A case of extraovarian primary peritoneal carcinoma in an oophorectomized-hysterectomized patient: a diagnostic dilemma

Extra Ovarian Primary Peritoneal Carcinoma (EOPPC) is a rare type of adenocarcinoma of the pelvic and abdominal peritoneum. The objective examination and the histological aspect of the neoplasia virtually overlaps with that of ovarian carcinoma. The reported case is that of a 72 year-old patient who had undergone a total hysterectomy with bilateral annessiectomy surgery 20 years earlier subsequently to a diagnosis for uterine leiomyomatosis. The patient came to our attention presenting recurring abdominal pain, constipation, weight loss, severe asthenia and fever. Her blood test results showed hypochromic microcytic anemia and a remarkable increase CA125 marker levels. Instrumental diagnostics with Ultrasound (US) and CT scans indicated the presence of a single peritoneal mass (10-12 cm diameter) close to the great epiploon. The patient was operated through a midline abdominal incision and the mass was removed with the great omentum. No primary tumor was found anywhere else in the abdomen and in the pelvis. The operation lasted approximately 50 minutes. The post-operative course was normal and the patient was discharged four days later. The histological exam of the neoplasia, supported by immunohistochemical analysis, showed a significant positivity for CA 125, vimentin and cytocheratin, presence of psammoma bodies, and cytoarchitectural pattern resembling that of a serous ovarian carcinoma even in absence of primitiveness, leading to a final diagnosis of EOPPC. The patient later underwent six cycles of chemotherapy with paclitaxel (135 mg/m2/24 hr) in association with cisplatin (75mg/m2). At the fourth year follow-up no sign of relapse was observed. .

Inclusion as a Moral Challenge: the Potential of the Konstanz Method of Dilemma Discussion® (KMDD®)

This article presents the Konstanz Method of Dilemma Discussion ® (KMDD ®) and explains the integration of the KMDD ® in ethics lessons. In this paper, some special learning effects of this inclusive teaching and learning method are shown. Furthermore, it investigates the questions of how to achieve more knowledge in ethics lessons by dialogue and how to realize better moral development, particularly by handling of differentiation. Moral education of all participants who are involved in the learning process (learners and teacher alike) is a crucial task of every true inclusion. True inclusion means building optimal learning conditions in keeping with the free will of all participants. Because our society is transforming constantly in both global and demographic aspects, coping with these challenges is mandatory.

HIV Disclosure: Parental dilemma in informing HIV infected Children about their HIV Status in Malawi

Background Increasingly many perinatally HIV-infected children are surviving through adolescence and adulthood as a result of improvements in the management of paediatric HIV infection, particularly the increased use of combination therapy. It is usually the parents or guardians of these children who are faced with the task of informing the child living with HIV about his or her positive status. However, many parents—particularly biological parents —find this disclosure process difficult to initiate, and this study explored some of the difficulties that these parents encounter. Objective This study set out to explore potential factors that challenge parents and guardians when informing their perinatally HIV-infected child about the child’s HIV status. Design This was a qualitative narrative study that employed in-depth interviews with parents or guardians of children perinatally infected with HIV. A total of 20 parents and guardians of children who attend the outpatient HIV clinic at the Baylor College of Medicine-Abbott Fund Children’s Clinical Centre of Excellence (COE) in Lilongwe, Malawi were interviewed. Of these, 14 were biological parents and six were guardians. Results Guardians and parents expressed uneasiness and apprehension with the disclosure conversation, whether or not they had already told their child that he or she had HIV. Participants who had not told their children recounted that they had contemplated starting the conversation but could not gather enough courage to follow through with those thoughts. They cited the fear of robbing their child of the happiness of living without the knowledge of being positive, fear of making their own status known to more people, and fear of confrontation or creating enmity with their child as impediments to disclosing their child’s positive HIV status to him or her. Conclusions It is apparent that guardians—more particularly biological parents—of children perinatally infected by HIV find it difficult to inform their children about their children’s HIV status. From this disempowered position, parents dread the disclosure of a positive HIV status to a child as a psychosocial process that has the potential to disturb a family’s previously established equilibrium with threats of stigmatization, marginalization, and parent-child conflict. This calls for strategies that could support parents to make disclosure to the child less challenging.

