Ongoing Dilemmas Research Articles

The Challenge and Complexities of Physical Abuse

The Challenge and Complexities of Physical Abuse

Dilemmas in treating smoldering multiple myeloma.

Novel therapies hold promise for high-risk smoldering multiple myeloma (SMM). Recent studies suggest that modern combination approaches can be options for high-risk SMM to obtain deep molecular responses with favorable toxicity profiles. Although pioneering treatment trials based on small numbers of patients suggest progression-free and overall survival benefits, application of the data to real-life practice remains to be validated. Therapeutic modulation of disease tempo, disease burden, clonal evolution, and tumor microenvironment in SMM remains to be understood and calls for reliable biomarkers reflective of disease biology. Here, we review studies that open a new management platform for SMM, address ongoing dilemmas in practice and under investigation, and highlight emerging scientific questions in the era of SMM treatment.

Simulation-based constructivist approach for education leaders

The purpose of this study was to reflect the leadership strategies that may arise using a constructivist approach based on organizational learning. This approach involved the use of simulations that focused on ethical tensions in school principals’ daily experiences, and the development of codes of ethical conduct to reduce these tensions. The study included 50 teachers who served in school leadership roles in addition to their regular teaching jobs. The teachers participated in 50 simulation sessions. The data were analyzed with ATLAS.ti 5.0. Five dimensions of tensions between leadership strategies were found to be related to the central concept of “Leadership strategies derived from simulations:” Engaging versus Monitoring; Envisioning versus Implementing; Implementing versus Engaging; Monitoring versus Envisioning, and Articulating versus Envisioning—demonstrating the complexity of dialogue during the simulations, which include a multifaceted model of tension between values, and codes of ethical conduct. The study findings may encourage school principals and education leaders to use simulations to help unravel ongoing ethical dilemmas in school for the development of leadership strategies based on organizational and constructivist learning theories. These learning conditions may provide fertile ground for practicing difficult ethical decision-making and thus enhance the professional development of education leaders.

From Morality to Equality: Laborr's Sexuality Conundrum

This paper analyses Australian federal Labor governments' changing policies on same-sex issues, with a particular focus on the period from the Whitlam government on. It traces how policy conceptions changed as Labor governments moved beyond arguments about sexual morality and criminality to engage with arguments about equality. In the process, Labor reforms that removed discrimination against gays and lesbians increasingly challenged heteronormative conceptions of citizenship rights and entitlements that had their origins in older citizenship models based around a male-breadwinner/head of (a heterosexual) family. However, pursuing same-sex equality issues remained contentious for some Labor politicians who argued that same-sex rights were actually an 'elite' issue that alienated traditional Labor voters. Indeed, the granting of a conscience vote on same-sex marriage reflects those ongoing tensions and dilemmas, including the continuing influence of earlier views that same-sex issues are a morality issue rather than an equality issue.

Dialogues from the ‘Coalface’:DSM‐5 and Emotional Process in a Clinical Setting

In this article, we propose that emotional reactivity can influence dialogue around theDiagnostic and Statistical Manual of Mental Disorders(DSM‐5) and the wider issues included in the debate. We explore this emotional process and the impact that it has on our clinical practice, our clients’ experiences, our experience of ourselves as clinicians and the ways we work with other professionals. We begin by presenting clinical scenarios, then briefly summarise key ideas from theDSM‐5 debate, and draw on Bowen Family Systems Theory to explore a number of ways that emotional reactivity to these ideas can manifest itself in multidisciplinary and collegial relationships. We conclude that it is helpful to increase awareness of our own emotional processes to best avoid becoming reactive to, or dismissive of, alternative paradigms or knowledge bases that may be of use to our clients. We describe a number of principles and ideas that we have found useful in this context and identify ongoing dilemmas in our practice.

Trust and accountability in Ireland: the case of An Garda Síochána

Fieldwork and interviews gathered over more than two years with members of the Garda, the Garda Inspectorate, and scholars of policing in Ireland, are used to assess the nature of accountability of the An Garda Síochána. Beginning with an overview of police accountability, the paper advances a perspective integrating the historical, emotional and symbolic aspects of police legitimacy and the extant mandate. While the Garda are well respected by the public, they demonstrate the power of politics, sentiments, emotions and memory in shaping this level of police trust and accountability. This is suggested by an analysis of the origins of the An Garda Síochána, their current status, their on-going dilemmas and their current resilience. It is argued that the Garda are sacred and viewed as legitimate as a result of their connections to the origin of the state. This fact insulates them from swings in public opinion even in the face of scandal. Their obligations to central government and a tight connection to national security insulate them from direct accountability to the public. As a result, efforts to produce accountability via case law, complaints systems and external assessments have had thus far only modest impact on the structure and function of the Garda.

