Development of an approach to estimating mid- to long-term critical loads for radiocaesium contamination of cow milk in western Europe

This paper describes the application of the critical load methodology, developed to set emission targets for atmospheric pollutants, to radioecology. The critical load can be redefined within radioecology as the radionuclide deposition at which radionuclide activity concentrations in a specified food product will exceed the maximum permitted level. An empirically based approach is described which provides estimates of critical load values for cow milk in the mid- to long-term after an accident when soil-to-plant transfer of radiocaesium is largely responsible for plant radiocaesium contamination. The areas identified as being most potentially vulnerable to radiocaesium deposition using this approach are those with extensive areas of organic soils such as western Scotland, parts of Ireland, The Netherlands and Denmark. The classification of European soil types into soil groups with significantly different soil-to-plant transfer of radiocaesium, and the allocation of a transfer value to each soil group provide the greatest uncertainties within this approach. Potential problems and deficiencies affecting the estimation of parameter values are discussed.

Diameter of inferior caval vein (VCD) and bioelectrical impedance analysis (BIA) for the analysis of hydration status in patients on hemodialysis

BACKGROUND

Vena cava diameter (VCD) measurement is an accepted method to evaluate hydration status in patients on hemodialysis. Bioelectrical impedance analysis (BIA) is a less laborious method to assess hydration variables and more suitable for routine patient care. However, BIA has not yet been validated in dialysis patients. We investigated whether BIA can replace VCD in patients on hemodialysis.

METHODS

In 20 stable hemodialysis patients [age (+/-SD): 47+/-17 yrs, dialysis duration (+/-SD): 76+/-59 months] hydration status was evaluated by VCD. Impedance variables such as resistance, reactance and phase angle were provided by BIA. They were used to calculate intracellular water (ICW), extracellular water (ECW) and total body water (TBW).

RESULTS

VCD did not correlate with TBW-BIA, but correlated with ECW/TBW (r = 0.46; p<0.025), ECW/m2 (r = 0.42; p<0.005) and ICW/ECW (r = -0.49; p<0.005). Hemodialysis decreased TBW with 2.7+/-1.91. The difference in ECW before and after dialysis (8.9+/-1.3 and 7.4+/-1.41, respectively) was significant (p = 0.001). The same did not hold true for ICW (13.3+/-1.4 and 13.1+/-1.41). Major underhydration (n = 9; VCD <6.5 mm/m2) revealed sharp limits for ICW/ECW (>1.80) and ECW/TBW (<0.35), whereas these BIA-variables were significantly (p<0.005) different from those in minor underhydration (n = 8; 6.6 < VCD <8.0 mm/m2), normohydration (n = 15; 8 <VCD <11.5 mm/m2) and overhydration (n = 7; VCD >11.5 mm/m2).

CONCLUSION

BIA can replace VCD only in major underhydration (VCD < 6.5 mm/m2). Fluid loss during hemodialysis is caused by a decrease of ECW, compatible with the postulation that excess fluid volume is carried by the extracellular compartment.

Treatment with recombinant granulocyte colony-stimulating factor (Filgrastin) stimulates neutrophils and tissue macrophages and induces an effective non-specific response against Mycobacterium avium in mice

A role of neutrophils in the host response against Mycobacterium avium (MAC) has recently been suggested. To investigate this matter further, we determined the effect of granulocyte colony-stimulating factor (G-CSF) on the outcome of MAC infection in mice. C57BL/6bg+/bg- black mice were intravenously infected with 1 x 10(7) MAC and then divided into four experimental groups to receive G-CSF as follows: (i) 10 micrograms/kg/day; (ii) 50 micrograms/kg/day; (iii) 100 micrograms/kg/day; (iv) placebo control. Mice were killed at 2 and 4 weeks of treatment to determine the bacterial load of liver and spleen. Treatment with G-CSF at both 10 and 50 micrograms/kg/day doses significantly decreased the number of viable bacteria in liver and spleen after 2 weeks (approximately 70.5% and 69.0%, respectively), and after 4 weeks (approximately 53% and 52%, respectively, P < 0.05 compared with placebo control). Treatment with 100 micrograms/kg/day did not result in decrease of bacterial colony-forming units in the liver and spleen after 4 weeks. Administration of G-CSF induced interleukin-10 (IL-10) and IL-12 production by splenocytes. To examine if the protective effect of G-CSF was accompanied by the activation of phagocytic cells, blood neutrophils and splenic macrophages were purified from mice receiving G-CSF and their ability to kill MAC was examined ex vivo. Neutrophils and macrophages from G-CSF-treated mice were able to inhibit the growth of or to kill MAC ex vivo, while phagocytic cells from untreated control mice had no anti-MAC effect. These results suggest that activation of neutrophils appears to induce an effective non-specific host defence against MAC, and further studies should aim for better understanding of the mechanisms of protection.