Defining reference service life : an open innovation approach

The endeavour to obtain estimates of durability of components for use in lifecycle assessment or costing and infrastructure and maintenance planning systems is large. The factor method and the reference service life concept provide a very valuable structure, but do not resolve the central dilemma of the need to derive an extensive database of service life. Traditional methods of estimating service life, such as dose functions or degradation models, can play a role in developing this database, however the scale of the problem clearly indicates that individual dose functions cannot be derived for each component in each different local and geographic setting. Thus, a wider range of techniques is required in order to devise reference service life. This paper outlines the approaches being taken in the Cooperative Research Centre for Construction Innovation project to predict reference service life. Approaches include the development of fundamental degradation and microclimate models, the development of a situation-based reasoning ‘engine’ to vary the ‘estimator’ of service life, and the development of a database on expert performance (Delphi study). These methods should be viewed as complementary rather than as discrete alternatives. As discussed in the paper, the situation-based reasoning approach in fact has the possibility of encompassing all other methods.

Vision, functional and cognitive determinants of motor vehicle incidents in older drivers

Background: The proportion of older individuals in the driving population is predicted to increase in the next 50 years. This has important implications for driving safety as abilities which are important for safe driving, such as vision (which accounts for the majority of the sensory input required for driving), processing ability and cognition have been shown to decline with age. The current methods employed for screening older drivers upon re-licensure are also vision based. This study, which investigated social, behavioural and professional aspects involved with older drivers, aimed to determine: (i) if the current visual standards in place for testing upon re-licensure are effective in reducing the older driver fatality rate in Australia; (ii) if the recommended visual standards are actually implemented as part of the testing procedures by Australian optometrists; and (iii) if there are other non-standardised tests which may be better at predicting the on-road incident-risk (including near misses and minor incidents) in older drivers than those tests recommended in the standards. Methods: For the first phase of the study, state-based age- and gender-stratified numbers of older driver fatalities for 2000-2003 were obtained from the Australian Transportation Safety Bureau database. Poisson regression analyses of fatality rates were considered by renewal frequency and jurisdiction (as separate models), adjusting for possible confounding variables of age, gender and year. For the second phase, all practising optometrists in Australia were surveyed on the vision tests they conduct in consultations relating to driving and their knowledge of vision requirements for older drivers. Finally, for the third phase of the study to investigate determinants of on-road incident risk, a stratified random sample of 600 Brisbane residents aged 60 years and were selected and invited to participate using an introductory letter explaining the project requirements. In order to capture the number and type of road incidents which occurred for each participant over 12 months (including near misses and minor incidents), an important component of the prospective research study was the development and validation of a driving diary. The diary was a tool in which incidents that occurred could be logged at that time (or very close in time to which they occurred) and thus, in comparison with relying on participant memory over time, recall bias of incident occurrence was minimised. Association between all visual tests, cognition and scores obtained for non-standard functional tests with retrospective and prospective incident occurrence was investigated. Results: In the first phase,rivers aged 60-69 years had a 33% lower fatality risk (Rate Ratio [RR] = 0.75, 95% CI 0.32-1.77) in states with vision testing upon re-licensure compared with states with no vision testing upon re-licensure, however, because the CIs are wide, crossing 1.00, this result should be regarded with caution. However, overall fatality rates and fatality rates for those aged 70 years and older (RR=1.17, CI 0.64-2.13) did not differ between states with and without license renewal procedures, indicating no apparent benefit in vision testing legislation. For the second phase of the study, nearly all optometrists measured visual acuity (VA) as part of a vision assessment for re-licensing, however, 20% of optometrists did not perform any visual field (VF) testing and only 20% routinely performed automated VF on older drivers, despite the standards for licensing advocating automated VF as part of the vision standard. This demonstrates the need for more effective communication between the policy makers and those responsible for carrying out the standards. It may also indicate that the overall higher driver fatality rate in jurisdictions with vision testing requirements is resultant as the tests recommended by the standards are only partially being conducted by optometrists. Hence a standardised protocol for the screening of older drivers for re-licensure across the nation must be established. The opinions of Australian optometrists with regard to the responsibility of reporting older drivers who fail to meet the licensing standards highlighted the conflict between maintaining patient confidentiality or upholding public safety. Mandatory reporting requirements of those drivers who fail to reach the standards necessary for driving would minimise potential conflict between the patient and their practitioner, and help maintain patient trust and goodwill. The final phase of the PhD program investigated the efficacy of vision, functional and cognitive tests to discriminate between at-risk and safe older drivers. Nearly 80% of the participants experienced an incident of some form over the prospective 12 months, with the total incident rate being 4.65/10 000 km. Sixty-three percent reported having a near miss and 28% had a minor incident. The results from the prospective diary study indicate that the current vision screening tests (VA and VF) used for re-licensure do not accurately predict older drivers who are at increased odds of having an on-road incident. However, the variation in visual measurements of the cohort was narrow, also affecting the results seen with the visual functon questionnaires. Hence a larger cohort with greater variability should be considered for a future study. A slightly lower cognitive level (as measured with the Mini-Mental State Examination [MMSE]) did show an association with incident involvement as did slower reaction time (RT), however the Useful-Field-of-View (UFOV) provided the most compelling results of the study. Cut-off values of UFOV processing (>23.3ms), divided attention (>113ms), selective attention (>258ms) and overall score (moderate/ high/ very high risk) were effective in determining older drivers at increased odds of having any on-road incident and the occurrence of minor incidents. Discussion: The results have shown that for the 60-69 year age-group, there is a potential benefit in testing vision upon licence renewal. However, overall fatality rates and fatality rates for those aged 70 years and older indicated no benefit in vision testing legislation and suggests a need for inclusion of screening tests which better predict on-road incidents. Although VA is routinely performed by Australian optometrists on older drivers renewing their licence, VF is not. Therefore there is a need for a protocol to be developed and administered which would result in standardised methods conducted throughout the nation for the screening of older drivers upon re-licensure. Communication between the community, policy makers and those conducting the protocol should be maximised. By implementing a standardised screening protocol which incorporates a level of mandatory reporting by the practitioner, the ethical dilemma of breaching patient confidentiality would also be resolved. The tests which should be included in this screening protocol, however, cannot solely be ones which have been implemented in the past. In this investigation, RT, MMSE and UFOV were shown to be better determinants of on-road incidents in older drivers than VA and VF, however, as previously mentioned, there was a lack of variability in visual status within the cohort. Nevertheless, it is the recommendation from this investigation, that subject to appropriate sensitivity and specificity being demonstrated in the future using a cohort with wider variation in vision, functional performance and cognition, these tests of cognition and information processing should be added to the current protocol for the screening of older drivers which may be conducted at licensing centres across the nation.

