An ecosystem approach to mentoring research faculty in schools of nursing: The pacific northwest interdependence mentoring model

BACKGROUND

Mentoring can facilitate faculty career development and retention. Given ongoing challenges in academic nursing (e.g., shrinking number of experienced mentors), it is necessary to revisit and improve upon existing mentoring models and practices to support current and future nurse researchers.

PURPOSE

To describe the development of a new faculty-to-faculty research mentoring model.

METHODS

Construction of a model describing mentoring needed by research-focused nurse faculty based on analysis of the literature alongside the authors' personal experiences.

FINDINGS

The Pacific Northwest Interdependence Mentoring Model (PIMM) describes academic nursing as an ecosystem that fosters caring, trust, solidarity, equity, openness, and interdependent relationships among research faculty, administration, institutions, and funding sources.

DISCUSSION

Although mentoring environments differ in unique strengths, weaknesses, mission, culture, and values, the PIMM's approach could be applicable for many schools of nursing and beyond to support the growth of the nursing discipline.

Advance Care Planning in Serious Illness: A Narrative Review

CONTEXT

Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility.

OBJECTIVE

To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness.

METHODS

We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care.

RESULTS

Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations.

CONCLUSIONS

We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.

Patient and Family Participation in Medication Decisions on Discharge to Hospice Care

Background: High-quality hospice care is characterized by patient-centered care and shared decision making between patients, families, and health care workers. However, little is known regarding the frequency and characteristics of patient and family participation in medication decisions on transition to hospice care. Objective: To quantify the frequency and characteristics of patient and/or family participation in medication decisions. Subjects: Adult (age ≥18 years) patients discharged from Oregon Health & Science University Hospital (OHSU) to hospice care between January 1, 2010 and December 31, 2016. Design: Cross-sectional study. Measures: The primary outcome was documented patient and/or family participation. Patient or family participation was defined as documentation of patient or family member discussion surrounding medication decisions in the discharge summary. We used logistic regression to identify patient and admission characteristics associated with documentation of patient or family member participation in medication decisions. Results: Among 348 eligible patients, patient and/or family participation was documented in 22% of discharges to hospice care. Higher Charlson comorbidity index (adjusted odds ratio [aOR]: 1.09, 95% confidence interval [CI]: 1.01-1.17) and having a diagnosis of cancer (aOR: 1.99, 95% CI: 1.16-3.43) were associated with an increased documentation of patient or family member participation in medication decisions. Patients admitted to the intensive care unit were less likely to have patient/family member participation (aOR: 0.55, 95% CI: 0.32-0.94). Having a specialty palliative care consultation was not significantly associated with patient or family member participation in medication decisions (aOR: 0.77, 95% CI: 0.40-1.48). Conclusions: Patient or family participation in medication decisions was documented for only 22% patients on discharge to hospice care. Opportunities to improve participation likely include increasing knowledge and capacity regarding primary palliative care for all clinicians and implementation of specialized interventions for patients and families transitioning to hospice care from acute care settings.

Cis-regulatory elements of the cholinergic gene locus in the silkworm Bombyx mori

Genes of choline acetyltransferase (ChAT) and vesicular acetylcholine transporter are encoded in the same gene locus, called the cholinergic gene locus. They are essential in cholinergic neurons to maintain their functional phenotype. The genomic structure of the cholinergic gene locus is conserved among invertebrates to mammals. However, the cholinergic gene expression in a specific subset of neurons is unknown in insects except for Drosophila melanogaster. In this study, we analysed the upstream sequence of cholinergic gene locus in the silkworm Bombyx mori to identify specific cis-regulatory regions. We found multiple enhancer regions that are localized within 1 kb upstream of the cholinergic gene locus. The combination of promoter assays using small deletions and bioinformatic analysis among insect species illuminates two conserved sequences in the cis-regulatory region: TGACGTA and CCAAT, which are known as the cAMP response element and CAAT box, respectively. We found that dibutyryl-cAMP, an analogue of cAMP, influences the expression of ChAT in B. mori. Tissue-specific expression analysis of transcriptional factors identified potential candidates that control the cholinergic gene locus expression. Our investigation provides new insight into the regulation mechanism of cholinergic neuron-specific gene machinery in this lepidopteran insect.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Mucor pulmonary embolism in a patient with myelodysplastic syndrome