Expression of cytoskeletal proteins differentiates between progressors and non-progressors in treated idiopathic membranous nephropathy

Myofibroblasts play an important role in wound healing in a variety of tissue injuries. They have also been implicated in tissue fibrosis including renal scarring. This study was aimed at defining their role in one of the commonest forms of nephrotic syndrome in adults, namely membranous nephropathy. We have studied 21 patients with biopsy proven idiopathic membranous nephropathy who were treated with glucocorticoids, attempting to define the role of myofibroblasts (alpha-smooth muscle actin-positive as well as vimentin-positive cells) in the progression of this form of nephropathy. There were 13 non-progressors (NP) and 8 progressors (P). The clinical, histological, and immunohistochemical characteristics of both groups were compared. Immunohistochemical staining for myofibroblasts cytoplasmic markers a-smooth muscle actin (alpha-SMA) and vimentin relied on an avidin-biotin-peroxidase method. The level of blood pressure, degree of proteinuria, severity of interstitial infiltrate and interstitial fibrosis did not differentiate P from NP. However, vascular sclerosis was more severe in P compared to NP (p < 0.016) and its severity predicted the subsequent functional outcome (slope of the 1/serum creatinine against time; r2 = 0.618, p < 0.01). Mesangial alpha-SMA was significantly higher in P (31 +/- 18.6%) than in NP (14.5 +/- 9.8%), p < 0.015. Interstitial alpha-SMA immunostain was also higher in P but did not reach statistical significance. However, the number of interstitial myofibroblasts (alpha-SMA positive cells) closely predicted the subsequent rate of the progression of chronic renal failure (r2 = 0.919, p < 0.0001). Mesangial vimentin expression was not different between both groups. By contrast, interstitial vimentin immunostain was higher in P (19.1 +/- 8.8%) compared to NP (7.9+/-5.6 %), p < 0.002. These data suggest that the expression of mesangial and interstitial cytoskeletal proteins (alpha-SMA and vimentin) may have useful prognostic implications as they appear to differentiate between patients with membranous nephropathy who respond to immunosuppression and those who continue to progress.

Four-site skinfold anthropometry (FSA) versus body impedance analysis (BIA) in assessing nutritional status of patients on maintenance hemodialysis: which method is to be preferred in routine patient care?

BACKGROUND

Both four-site skinfold anthropometry (FSA) and bioelectrical impedance analysis (BIA) claim to be useful in routine clinical practice of maintenance dialysis as easy methods to assess nutritional status. The purpose of this study was to investigate which of these two methods is to be preferred.

METHODS

Both before and after dialysis nutritional and hydration status were evaluated by BIA in 20 stable hemodialysis patients. Variables of nutritional status as lean body mass (LBM) and body fat (BF) were assessed by four-site skinfold anthropometry (LBM-FSA and BF-FSA) and BIA (LBM-BIA and BF-BIA). Variables of hydration status were total body water (TBW), its distribution into intracellular and extracellular compartments (ICW and ECW, respectively) and ICW/ECW.

RESULTS

Weight loss during dialysis correlated with a change of LBM-FSA (r = 0.75, p <0.005) and also with that of LBM-BIA (r = 0.69, p < 0.005). To promote reliability of follow-up measurements in intervention studies it is warranted to evaluate nutritional status in an unchanged hydration status. The highly significant correlation (r = 0.93, p < 0.005) between the two techniques and the comparability between means and SD indicate that both techniques were almost equivalent to each other, although, compared to LBM-BIA, LBM-FSA was less affected by changes in fluid status. The sam held true for BF-BIA and BF-FSA. BF-FSA correlated significantly with BF-BIA (r = 0.65, p <0.005), whereas no difference of mean +/- SD was found between BF-FSA and BF-BIA.