Introduction

The title of this book, Hard Lesson: Reflections on Crime control in Late Modernity, contains a number of clues about its general theoretical direction. It is a book concerned, fist and foremost, with the vagaries of crime control in western neo-liberal and English speaking countries. More specifically, Hard Lessons draws attention to a number of examples in which discrete populations – those who have in one way or another offended against the criminal law - have become the subjects of various forms of stare intervention, regulation and control. We are concerned most of all with the ways in which recent criminal justice policies and practices have resulted in what are variously described as unintended consequences, unforeseen outcomes, unanticipated results, counter-productive effects or negative side effects. At their simplest, such terms refer to the apparent gulf between intention and outcome; they often form the basis for considerable amount of policy reappraisal, soul searching and even nihilistic despair among the mamandirns of crime control. Unintended consequences can, of course, be both positive and negative. Occasionally, crime control measures may result in beneficial outcomes, such as the use of DNA to acquit wrongly convicted prisoners. Generally, however, unforeseen effects tend to be negative and even entirely counterproductive, and/or directly opposite to what were originally intended. All this, of course, presupposes some sort of rational, well meaning and transparent policy making process so beloved by liberal social policy theorists. Yet, as Judith Bessant points out in her chapter, this view of policy formulation tends to obscure the often covert, regulatory and downright malevolent intentions contained in many government policies and practices. Indeed, history is replete with examples of governments seeking to mask their real aims from a prying public eye. Denials and various sorts of ‘techniques of neutralisation’ serve to cloak the real or ‘underlying’ aims of the powerful (Cohen 2000). The latest crop of ‘spin doctors’ and ‘official spokespersons’ has ensured that the process of governmental obfuscation, distortion and concealment remains deeply embedded in neo-liberal forms of governance. There is little new or surprising in this; nor should we be shocked when things ‘go wrong’ in the domain of crime control since many unintended consequences are, more often than not, quite predictable. Prison riots, high rates of recidivism and breaches of supervision orders, expansion rather than contraction of control systems, laws that create the opposite of what was intended – all these are normative features of western crime control. Indeed, without the deep fault lines running between policy and outcome it would be hard to imagine what many policy makers, administrators and practitioners would do: their day to day work practices and (and incomes) are directly dependent upon emergent ‘service delivery’ problems. Despite recurrent howls of official anguish and occasional despondency it is apparent that those involved in the propping up the apparatus of crime control have a vested interest in ensuring that polices and practices remain in an enduring state of review and reform.