Mucormycosis is a life-threatening infectious disease that occurs most commonly in immunocompromised patients such as those with hematological malignancies. Its clinical symptoms and associated radiological findings vary and specific biomarkers and culture characteristics have not been defined. An 85-year-old man who had been treated for myelodysplastic syndrome and tuberculosis for several months presented with subacute fever and worsening left-side chest pain. Contrast-enhanced computed tomography images depicted massive tumor-like consolidation without enhancement, expanding from the left lower lobe. Emboli that did not respond to anticoagulants were detected in the left descending pulmonary artery. Despite intensive treatment he developed multiple organ failure and died 47 days after hospitalization. Gross pathology of a lung autopsy specimen revealed left lower pulmonary arterial emboli and pulmonary infarction, which was concluded to be the direct cause of death. The emboli were histopathologically identified as invasive mycelia in vessels. Mucor sp. was detected via real-time polymerase chain reaction and immunohistopathological analyses revealed that the mold in the blood vessels of lung tissue was partially positive for the mucor antigen. In the present case of Mucor sp. pulmonary emboli in a patient with myelodysplastic syndrome, radiographic findings were hard to distinguish from those typical of a lung abscess.

Enhancing Advance Care Planning Conversations by Nurses in a Bone Marrow Transplantation Unit

OBJECTIVES

To describe the impact of advance care planning (ACP) education on nurses' confidence in ACP knowledge and practice and to identify barriers to facilitate ACP conversation in a bone marrow transplantation unit.

SAMPLE & SETTING

60 nurses working in the bone marrow transplant unit at Oregon Health and Science University, an academic medical center.

METHODS & VARIABLES

The aim of this quality improvement project was to increase ACP conversations by nurses. The authors used a single-group pre-/post-test design to assess the effectiveness of a 30-minute educational intervention in changing nurses' confidence and practice. Group interviews were conducted to identify barriers to ACP.

RESULTS

The educational intervention increased nurses' confidence in knowledge about ACP. The number of nurses who discussed ACP with patients also increased, but it was not statistically significant. Lack of time, inefficient workflow, and concerns about questioning providers' understanding of patient preferences were identified as barriers for nurses engaging in and documenting ACP conversations.

IMPLICATIONS FOR NURSING

In addition to appropriate education, strategies that help tailor ACP practice to fit into nurse workflow and promote collaboration with other healthcare team members are needed to change nurses' ACP practice.

Care coordination: Identifying and connecting the most appropriate care to the patients

Although nurses are increasingly expected to fulfill the role of care coordinator, the knowledge and skills required to be an effective care coordinator are not well understood. The purpose of this study was to describe the knowledge and skills required in care coordination practice using an interpretive phenomenological approach. Fifteen care coordinators from 10 programs were interviewed over a 6-month period. Semi-structured face-to-face interviews were audio recorded, transcribed, and analyzed using interpretive phenomenology. The central theme of care coordination practice was bridging the patient and the healthcare systems. To bridge, care coordinators needed to have knowledge of the patient and healthcare system as well as the skills to identify and negotiate treatments appropriate for the patient. The most salient finding and new to this literature was that care coordinators who used their medical knowledge about available treatment options to discern and negotiate for the most appropriate care to the patient made differences in patient outcomes. Nurses with medical and healthcare system knowledge, combined with the skills to navigate and negotiate with others in an increasingly complex healthcare system, are well situated to be care coordinators and generate optimal outcomes. Further investigations of critical care coordinator competencies are needed to support nurses currently enacting the role of care coordinator and to prepare future nurses to fulfill the role.

Topical application of glycyrrhetinic acid in the gingival sulcus inhibits attachment loss in lipopolysaccharide-induced experimental periodontitis in rats

BACKGROUND AND OBJECTIVE

Attachment loss of the junctional epithelium and alveolar bone destruction are signs of periodontitis, which is mainly caused by an inflammatory response to dental plaque. Glycyrrhetinic acid (GA), a component of the licorice herb, has been shown to have important anti-inflammatory activities; however, there are no previous reports on the ability of its inhibitory effects to prevent periodontal diseases. Hence, in this study, using our experimental periodontitis model, we attempted to evaluate whether GA had an effect on the prevention of attachment loss and alveolar bone loss.