CONCLUSION

FSA and BIA are almost comparable techniques to assess both LBM and BF, although FSA is less affected by changes in fluid status. However, assessing LBM in normohydration is mandatory. Compared with FSA, BIA is able to establish hydration status and lacks depency on operator interpretation. Therefore, in routine patient care the BIA technique is the one to be preferred.

Plasmalogens effectively reduce the surface tension of surfactant-like phospholipid mixtures

The alkenyl-acyl subclass of phosphatidylethanolamine (PtdEtn) and phosphatidylcholine (plasmalogens) are minor components of alveolar surfactant. Plasmalogens promote and stabilize hexagonal structures of phospholipids. In another study (W.R. Perkins, R.B. Dause, R.A. Parente, S.R. Michey, K.C. Neuman, S.M. Gruner, T.F. Taraschi, and A.S. Janoff. Science 273: 330-332, 1996), it was shown that polymorphic phase behavior may have an important role in the effective functioning of pulmonary surfactant. Therefore, we hypothesized that surface properties of phospholipid mixtures that contain plasmalogens are superior to plasmalogen-free mixtures. The effect of plasmalogens on surface tension of surfactant-like phospholipid mixtures (70 mol% dipalmitoyl phosphatidylcholine, 10 mol% phosphatidylglycerol, and 20 mol% PtdEtn) was measured. Using the pulsating bubble surfactometer, we show that an increasing amount of ethanolamine plasmalogens [plasmenylethanolamine (PlsEtn) results in reduction of surface tension (0 mol% PlsEtn 44.7 +/- 1.7, 2 mol% 33.5 +/- 1.7, 4 mol% 36 +/- 3.1, 6 mol% 26.2 +/- 2.9, and 8 mol% 22.2 +/- 0.3 mN/m). By means of the captive bubble surfactometer, minimal surface tension reached with 8 mol% PlsEtn was even lower (3.8 +/- 0.7 mN/m). With regard to morphological studies (B. Fringes, K. Gorgas, and A. Reith. Eur. J. Cell Biol. 46: 136-143, 1988), clofibrate treatment of rats might increase the plasmalogen content of alveolar surfactant. However, in the present study, we could not show that synthesis and secretion of plasmalogens are affected by clofibrate treatment.

Narrative case analysis of HIV infection in a battered woman

The narrative case analysis of HIV infection in a battered woman, taken from a qualitative study of women's experiences living with HIV/AIDS, conveys unusual insights into the context of violence that surrounded this woman's exposure to HIV. In her narrative, she describes the complex web of abuse she lived with day-to-day and the road she travels with AIDS as a result. Her abuse perpetrator infected her with HIV, and the whole atmosphere of violence, annihilation of self-worth, and oppressive restrictions likely contributed to the late-stage identification and treatment of her HIV-related disease. The discussion explores how domestic violence may place battered women at increased risk of becoming HIV infected. Clinical recommendations suggest that efforts to stop the battering of women and to prevent the spread of HIV in women must be combined to offer effective protection for women.

The experiences of lesbians of color in health care encounters

Abstract In this feminist narrative study, lesbians of color gave testimony to the effects of prejudice in face-to-face health care interactions. A major objective was to involve participants from a broad range of ethnic/racial backgrounds and socio-economic circumstances in open-ended interviews about their experiences receiving health care. Half of the 45 women in the sample were lesbians of color: 20% (9) African American, 18% (8) Latina, 11% (5) Asian/Pacific Islander, and 2% (1) Native American. Results suggest that if we wish to improve access to and quality of health services, those in the health care field must address race, class, gender, and sexual orientation prejudice in health care interactions, acknowledging the role discriminatory behavior plays in diminishing the availability of health care for lesbians of color.

A descriptive study of the handwashing environment in a long-term care facility

The authors present a clinical research project accomplished by a nurse during her first year of practice after graduating from a B.S.N. program. In her caregiving at a long-term care facility subacute unit, she was unable to do proper handwashing. The poorly placed pump-style paper towel dispensers were inadequate for the task. She knew that handwashing before and after resident contact is the single most effective infection control measure to prevent nosocomial infections. In consultation with her university professor, she designed and implemented a descriptive study of the facility's handwashing environment. She mapped and measured handwashing areas, explained constrictions the environment placed on handwashing technique, collected random cultures from the sinks and dispenser levers, and illustrated for administrative and auxiliary personnel the basic principles of microbiology. Implications for infection prevention and control in long-term care facilities are discussed in light of increased "high-end skilled nursing" being offered in subacute units.