Mixing colours: An ICT tool based on a semiotic framework for mathematical meaning-makng about ratio and fractions

This paper reports on the research and development of an ICT tool to facilitate the learning of ratio and fractions by adult prisoners. The design of the ICT tool was informed by a semiotic framework for mathematical meaning-making. The ICT tool thus employed multiple semiotic resources including topological, typological, and social-actional resources. The results showed that individual semiotic resource could only represent part of the mathematical concept, while at the same time it might signify something else to create a misconception. When multiple semiotic resources were utilised the mathematical ideas could be better learnt.

Learning to program : from pear-shaped to pairs

The consistently high failure rate in Queensland University of Technology’s introductory programming subject reflects a similar dilemma facing other universities worldwide. Experiments were conducted to quantify the effectiveness of collaborative learning on introductory level programming students over a number of semesters, replicating previous studies in this area. A selection of workshops in the introductory programming subject required students to problem-solve and program in pairs, mimicking the eXtreme Programming concept of pair programming. The failure rate for the subject fell from what had been an average of 30% since 2003 (with a high of 41% in 2006), to just 5% for those students who worked consistently in pairs.

Mixing colours : an ICT tool based on a semiotic framework for mathematical meaning-making about ratio and fractions

This paper reports on the research and development of an ICT tool to facilitate the learning of ratio and fractions by adult prisoners. The design of the ICT tool was informed by a semiotic framework for mathematical meaning-making. The ICT tool thus employed multiple semiotic resources including topological, typological, and social-actional resources. The results showed that individual semiotic resource could only represent part of the mathematical concept, while at the same time it might signify something else to create a misconception. When multiple semiotic resources were utilised the mathematical ideas could be better learnt.

Development and use of clinical guidelines

The purpose of this chapter is to provide an overview of the development and use of clinical guidelines as a tool for decision making in clinical practice. Nurses have always developed and used tools to guide clinical decision making related to interventions in practice. Since Florence Nightingale (Nightingale 1860) gave us ‘notes’ on nursing in the late 1800s, nurses have continued to use tools, such as standards, policies and procedures, protocols, algorithms, clinical pathways and clinical guidelines, to assist them in making appropriate decisions about patient care that eventuate in the best desired patient outcomes. Clinical guidelines have enjoyed growing popularity as a comprehensive tool for synthesising clinical evidence and information into user-friendly recommendations for practice. Historically, clinical guidelines were developed by individual experts or groups of experts by consensus, with no transparent process for the user to determine the validity and reliability of the recommendations. The acceptance of the evidence-based practice (EBP) movement as a paradigm for clinical decision making underscores the imperative for clinical guidelines to be systematically developed and based on the best available research evidence. Clinicians are faced with the dilemma of choosing from an abundance of guidelines of variable quality, or developing new guidelines. Where do you start? How do you find an existing guideline to fit your practice? How do you know if a guideline is evidence-based, valid and reliable? Should you apply an existing guideline in your practice or develop a new guideline? How do you get clinicians to use the guidelines? How do you know if using the guideline will make any difference in care delivery or patient outcomes? Whatever the choice, the challenge lies in choosing or developing a clinical guideline that is credible as a decision-making tool for the delivery of quality, efficient and effective care. This chapter will address the posed questions through an exploration of the ins and outs of clinical guidelines, from development to application to evaluation.

Indig-curious : what are the challenges for non Aboriginal theatre practitioners in accessing and interpreting Aboriginal themes?