MATERIAL AND METHODS

Rats were intraperitoneally immunized with Escherichia coli lipopolysaccharide (LPS). The LPS group (n = 5) received 3 topical applications of 50 μg/μL of LPS followed by one application of the vehicle (propylene glycol:ethyl alcohol:phosphate-buffered saline [PBS] = 8:1:1) into the gingival sulcus. This protocol was repeated twice per day for 10 days. The low (n = 5) and high (n = 5) groups received topical application of LPS and 0.03% or 0.3% GA, respectively. The control group received topical application of PBS and vehicle. The rats were killed on the 10th day. Attachment loss, alveolar bone level and inflammatory cell infiltration were investigated histometrically. The formation of immune complexes and infiltration of LPS were evaluated immunohistologically.

RESULTS

Attachment loss, formation of immune complexes and infiltration of inflammatory cells were increased in the LPS group compared with the control group, and were completely inhibited in the low and high groups compared with the LPS group. The LPS group showed greater alveolar bone destruction compared with the control group and GA-treated groups. In addition, invasion of LPS was detected in the LPS group, was absent in the control group and was weaker in the GA-treated groups than in the LPS group.

CONCLUSION

In the present study, we showed that GA inhibits periodontal destruction in the rat experimental periodontitis model.

Rapid and sensitive detection of neuron specific enolase with a polydopamine coated plasmonic chip utilizing a rear-side coupling method

A rapid and sensitive detection of a cancer marker, neuron specific enolase (NSE), is demonstrated by using a disposable silver plasmonic chip functionalized with a mussel-inspired polydopamine (PDA) coating.

Factors affecting the potential for posterior bony impingement after total hip arthroplasty

Aims

Our aim was to evaluate the radiographic characteristics of patients undergoing total hip arthroplasty (THA) for the potential of posterior bony impingement using CT simulations.

Patients and Methods

Virtual CT data from 112 patients who underwent THA were analysed. There were 40 men and 72 women. Their mean age was 59.1 years (41 to 76). Associations between radiographic characteristics and posterior bony impingement and the range of external rotation of the hip were evaluated. In addition, we investigated the effects of pelvic tilt and the neck/shaft angle and femoral offset on posterior bony impingement.

Results

The range of external rotation and the ischiofemoral length were significantly lower, while femoral anteversion, the ischial ratio, and ischial angle were significantly higher in patients with posterior bony impingement compared with those who had implant impingement (p <  0.05). The range of external rotation positively correlated with ischiofemoral length (r = 0.49, p < 0.05), and negatively correlated with ischial length (r = -0.49, p < 0.05), ischial ratio (r =- 0.49, p < 0.05) and ischial angle (r = -0.55, p < 0.05). The range of external rotation was lower in patients with posterior pelvic tilt (p < 0.05) and in those with a high offset femoral component (p < 0.05) due to posterior bony impingement.

Conclusion

Posterior bony impingement after THA is more likely in patients with a wider ischium and a narrow ischiofemoral space. A high femoral offset and posterior pelvic tilt are also risk factors for this type of impingement. Cite this article: Bone Joint J 2017;99-B:1140–6.

Relief of Suffering and Regard for Personhood: nurses’ ethical concerns in Japan and the USA

The ethical concerns of Japanese nurses are compared with those of previously described nurses from the USA. Patient comfort was a primary concern of nurses from both countries. Participants described an ethical imperative to provide adequate pain medication for patients and prevent unnecessary and uncomfortable invasive tests and procedures, especially at the end of life as the focus changed from ‘cure’ to ‘care’. The notion of regard for personhood varied, based on the communication styles and definition of the self inherent in the different cultures of the nurses. A common meaning centred around knowing patients as persons, listening to their needs and preferences, supporting their everyday choices through advocacy, and maintaining their dignity. Despite background cultural differences, there are common ethical concerns between nurses in Japan and the USA. This article invites readers to reflect on everyday nursing practices that exemplify ethical expertise, and the significance of this expertise in uncovering and articulating nursing ethics across cultures.