Trauma of discovery: women's narratives of being informed they are HIV-infected

The purposes of this research report are to describe women's subjective experiences of being informed of a positive HIV antibody test and, from their point of view, to explain the meaning and impact of discovering that one is HIV-infected. In this qualitative narrative study, a racially diverse, low-income sample of 38 HIV-infected women shared their stories of HIV discovery during in-depth interviews. Findings of a multi-staged narrative analysis suggest that, for women like those in this study, the discovery of HIV seropositivity is a traumatic event, carrying with it elements that are common to other types of trauma: perceived threat to one's life and perceived responsibility for the deaths of others. Overarching personal meanings, or metaphors, framed these women's experiences of the trauma of HIV discovery. HIV discovery was an epiphany for 10% of the sample, a confirmation for 37%, and a calamity for 53%. Among their calamitous reactions were shock, fear, anguish, and suicidality. The impact of learning that they were HIV-infected often took its toll in unrelenting misery, escalated drug use, transmission risks, and destabilization of relationships, income, and shelter. Extensive excerpts from participants' interviews illustrate analytic findings. Implications for counselling and follow-up at diagnosis and early in the course of HIV illness are elaborated.

Pemberton pericapsular osteotomy to treat a dysplastic hip in cerebral palsy

We reviewed the results of Pemberton pericapsular osteotomy in nineteen hips (fifteen patients) that were subluxated (fifteen hips) or dislocated (two hips) or had severe acetabular dysplasia (two hips) secondary to spastic cerebral palsy. At least one concomitant procedure was performed in fifteen hips. These procedures included an intertrochanteric osteotomy to correct excessive femoral anteversion or valgus deformity of the neck-shaft angle (thirteen hips), a soft-tissue release (nine hips), and an open reduction (three hips). Four hips had no concomitant procedure. Five of the nineteen hips were painful preoperatively. The average age of the patients at the time of the index operation was seven years and nine months (range, three years and five months to twelve years and three months). The average duration of follow-up was ten years and nine months (range, three years and one month to nineteen years and nine months). All osteotomy sites healed without complications. At the latest follow-up examination, all of the hips were pain-free and satisfactorily reduced and none of the patients had deterioration in function. The average center-edge angle was -5 degrees (range, -45 to 18 degrees) preoperatively and 38 degrees (range, 17 to 53 degrees) at the latest follow-up examination. The average migration index of Reimers was 55 per cent (range, 30 to 100 per cent) preoperatively compared with 12 per cent (range, 0 to 46 per cent) at the latest follow-up examination. Sixteen of the nineteen hips were followed until closure of the triradiate cartilage. There were no instances of posterior uncovering or osteonecrosis of the femoral head or premature closure of the triradiate physeal cartilage leading to deficient acetabular coverage. Our results suggest that good clinical and radiographic results can be achieved with the Pemberton pericapsular osteotomy, with simultaneous intertrochanteric osteotomy and soft-tissue release when indicated, as treatment for subluxation or dislocation of the hip or acetabular dysplasia in cerebral palsy.

Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial

BACKGROUND

An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems.

METHODS

Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia.

RESULTS

Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula.

CONCLUSIONS

Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.

Detection of hydration status by total body bioelectrical impedance analysis (BIA) in patients on hemodialysis

The purpose of the present study was to investigate whether total body bioelectrical impedance analysis (BIA) could be appropriate to assess normohydration (i.e. dry weight) in hemodialysis patients. This study is warranted, because the simultaneous assessment of both hydration and nutritional status by BIA requires the presence of a situation of normohydration in order to guarantee valid conclusions about the nutritional analysis. Segmental bioelectrical impedance was performed to classify patients according to their hydration status. BIA measurements revealed significant differences in TBW, ECW and ICW/ECW between three hydration subgroups (under-, normo-, and overhydration), whereas ICW was similar. Therefore, TBW, ECW and ICW/ECW appear appropriate variables to assess hydration status in patients on hemodialysis. Hemodialysis diminished ECW significantly, whereas ICW did not change, suggesting that a decrease of ECW explains the fluid loss during hemodialysis.

