Bio-hythane production from cassava residue by two-stage fermentative process with recirculation.

The two-stage hythane fermentation of cassava residue low in protein, rich in iron, and deficient in nickel and cobalt, resulted in failure after long-term operation, showing a radical decrease in methane production along with an increase in volatile fatty acids (VFAs) accumulation in the second stage. Based on the gap between theoretical demand and existing content of nutrients, the effect of their additions on hythane fermentation was validated in the repeated batch experiment and continuous experiment. The proliferation of hydrolysis bacteria, acidogens, and hydrogen producing bacteria and methanogens was guaranteed by sufficient N (0.7g/L), S (30mg/L), Ni (1.0mg/L), and Co (1.0mg/L), and the metabolism of a sustainable hythane fermentation was recovered. In this optimal nutrient combination of above trace elements, the highest hythane yield (426m3 hythane with 27.7% of hydrogen from 1ton of cassava residue) was obtained.

Relational narrative: the postmodern turn in nursing ethics.

A philosophy of nursing requires an ethical cornerstone. I describe three dialectical layers of an ethical cornerstone: subjective immersion, objective detachment, and relational narrative. Dialectically, the move from immersion to detachment is the turn from communitarian to rational ethics, replacing traditions with universal principles. The move from universalism to engagement is the turn from rational to relational ethics, replacing detached reason with engagement between particular selves. Conceptually, the three layers correspond to premodern, modern, and postmodern ethics. I propose that the layers be viewed not as stages, but as elements that coexist in an ethically vital profession, and I conclude with an illustration of their coexistence in a clinical situation.

Narrative and exploration: toward a poetics of knowledge in nursing.

The dualism of subject and object has been a traditional model for nursing knowledge. That model is portrayed here as an epistemological exile. Our self-imposed exile from the lived world of nursing can be remedied by inquiry based on engagement rather than distance. One model for engaged inquiry is explorers' journeys in remote regions. Knowledge of a region can be local or colonial, according to the explorer's stake in the region as homeland or territory. Nursing is an existential region where people live. In the exploration of nursing as homeland, knowledge takes the form of local narrative, the story of a place told by its inhabitants. Narrative inquiry offers nursing an epistemology that is both ethically and aesthetically congruent with its practice of engagement.

Establishing partnerships with family caregivers. Local and cosmopolitan knowledge.

Families now provide most of the care received by older people in the United States. Proposed changes in the health care system will mean that families must take an even greater role in delivering health care. It is crucial that nurses practicing in a variety of settings be prepared to establish partnerships with family caregivers in order to attend to the long-term care needs of older people.

Clinical epistemology: a dialectic of nursing assessment.

Clinical assessment in nursing combines general knowledge from theory and research with particular knowledge about a client. A philosophical account of this synthesis is required to elucidate the paradox of knowledge that is both general and particular. The approach developed here is a dialectical model of clinical knowledge that culminates in existential safety rather than epistemic certainty. In the model, nursing assessment is the progression from subjective vulnerability through levels of objectivity (disengagement, reduction, holism) to an intersubjectivity in which nurse and client express their combined understanding in a relational narrative. The discussion concludes with reflection on the role of theory in a dialectically complete clinical narrative.

Establishing partnerships with family caregivers. Local and cosmopolitan knowledge.

1. The concepts of local and cosmopolitan knowledge may be used by gerontological nurses in creating partnerships with family caregivers to frail older people. 2. Local knowledge is the understanding and skills that the family brings to the caregiving situation; cosmopolitan knowledge is the understanding and skills that the gerontological nurse brings to the situation. 3. Four nursing interventions are guided by the conceptualization of local and cosmopolitan knowledge: acknowledging and affirming local knowledge when it is adequate; developing or enhancing local knowledge when it is inadequate; assisting family caregivers to apply local knowledge to problem solving; and blending local and cosmopolitan knowledge.

Existential ecology: the human/natural world.

Medicine and ecology share the concern for reconciling human aims and natural processes. That reconciliation is attempted through analogous approaches in the two fields. A dialectical model, described here, provides conceptual organization of those approaches into a coherent progression of paradigms, both existential and theoretical: (1) vulnerability, the immediacy of human exposure to nature's power and the futility of human ascendancy; (2) disengagement, the rational and the romantic objectification of nature; (3) dissection, the scientific and cultural reduction of nature to specimens; (4) holism, the conceptualization of the ecosystem; (5) inherence, the human involvement with nature as home, entailing a local rather than colonial ethic and epistemology. Culmination of the dialectic in ecology, as in medicine, is reconcilation with the otherness of nature, recovering both environment and embodiment as forms of human existence.

Clinical subjectivity. Advocacy with silent patients.

Advocacy typically has been understood as assistance to patients in giving voice to their values. With silent patients, however, advocacy involves more: the nurse speaking with the patient's voice. That dimension of advocacy represents its greatest challenge as a moral position. Other positions offer easier approaches to moral issues with silent patients. Utilitarianism and beneficence require little, if any, access to patient subjectivity. For the nurse committed to regard for patient self-determination, access to the subjective world of silent patients is crucial. That access is possible only when the nurse's voice, like the patient's, arises from the experience of embodiment. Silent patients cannot be represented by the words of bodiless advocates. Embodiment--of nurse and patient--is the avenue to subjectivity and the essential basis for a moral commitment to advocacy.

An ethical case for patient self-determination.

The self-determination of patients can be impeded or enhanced to a significant extent by the professionals who care for them. The autonomy of cancer patients especially is affected by their care givers. These patients often face difficult choices in the management of their illness: decisions about pain control, treatment choice, research participation, family involvement, withdrawal of treatment, and the degree to which they wish to be informed in making each of these decisions. The extent to which consent is free and informed and the autonomy of the patient not impeded, but positively enhanced, is determined by the professional. Is it fair to assign the professional so much responsibility for patient autonomy? Are patients not free to make decisions as they wish? In a technological society, serious illness is managed by professionals who incur a major share of responsibility for the degree of freedom that patients exercise. When patients are not encouraged and assisted to exercise their freedom, they cannot be autonomous. When an experience is brought under professional management, self-determination is possible only to the extent that it is both protected and promoted, or actively advocated. In the care of cancer patients, the central responsibility for advocacy belongs to the professional best situated within the framework of health care to sustain a partnership with the patient, and that professional is the nurse.

Touch and technology: Two paradigms of patient care.

Technology violates human dignity only to the extent that its use reduces persons to the moral status of objects. The prevalence of technology in health care is an extension of the scientific paradigm, in which the body is reduced to an object void of subjectivity. The empathie paradigm, in contrast, is based upon the moral primacy of subjectivity. Empathic touch-as distinct from instrumental and philanthropic touch-establishes a clinical relation of intersubjectivity, affirming in patients the dignity and worth that morally distinguish persons from objects.

Truth: treatment of choice, scarce resource, or patient's right?

Two approaches are described for addressing ethical problems of truth telling. In neither approach is truth telling an ethical absolute, but rather a means of attaining the goal that is assumed for medicine. The first approach, based upon the aim of benefiting the patient, is the view that information is to be disclosed or withheld according to the anticipated effect upon the patient's well-being. The second approach, based upon the aim of facilitating patient autonomy in health matters, is the view that informed decision making requires access to all information the patient considers relevant. While the choice between the two views belongs to the individual practitioner, the author proposes that the autonomy position affords the greatest benefit to both patient and physician.