Predictors of Patient Satisfaction With Telephone Nursing Services

Patient satisfaction has been shown to be a factor in clinical outcomes, health care quality, and patient follow-through. Thus, a high level of satisfaction is a desired outcome of patient care. This article examines predictors of patient satisfaction with telephone nursing services among a sample of 1,939 respondents, using a conceptual model derived from the literature and preliminary work. The study was conducted in medical offices and call centers of a large national health maintenance organization. Calls were taped and content coded and then matched with caller questionnaire data. In the final multivariate predictive models, patient health status; caller ratings of expectations met by the nurse for listening, clarity, and collaboration; and nurse competence were the strongest predictors of satisfaction. Consistent with the literature, findings suggest that nurses should expand interpersonal communication skills, and systems should reduce barriers to effective listening, clarity, and collaboration with callers.

Predicting Patient Follow-Through on Telephone Nursing Advice

Although use of telephone advice nursing services continues to grow, little research has addressed factors that affect crucial call outcomes like follow-through on the advice given. This article describes aspects of the advice call process and examines predictors of caller follow-through, using a conceptual model derived from the literature and the authors' preliminary work. Calls to call centers and medical offices of a large health maintenance organization were taped, then content was coded and matched with caller questionnaire (CQ) data. Out of 1,863 participants, 1,489 reported following all the advice. In the final multivariate predictive model, statistically significant predictors of follow-through were patient health status, caller's rating of nurse helpfulness, and the extent to which caller expectations for collaboration were met and the caller understood the advice given. Results suggest that nurses should receive continuous training on effective communication techniques, and advice nurse performance standards that create barriers to communication should be modified.

Factors associated with mothers not vaccinating their children against mumps in Japan

OBJECTIVES

In Japan, mumps immunization is not mandatory, and the prevalence of mumps immunization among eligible children is only about 30%, raising concerns about increased risk of meningitis, encephalitis and deafness caused by mumps. In 2011, to understand why families are not voluntarily immunizing their children against mumps, we surveyed mothers who were university graduates to examine the factors and barriers influencing mumps vaccination in Japan.

STUDY DESIGN

A cross sectional design.

METHODS

We sent questionnaires including questions on demographic data and vaccination status, barriers and factors for immunizations to university alumnae to recruit participants. Data were analysed by Student's t-test for continuous variables and by univariate and multivariate analysis to obtain the odds ratio and adjusted odds ratio.

RESULTS

Two hundred and twenty-six mothers with children responded with an average (range) age of 44.7 years (SD = 5.02; 30-55 years). Adjusted odds ratios (aOR) from logistic regression analysis identified fear of harmful side-effects (aOR, 2.55; 95% CI, 1.10 to 5.89), the vaccination not being mandatory (aOR, 3.30; 95% CI, 1.41 to 7.72), perceived non-efficacy (aOR, 6.21; 95% CI, 1.85 to 20.91) and being busy (aOR, 3.30; 95% CI, 1.21 to 9.01) were significantly and inversely associated with mumps vaccination. Recommendations from family doctors (aOR, 0.35; 95% CI, 0.17 to 0.71), living abroad when their children would be vaccinated (aOR, 0.10; 95% CI, 0.02 to 0.68) and the maternal age (aOR, 0.91; 95% CI, 0.85 to 0.96) were significant and positively associated with vaccination.

CONCLUSIONS

In the absence of mandatory vaccinations, a public education campaign about mumps, their potential consequences and the nature and value of vaccination could improve the prevalence of mumps vaccination among children and prevent the consequences of this disease.

Adapting cognitive interviewing for nursing research

Cognitive interviewing (CI) has been used by instrument developers to examine how well an instrument generates the intended data when tested with prospective respondents. In using CI to test a new instrument to measure patients' perceptions of the quality of nursing care, the authors found challenges in applying a theory-based traditional CI approach derived from experimental psychology to more clinically oriented nursing research. The purposes of this article are to describe these challenges and the modifications of CI to capture the nursing care perspectives of hospitalized participants, and to present interpretive phenomenology as a theoretical orientation for clinically situated CI.