Conceptualising creativity in the creative arts: Seeking common ground

This paper reports on a research study that investigated how university academics in the creative arts conceptualise creativity, both as a general concept and also as a set of situated disciplinary beliefs and practices. The study, located primarily in the UK and Australia, reveals that the problems of defining and articulating creativity lead to a series of ongoing dilemmas for teaching and assessment in the creative arts. These dilemmas include the ability to explain and foster the creative endeavour with students; to provide transparency to students about expectations and standards; and to make demonstrably fair and reliable judgements about student work in a relatively subjective domain. It argues that if tertiary-level teachers are to devise creative curricula, facilitate creative environments and make judgements about the quality of creative work, they need to both share an understanding about the creative endeavour and the ability to communicate this to students effectively.

Career learning and development: a social constructivist model for the twenty-first century

In the UK there have been several calls for new models ‘fit for purpose’ for careers work in the twenty-first century and in response, this article presents a model for career learning and development. This brings together recent theory regarding the ways in which people make career decisions throughout their lives in rapidly changing, turbulent labour markets and globalised economies. The model is articulated through the metaphor of a suspension bridge, which is used to explore and explain the ongoing dilemmas experienced by career practitioners and their clients as they seek to balance the opposing tensions that enable the bridge to fulfil its vital functions.

Multivessel Coronary Artery Spasm

Coronary spasm is increasingly recognised as an important aetiological mechanism causing myocardial ischaemia. Occasionally cases present with evidence of ST segment elevation myocardial infarction, usually secondary to spasm confined to a solitary coronary artery. We present the rare and life-threatening case of severe coronary spasm afflicting all three major epicardial arteries simultaneously. It describes the difficult emergency scenario and ongoing management dilemmas encountered by physicians confronted with multivessel coronary spasm. Moreover we discuss the malignant prognosis associated with this ailment and describe the potential insights provided by cardiac magnetic resonance imaging that might identify those at greatest risk after the index event.

Challenges in the Diagnosis of the Antiphospholipid Syndrome

The antiphospholipid syndrome (APS) is an important cause of acquired thromboembolic complications and pregnancy morbidity. Its diagnosis is based on clinical and laboratory criteria, defined by strict guidelines. The original clinical and laboratory criteria for the identification of APS patients were published in 1999, in the so-called Sapporo criteria. In 2006 these criteria were revised, and recently more precise guidelines for analysis of the lupus anticoagulant have been provided. However, several questions related to the diagnosis of APS remain unanswered. In addition to providing a historical perspective, this review covers several challenges in the diagnosis of APS with respect to clinical and laboratory features, while highlighting pathogenic pathways of the syndrome. We discuss ongoing dilemmas in the diagnosis of this complex disease. Although antiphospholipid antibodies are found in association with various clinical manifestations, the older established clinical criteria were not substantively altered in the 2006 update. Several laboratory tests recommended in the latest criteria, including phospholipid-dependent coagulation tests for the detection of the lupus anticoagulant and ELISAs for measuring anticardiolipin and beta2-glycoprotein I antibodies, still show methodological and diagnostic shortcomings. In addition, antiphospholipid antibodies have been described against other antigens, but their clinical role remains uncertain. Despite updated APS criteria, diagnosis of this syndrome remains challenging. Further research on clinically relevant antibodies and standardization of their detection are needed to improve clinical risk assessment in APS.

The antiphospholipid syndrome: a large elephant with many parts or an elusive chameleon disguised by many colours?

The antiphospholipid syndrome (APS) is characterized by a range of clinical features (primarily thrombosis and/or obstetric-related), together with the presence of antiphospholipid antibody (aPL) as detected by a diverse range of laboratory tests. APS remains a significant diagnostic and management challenge for clinicians across a wide range of specialties, some 30 years after APS was first described as a discrete clinical entity. This is due to ongoing issues regarding nomenclature, the diagnosis of APS in individual patients, the expanding range of recognized clinical manifestations and of APS-related laboratory tests, and management issues in particular APS patient subgroups (including obstetric and catastrophic APS). In addition to the presence of appropriate clinical features, the diagnosis of APS fundamentally requires the finding of positive aPL test result(s), which is hampered by ongoing problems with assay reproducibility and standardization. This review focuses on ongoing dilemmas and issues related to clinical and laboratory aspects of APS including: (1) diagnostic challenges posed by the protean clinical manifestations of APS; (2) current nomenclature and recent proposals for revision of the 2006 international classification criteria; (3) an overview of some key issues related to aPL testing; (4) potential pitfalls of applying the APS classification criteria as diagnostic criteria; and (5) the controversial subgroups of seronegative APS and non-APS aPL positivity.

International Human Rights Law Theory

This draft textbook chapter on international human rights law theory aims to give a comprehensive overview of the field to those interested in its ongoing dilemmas. It covers both the theory of human rights, of international human rights, and of international human rights law, as three integrated dimensions: human rights, the international and the legal. I would recommend the chapter as an introduction to a class on international human rights, at both the undergraduate and graduate levels.Note: although the chapter will be published in a different form in an actual book, I anticipate that this electronic version will be updated at regular intervals, and will therefore emerge as a live (although probably not quite real time) resource, that makes the most of a medium such as SSRN to post up to date content.

