the development and structure of the British National Health Service through lectures and discussion in the US and England, and through 2 weeks of experience in England which include working with community health nurses in a district health authority. Related special experiences are planned which may include interviews with nurses involved in policy development, education, administration and specialty areas. Each student identifies an interest to pursue independently from the perspective of community care. As the student participates in the programme, alternative ways to give familiar care challenge formerly held beliefs. Health care emerges as a dynamic system, one that responds to issues, effects policy, and influences the role of health care providers.

Is it ethical to recruit foreign nurses?

Active recruitment of foreign-educated nurses is seen as one solution to the U.S.'s nursing shortage. Such recruitment, however, is seen by some of America's neighbors as an assault on their already weak health care systems. Others argue that nurses should be able to choose where they work.

Pseudocyst of tumor involution: a sign of nodal control in radiation therapy of head and neck carcinoma.

Regression of large metastatic lymph nodes in head and neck carcinoma following successful radiation therapy is a relatively lengthy process. This is especially true for nodes containing central necrosis. This article on serial CT scans identifies morphologic changes of prognostic significance, demonstrated on the basis of two case reports. Specifically identified are the transitional morphologic state, which is radiographically indistinguishable from an inflammatory condition, and, in addition, a seemingly end-stage of nodal tumor involution, which is represented by a pseudocyst formation, in a patient of long-standing duration.

Reappraisal of the role of radiation therapy in the management of Hodgkin's lymphoma with large intrathoracic masses.

Patients diagnosed as having Hodgkin's lymphoma with large intrathoracic masses are nowadays generally treated with a combination of chemotherapy and radiation therapy. This approach is usually indicated for more advanced stages and for cases with extranodal extension and presentation. However, the same policy is often implemented even in patients with early stage disease whenever they present with voluminous mediastinal and/or hilar masses. Especially in young persons, this approach to treatment has life-long lasting repercussions on both their general health and social fulfillment. In this article, an alternative approach is suggested. It consists of protracted, high-dose radiation therapy to the large tumor masses using the shrinking field technique and with a dose in the range of 50 to 60 Gy delivered over an approximately 3-month period. This proposition is based on the author's clinical experience and is documented in the article.

Experimental design for vaccine preparations against human malignant tumors.

The cancer cell is immunoresponsive and indirectly immunocompetent cell inserting itself in an extremely delicate system of natural antibodies and their respective anti-idiotypes. In regulatory sense it mimicks--in the Richter's model of immune system function--second order of response by antigenic cell surface product of malignant transformation, acting functionally as incomplete anti-idiotypic antibody (homobody) with exteriorized tumor antigen. It successfully competes with the natural anti-idiotypic antibodies replacing their repressive function by inducive one, and by doing so, changing natural antibody response by two orders of magnitude. The proposed experimental design would hybridize in separate experiments in one molecule: anti-HLA and anti-tumor xenogeneic antibodies obtained from animals and used for passive immunization; unaltered tumor antigen with organ-specific histocompatibility antigen having a preserved capacity of associative recognition. The latter process of humoral exteriorization of antigens would be elicited in animals and these immunoglobulin molecules (homobodies) would be used in humans for active immunization or in isogeneic animals for a production of antisera for passive immunization. Both these types of immunization would revert deranged immunological response in the cancer patient back to its normal order. Appropriate absorptions at critical steps would assure high specificity of the antisera.

Unusual radiation-induced pneumopathy.

Rare and unusual features of malignant tumors are spontaneous tumor regression and tumor maturation. An even more unusual pattern is the "reactive" mass formation produced by fibrous tissue proliferation and inflammation following radiotherapy and simulating tumor recurrence, like in the following case of pulmonary carcinoid. Radiological and pathological documentations are presented and discussed.

Peracute radiation pneumonitis: A case report and review of the literature.

Progressive tendencies in curative radiation therapy approach in the treatment of bronchogenic carcinoma will generally prolong a treatment course and modify the manifestation of radiation pneumonitis. There will probably be a tendency for an earlier onset of its acute phase, especially if the irradiated lung was atelectatic with or without post-obstructive pneumonia or if there were changes of chronic pulmonary disease. A peracute phase of radiation pneumonitis after a tumor dose of 6400 cGy in 29 fractions over 48 days starting within one week after the completion of irradiation is documented and discussed. Literature dealing with clinical, pathological, pathophysiological, and radiographic manifestations of radiation pneumonitis is shortly reviewed. Usage of corticosteroid therapy in the acute phase of radiation pneumonitis is described and controversial reports on this subject are mentioned. Beneficial effect of dexamethasone in the presented case is demonstrated on sequential radiograms.