Quality improvement in nursing: administrative mandate or professional responsibility?

For professionals, providing quality service and striving for excellence are ethical responsibilities. In many hospitals in the United States, however, there is evidence indicating that current quality improvement (QI) involving nurses is not always driven by their professional accountability and professional values. QI has become more an administrative mandate than an ethical standard for nurses. In this paper, the tension between QI as nurses' professional ethics and an administrative mandate will be described, and the implicit ideal-reality gap of QI will be examined. The threat to professional nursing posed by the current approach to QI will be examined, and ways to incorporate nursing professional values in a practical QI effort will be explored.

Dioxins in ascites and serum of women with endometriosis: a pilot study

BACKGROUND

Animal studies and laboratory experiments have demonstrated that exposure to dioxins may be involved in the pathophysiology of endometriosis. However, recent epidemiological investigations have shown conflicting results. Although peritoneal fluid is a specific microenvironment playing a pivotal role in the development of endometriosis, to our knowledge, there is no published study evaluating the concentrations of dioxins in serum and peritoneal fluid simultaneously. The present study explores the possible correlation between the local peritoneal fluid levels of dioxins and concurrent endometriosis.

METHODS

There were 17 infertile women enrolled in the present study. After the diagnostic laparoscopic examination, the women were divided into two groups: endometriosis (n = 10) and controls (n = 7). We measured 29 dioxins simultaneously in serum and peritoneal fluid samples: 7 polychlorinated dibenzo-p-dioxins (PCDDs), 10 polychlorinated dibenzofurans (PCDFs), and 12 polychlorinated biphenyls (dioxin-like PCBs). A dioxin toxic equivalency (TEQ) system was utilized to calculate the dioxin concentration in each sample.

RESULTS

Serum concentrations of itemized components of 29 dioxins were similar in the endometriosis patients compared with the controls. Higher concentrations of PCDFs and dioxin-like PCBs were observed in peritoneal fluid than in serum, whereas the reverse was shown for PCDDs. Statistical analysis showed that higher levels of dioxin TEQ (PCDDs and PCDFs) in peritoneal fluid were significantly associated with an increased risk of endometriosis (OR: 2.5; 95% CI: 1.17-5.34; P = 0.035).

CONCLUSIONS

This is the first report suggesting that higher concentrations of dioxins (PCDDs and PCDFs) in peritoneal fluid are linked to endometriosis. More detail and epidemiological research is warranted to further explore this link.

Ethical practice in end-of-life care in Japan

Nurses are obliged to provide quality nursing care that meets the ethical standards of their profession. However, clear descriptions of ethical practice are largely missing in the literature. Qualitative research using a phenomenological approach was conducted to explicate ethical nursing practice in Japanese end-of-life care settings and to discover how ethical practices unfold in clinical situations. Two paradigm cases and contrasting narratives of memorable end-of-life care from 32 Japanese nurses were used to reveal four levels of ethical practice: ethical, distressed, uncertain, and unethical. Having the ability to actualize, justify, and recognize what is the good and/or right differentiated between these levels of ethical practice, empirical descriptions of which are given, followed by discussion of how nurses gain the skilled knowledge necessary for ethical practice.

Mapping of susceptibility locus for endometriosis within the HLA region using microsatellite markers in Japanese women

Endometriosis is a female disorder characterized by the presence of uterine endometrial tissue in ectopic loci. Previous studies reported a higher prevalence of particular human leukocyte antigen (HLA) in endometriosis. In order to confirm the association between endometriosis and the HLA region, 15 polymorphic microsatellite markers distributed in the HLA class II to class III region were subjected to association analysis by polymerase chain reaction (PCR)-based DNA typing of 89 patients and 136 healthy controls. Statistical analysis of the allelic frequency at each microsatellite locus showed that there were no statistically significant differences in the allele frequency distributions between the cases and controls. This finding suggests that the etiology of endometriosis does not involve the HLA class II genomic region and a portion of class III genomic region in the Japanese population.