The use of D-dimer testing and impedance plethysmographic examination in patients with clinical indications of deep vein thrombosis

OBJECTIVE

To prospectively test the hypothesis that a diagnosis of deep vein thrombosis can be excluded in outpatients who present with clinical indications of deep vein thrombosis and whose results of D-dimer testing and impedance plethysmographic examination on the day of presentation are normal.

DESIGN

Prospective cohort study.

SETTING

Four university-affiliated hospitals.

METHODS

Three hundred ninety-eight consecutive patients with clinical indications of deep vein thrombosis were included in the final analysis. All patients underwent an assessment of pretest probability, bedside D-dimer testing, and impedance plethysmographic examination. In most patients, if the results of D-dimer testing and impedance plethysmographic examination were negative for deep vein thrombosis, anticoagulants were withheld and patients were followed up for 3 months. If the results of one or both tests were abnormal, an examination using venous compression ultrasonography or phlebography was performed.

RESULTS

In the majority of patients (69%), the results of D-dimer testing and impedance plethysmographic examination were normal. This combination had a negative predictive value of 98.5% (95% confidence interval, 96.3-99.6) for deep vein thrombosis.

CONCLUSION

The results of the D-dimer assay and impedance plethysmographic examination on the day of presentation can be used to treat the majority of outpatients who present with clinical indications of deep vein thrombosis without further testing.

Quality of life in patients on chronic dialysis: self-assessment 3 months after the start of treatment. The Necosad Study Group

The aim of the present multicenter study was to assess quality of life of Dutch dialysis patients 3 months after the start of chronic dialysis treatment. The quality of life was compared with the quality of life of a general population sample, and the impact of demographic, clinical, renal function, and dialysis characteristics on patients' quality of life was studied. New end-stage renal disease (ESRD) patients who were started on chronic hemodialysis or peritoneal dialysis in 13 dialysis centers in The Netherlands were consecutively included. Patients' self-assessment of quality of life was measured by the SF-36, a 36-item Short Form Health Survey Questionnaire encompassing eight dimensions: physical functioning, social functioning, role-functioning physical, role-functioning emotional, mental health, vitality, bodily pain, and general health perceptions. One hundred twenty hemodialysis and 106 peritoneal dialysis patients completed the SF-36. Quality of life of hemodialysis and peritoneal dialysis patients was substantially impaired in comparison to the general population sample, particularly with respect to role-functioning physical and general health perceptions. Mean role-functioning physical and general health perceptions scores of the hemodialysis patients corresponded with the lowest scoring 8% and 12%, respectively, of the reference group. Mean role-functioning physical and general health perceptions scores of the peritoneal dialysis patients corresponded with the lowest scoring 10% and 12%, respectively, of the reference group. Hemodialysis patients showed lower levels of quality of life than peritoneal dialysis patients on physical functioning, role-functioning emotional, mental health, and pain. However, on the multivariate level, we could only demonstrate an impact of dialysis modality on mental health. A higher number of comorbid conditions, a lower hemoglobin level, and a lower residual renal function were independently related to poorer quality of life. The variability of the SF-36 scores explained by selected demographic, clinical, renal function, and dialysis characteristics was highest for physical functioning (29.7%). Explained variability of the other SF-36 dimensions ranged from 6.9% for general health perceptions to 15.4% for vitality. We conclude that quality of life of new ESRD patients is substantially impaired. Comorbid conditions, hemoglobin, and residual renal function could explain poor quality of life only to a limited extent. Further research exploring determinants and indices of quality of life in ESRD patients is warranted. From a clinical perspective, we may conclude that quality of life should be considered in the monitoring of dialysis patients.