How do non-Indigenous theatre practitioners, especially actors, access and incorporate Aboriginal themes in the plays they create or perform in? Will it ever be acceptable for a non-Aboriginal actor to play an Aboriginal role? In literature there are clear protocols for writing Aboriginal characters and themes. In the visual arts and in dance, non-Indigenous practitioners might 'reference' Aboriginal themes, but what about in theatre performance? This research embodies one cultural dilemma in a creative project and exegesis: exploring the complex issues which emerge when an Aboriginal playwright is commissioned to write an 'Aboriginal themed' play for two non-Aboriginal actors.

The meaning of cancer for Australian Aboriginal women : changing the focus of cancer nursing

Aim: The purpose of the study was to explore why Aboriginal women participate in cancer screening programs but appear reluctant to following-up results, or accept medical advice about treatment. Methods: Interpretive ethnography, a qualitative methodology, was used to explore Aboriginal women’s perception of cancer, and the cultural context in which meaning was constructed and influenced treatment decision. Data collection, which occurred over two years, involved fieldwork, participant-observation, face-to-face interviews and focus groups, in two rural Aboriginal communities. Forty eight interviews were recorded from a cross section of the communities, including cancer survivors and patients, family members, health care providers and other women from the community. Results: Key findings were that Aboriginal women’s had a fearful and fatalistic attitude toward cancer, doubted the efficacy of treatment and carried an enduring ambivalence toward the authority of whiteman’s medicine. The women faced a dilemma of wanting access to cancer treatment options but feared entering hospital or clinics not attuned to their cultural needs. Conclusion: The findings highlight the need for a culture-centred approach that decentres the authority of conventional services and instead gives prominence to Aboriginal cultural values as a focal point in cancer control. It should be the responsibility of cancer nurses and others to engage with their local Aboriginal communities to build relationships that foster an exchange of learning about cultural differences that make a difference to how cancer control is practiced.

Digitualisation

The artwork was created to respond to the exhibition theme, "DIGILOG+IN". It aimed to express the beauty when digital and analogue materials are combined. It visualised an organic harmony between digital and natural objects through digitalisation and builded a fantasy of digital world. However, there was a conceptual dilemma that a “digitalisation” of natural objects into a digital format should merely become a digital work. In other words, a harmony between digital and analogue (natural) can be only achieved through a digitalising process by removing intrinsic nature of analogues. Therefore, the substance of analogues no longer exists in a digitally visualised form, but is virtually represented. The title of art work “digitualisation” is a combined word with “digi-tal” and vir-tualisation”. It refers to a digitally virtualising the substance of natural objects. The artwork visualised the concept of digitualisation by using natural objects (flowers) that are merged within a virtual space (a building entrance foyer).

Alternative systems for Intellectual Property in the digital age

This paper investigates the current turbulent state of copyright in the digital age, and explores the viability of alternative compensation systems that aim to achieve the same goals with fewer negative consequences for consumers and artists. To sustain existing business models associated with creative content, increased recourse to DRM (Digital Rights Management) technologies, designed to restrict access to and usage of digital content, is well underway. Considerable technical challenges associated with DRM systems necessitate increasingly aggressive recourse to the law. A number of controversial aspects of copyright enforcement are discussed and contrasted with those inherent in levy based compensation systems. Lateral exploration of the copyright dilemma may help prevent some undesirable societal impacts, but with powerful coalitions of creative, consumer electronics and information technology industries having enormous vested interest in current models, alternative schemes are frequently treated dismissively. This paper focuses on consideration of alternative models that better suit the digital era whilst achieving a more even balance in the copyright bargain.

Engineering curricula in the 21st century : the global scenario and challenges for India

In the 21st century's global economy, the new challenges facing the engineering profession have arrived, confirming the need to restructure engineering curricula, teaching and learning practices, and processes, including assessment. Possessing merely technical knowledge no longer guarantees an engineering graduate a successful career. And while all countries are facing this dilemma, India is struggling the most. It has been argued that most Indian engineering educational institutions struggle with the systemic problem of centralisation coupled with an archaic examination system that is detrimental to student learning. This article examines some internationally renowned educational institutions that are embracing the growing importance of non-technical subjects and soft skills in 21st century engineering curricula. It will then examine the problems that India faces in doing the same.