Quality nursing care for hospitalized patients with advanced illness: concept development

The quality of nursing care as perceived by hospitalized patients with advanced illness has not been examined. A concept of quality nursing care for this population was developed by integrating the literature on constructs defining quality nursing care with empirical findings from interviews of 16 patients with advanced illness. Quality nursing care was characterized as competence and personal caring supported by professionalism and delivered with an appropriate demeanor. Although the attributes of competence, caring, professionalism, and demeanor were identified as common components of quality care across various patient populations, the caring domain increased in importance when patients with advanced illness perceived themselves as vulnerable. Assessment of quality nursing care for patients with advanced illness needs to include measures of patient perceptions of vulnerability.

Nurses' responses to ethical dilemmas in nursing practice: meta-analysis

AIM

This paper is a report of a study to explore nurses' responses to ethical dilemmas in daily nursing practice.

BACKGROUND

Concern about nurses' ethical competence is growing. Most nurses perceived that there were barriers in their work environment to ethical practice, compromising their ability to perform ethically. Since most research focuses on contextual barriers to nurses' ethical practice, little is known about how nurses involve themselves in ethical decision-making and action in daily care.

METHOD

A meta-analysis of nurses' ethical behaviour was conducted using data from nine studies in four countries (n = 1592 registered nurses). In all studies, the Ethical Behaviour Test was used to measure nurses' ethical responses, based on an adapted version of Kohlberg's theory of moral development. Data were analysed using random-intercept regression analysis.

FINDINGS

All groups, except the expert group, displayed a uniform pattern of conventional ethical reasoning and practice. When nurses were faced with ethical dilemmas, they tended to use conventions as their predominant decision-guiding criteria rather than patients' personal needs and well-being.

CONCLUSION

Conformist practice (following conventions rather than pursuing good for the patient) constitutes a major barrier for nurses to take the appropriate ethical actions, as creativity and critical reflection are absent. There is an urgent need to find ways to promote nurses' ethical development from conventional to postconventional ethical practice. More research is needed to strengthen existing empirical evidence.

Effect of famotidine and lansoprazole on serum phosphorus levels in hemodialysis patients on calcium carbonate therapy

AIMS

Histamine H2 receptor antagonists (HRA) or proton pump inhibitors (PPI) are frequently administered to patients on hemodialysis, because their intestinal mucosa is fragile. Although three studies have indicated that concomitant HRA administration causes a decrease in the binding of phosphate by calcium carbonate, the HRA doses tested in these studies were 2-4 times higher than the recommended dose for hemodialysis patients. In addition, it remains unclear whether PPI therapy affects serum phosphate levels in hemodialysis patients taking calcium carbonate. Accordingly, the aim of this study was to evaluate the influence of lansoprazole and the recommended dose of famotidine on serum phosphate and calcium levels in hemodialysis patients.

METHODS

The study included 115 hemodialysis patients who were taking calcium carbonate and who were also treated with either famotidine (10 mg/day) or lansoprazole (30 mg/day). Changes of the mean serum phosphate and calcium levels over 2 months before and after the start of famotidine or lansoprazole therapy were compared. The same parameters were also compared when famotidine was switched to lansoprazole.

RESULTS

The mean serum phosphate level increased significantly after administration of either famotidine or lansoprazole (by 6.6 +/- 21.9% or 13.0 +/- 26.3%, p = 0.032 and p = 0.029, respectively). The mean serum calcium level was unchanged after administration of famotidine, but showed a significant decrease after administration of lansoprazole (by 3.44 +/- 7.73%, p = 0.013). Therefore, the calcium x phosphorus product was significantly increased by administration of famotidine, but not by administration of lansoprazole (6.68 +/- 23.37% and 8.73 +/- 27.41%, p = 0.046 and p = 0.251, respectively). When famotidine was switched to lansoprazole, the serum phosophate level did not change, but serum calcium decreased significantly by 3.8 +/- 13.0% (p = 0.0006).