Accelerated neutrophil apoptosis in the acquired immunodeficiency syndrome

Neutrophil (PMNL) function defects occur as a consequence of HIV infection. This study examined PMNL apoptosis in patients with the acquired immunodeficiency syndrome (AIDS) to determine if accelerated apoptosis contributes to impaired function. PMNL were isolated from 10 HIV-infected patients with CD4+ lymphocyte counts < 200/mm3 without signs of active infection and 7 healthy volunteers. PMNL were stained with acridine orange and ethidium bromide after 0, 3, 6, and 18 h in culture, and examined for the morphologic changes of apoptosis and viability by fluorescent microscopy. Apoptosis was also demonstrated by electron microscopy, flow cytometry, and DNA gel electrophoresis. Apoptosis was minimal at 0 h, but PMNL from AIDS patients exhibited significantly greater apoptosis than controls at 3 h (22.5+/-11.5 vs. 8.9+/-6.9%, P = 0.015), 6 h (38.1+/-14.2 vs. 18.1+/-4.5%, P = 0.003), and 18 h (71.3+/-19.0 vs. 38.8+/-16.7%, P = 0.002). Viabilities were > or = 88.0% for both groups from 0-6 h, but by 18 h viability was significantly decreased for the HIV group (58.8+/-12.4 vs. 83.5+/-10.4%, P = 0.001) due to an increase in non-viable apoptotic cells. Incubation with serum from AIDS patients had no effect on control PMNL, and incubation with control serum did not reduce the rate of apoptosis of PMNL from AIDS patients. Incubation with granulocyte colony-stimulating factor (G-CSF) in vitro significantly decreased apoptosis for PMNL from AIDS patients. PMNL from patients with AIDS exhibit markedly accelerated apoptosis ex vivo. In vivo, apoptosis and functional impairment of PMNL may contribute to the risk of secondary infections, and cytokine therapy may be of potential clinical benefit in this circumstance.

Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula

BACKGROUND

Conventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications.

METHODS

All patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival.

RESULTS

Fifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (+/- SD) improved from 2.6 (0.7) to 1.1 (1.2) (p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent).

CONCLUSIONS

The authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed.

Clinical implications of endoscopic ultrasound: the American Endosonography Club Study

BACKGROUND

Despite increased clinical use of endoscopic ultrasound (EUS), there are little data regarding complications of EUS or its impact on patient management.

METHODS

A prospective multicenter study was completed to evaluate clinical outcomes of EUS. Before each EUS examination the endosonographer recorded further theoretical patient management plans as if EUS was unavailable. After the EUS, endosonographers recorded actual management plans based on EUS results. The actual management plan after EUS was compared to the theoretical management before EUS. Complications were assessed in short-term follow-up.

RESULTS

Four hundred twenty-eight subjects were enrolled. Of subjects able to be evaluated, EUS changed the treatment plan in 74%. Management changes of major importance occurred in 120 patients (31% of subjects able to be evaluated) and included decisions regarding surgery (62 patients), decisions regarding nonsurgical invasive management (36 patients), and decisions regarding further follow-up (22 patients). When there was a change in management, the change was to less costly, risky, or invasive management in 55%, to more costly/risky/invasive in 37%, and to equally costly/risky/invasive in 8%. Short-term follow-up was completed in 81% of subjects, with six complications identified (1.7%). Three complications were mild, two were moderate, one severe, and none fatal.

CONCLUSIONS

(1) Changes in management plan may occur in the majority of patients based on EUS results. (2) The management changes are often of major importance with regard to health care costs and safety, and are more often in the direction of less costly, risky, and invasive management. (3) EUS is safe in experienced hands.

An occupational transmission of HIV: collision of ethical worlds in nursing practice

This article proposes a new theoretical frame for ethical practice in nursing by locating ethical questions within the worlds of everyday nursing experience. The authors advocate a process of ethical thought and action that is not so much a weighing of dichotomized alternatives as a continual journey in which nurses delve deeper into their examination of clinical contexts, structural contingencies, and the meanings of experience for themselves and their clients. This theoretical vision is illustrated with a case study about a nurse who was infected with HIV on the job. The purposes in presenting the case study are to give testament to this brave woman's story, illustrate the dynamics of a contextualized ethics, and challenge nurses to make changes in practice, policy, and structure to foster truly ethical work and relations with others.

Struggles with symptoms: women's narratives of managing HIV illness

The purpose of this research report is to derive a holistic view of the symptom experiences of women living with HIV/AIDS. A racially diverse sample of 38 HIV-infected women participated in in-depth narrative interviews describing their perceptions, evaluations, and responses related to HIV symptoms. Findings suggest a pattern to their struggles with symptoms: They experienced an accumulation of overwhelming symptoms, grew intensely fearful of these symptoms and what it meant to have HIV, and acted to protect themselves from allowing the HIV to "take hold". Many women perceived health care contact and cooperation with prescribed regimens as avenues for HIV to "take over" their lives, so they avoided these actions. Exemplar narratives illustrate analytic findings.