CONCLUSION

Not only administration of 20 mg/ day of famotidine as previously reported, but also 10 mg/day of this drug (the recommended dose for hemodialysis patients) caused a significant increase of serum phosphate in patients taking calcium carbonate. PPIs have been reported to show no effect on the serum phosphate level, but 30 mg/day of lansoprazole also caused a significant increase of serum phosphate in patients taking calcium carbonate.

Identification and detection of Pseudomonas plecoglossicida isolates with PCR primers targeting the gyrB region

Pseudomonas plecoglossicida is the agent of bacterial haemorrhagic ascites (BHA) in freshwater fish farming in Japan. To develop a rapid identification and detection method for P. plecoglossicida, a PCR amplification technique targeting the chromosomal DNA region coding the B subunit of the DNA gyrase (gyrB) was used. The nucleotide sequences of gyrB were determined in nine isolates of P. plecoglossicida and two other Pseudomonas species. On the basis of these determined sequences and the gyrB sequences of other Pseudomonas species or fish pathogenic bacteria deposited in international nucleotide sequence databases (GenBank/EMBL/DDBJ), PCR primers PL-G1F, PL-G1R, PL-G2F and PL-G2R were designed for specific amplification of the partial gyrB of P. plecoglossicida. The specificity of these primers in amplifying the gyrB of P. plecoglossicida was verified using selected strains of related bacterial species. The nested PCR technique was used to detect P. plecoglossicida from kidney and intestine of ayu. Primer pair PL-G1F and PL-G1R was used for the external PCR, and primer pair PL-G2F and PL-G2R for the internal PCR. Of 10 ayu juveniles, expected size PCR products were observed from intestine and kidney samples in one and two specimens, respectively. The PCR technique with primers based on the gyrB sequence is thus useful for the diagnosis of BHA.

Molecular typing by pulsed-field gel electrophoresis of Flavobacterium psychrophilum isolates derived from Japanese fish

Sixty-four isolates of Flavobacterium psychrophilum from ayu, Plecoglossus altivelis altivelis (Temminck & Schlegel), and other fish (n=16) in Japan and the type strain (NCIMB 1947(T)) were typed using pulsed-field gel electrophoresis (PFGE) with endonuclease BlnI and XhoI. These isolates were classified into 20 clusters and 42 genotypes by PFGE analysis. The most predominant cluster of isolates from ayu was cluster XII (n=20), followed by clusters XVII, XVI, XX, XI, IX, X, XIII and XV; the remaining 17 isolates from other fish were divided into clusters I, II, III, IV, V, VI, VII, VIII, XIV, XVIII and XIX. The PFGE genotype of isolates from ayu clearly differed from those of other fish. The isolates from ayu in Gunma Prefecture belonged to clusters XII, XVI, XVII and XX, and the strains of three of these clusters (XII, XVII and XX) were isolated from ayu in 15 of 19 prefectures. PFGE typing enabled more accurate classification of isolates into clusters than previously achieved by analysing the restriction fragment length polymorphism of PCR products. These results suggest that F. psychrophilum isolated from ayu and other fish are genetically different and strains with several PFGE types have spread within Japan.

PCR-RFLP genotypes associated with quinolone resistance in isolates of Flavobacterium psychrophilum

A novel genotyping method for epizootiological studies of bacterial cold-water disease caused by Flavobacterium psychrophilum and associated with quinolone resistance was developed. Polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) was performed on 244 F. psychrophilum isolates from various fish species. PCR was performed with primer pair GYRA-FP1F and GYRA-FP1R amplifying the A subunit of the DNA gyrase (GyrA) gene, which contained the quinolone resistance determining region. Digestion of PCR products with the restriction enzyme Mph1103I showed two genotypes, QR and QS. The difference between these genotypes was amino acid substitutions at position 83 of GyrA (Escherichia coli numbering). The genotype QR indicated an alanine residue at this position associated with quinolone resistance in F. psychrophilum isolates. Of the 244 isolates tested in this study, the number of QR genotype isolates was 153 (62.7%). In isolates from ayu (n=177), 146 (82.5%) were genotype QR. With combination of this technique and previously reported PCR-RFLP genotyping, eight genotypes were observed in F. psychrophilum isolates. Using this genotyping system, the relationships between genotype and host fish species, or locality of isolation, were analysed and are discussed.