Care Revisited: Family Resemblance as Context

Care and caring have been debated in the nursing literature formore than 30 years as concepts of importance to nursing. Nursing theorists in this arena have drawn on the work of other disciplines, particularly psychology and philosophy. This paper reviews the literature and suggests Wittgenstein’s notion of family resemblance as a way for the profession to resolve the ongoing dilemmas over definition, description, and measurement. The notion of family resemblance allows the profession to accept that the meaning of a term is in its use and that the uses of care in nursing are many.

Opening Up the Conversation on Genetics and Genomics in Families The Space for Communication Scholars

Advances in genetics and genomics research allow increasing numbers of family members to learn of their susceptibilities for inheriting genetic diseases. A family member diagnosed with a genetic disease is expected to notify other family members who may be at risk; these individuals confront the ongoing dilemmas of how to discuss familial genetic health. The complexities of family communication dynamics surrounding genetic health-related issues raise key challenges for many family members. Although communication-related research literature exists in genetic counseling, communication studies, and other social sciences, little scholarship integrates these findings. This chapter provides an interdisciplinary review of the available literature pertaining to the ways in which family members disclose and discuss genetic test results among family members; it discusses implications of genetic knowledge within the family and identifies areas of future related research. The authors call for increasing contributions from interpersonal, family, and health communication scholars to address the needs of families that are managing genetic health issues.

Management of an Unintentional Warfarin Overdose With Oral Vitamin K in the Outpatient Setting Prior to Elevation of the International Normalized Ratio

Anticoagulation therapy with warfarin continues to present ongoing therapeutic dilemmas because of the complexity associated with its narrow therapeutic range. Warfarin dosing regimens can be complicated and require frequent adjustments, which presents a significant opportunity for error, especially in patients that require extensive pharmacotherapy outside of anticoagulation. This case describes a 64-year-old patient during the warfarin dose titration phase of her anticoagulation therapy that confuses the physical appearance of her tablets, resulting in a warfarin overdose. Because warfarin overdosing rarely is discovered within minutes of its occurrence, standard reversal strategies in response to an elevated international normalized ratio (INR) that would be implemented do not apply to her case. Thus, oral vitamin K was administered to prevent the anticipated international normalized ratio rise that would be predicted. This prospective outpatient intervention prevented a hospital admission and reduced the patient's hemorrhagic risk related to excessive anticoagulation.

Social Networking as Ethical Discourse: Blogging a Practical and Normative Library Ethic

ABSTRACT Ethical codes have become static and the publication schedule in the scholarly literature cannot keep pace with the challenges facing the library profession. A dynamic, democratic ethical discourse is needed to define a pragmatic ethics that will meet ongoing dilemmas facing libraries. Social networking tools, and blogs in particular, have become a means for facilitating that conversation through the advent of a community of contributors sharing their values, debating ideals, and creating a forum to address conflicting opinions. This world of library bloggers has created a structure for an ongoing ethical discussion for libraries today.

Water injustices and potential remedies in indigenous rural contexts: A water justice analysis

This paper examines Indigenous water rights in rural and remote Australia and how water justice seems to be elusive in many of these spaces. The purpose of this literature review is to link water justice theory and practices to the way different water cultures are valued in Australia while simultaneously critiquing the water justice movement. This paper situates the notion of water justice as a specific kind of environmental justice to cater for the unique qualities that define this resource. In doing so, this paper draws on Schlosberg’s (2004) conception of environmental justice with its trivalent approach that describes the following three ‘circles of concern’: recognition of difference, plurality of participation, and finally equitable distribution of resources and costs and benefits. This framework provides that if the first two ‘circles of concern’ are not in existence in a natural resource management process, then inequitable distribution of that resource is a likely outcome. This paper presents two areas where water injustices exist in the context of Indigenous rural and remote Australia. The first relates to how Indigenous rights to water have been inadequately recognized and the second presents empirical data on water supply and sanitation in rural and remote Indigenous communities that demonstrates ongoing dilemmas around securing this basic human right. The undervaluing of cultural differences relating to water is argued to be antecedent to the injustice manifest in poor water supply and sanitation provision for Indigenous rural contexts. This paper does not attempt to survey the body of ethnographic work on society-water relations in rural and remote Indigenous Australian contexts but reviews the gaps in current mainstream acknowledgement of Indigenous water cultures. In exploring water justice in rural and remote Indigenous Australia, this paper offers a novel approach to a dilemma more frequently analysed solely as a health development issue.

Development of a modified diagnostic classification system for voice disorders with inter-rater reliability study

Diversity in nomenclature and on-going dilemmas over the conceptual bases for the classification of voice disorders make it virtually impossible for the collation and accurate comparison of evidence-based data across different clinical settings. This has significant implications for treatment outcome studies. The first aim of this study was to develop a modified diagnostic classification system for voice disorders with clearly defined operational guidelines by which we might reliably distinguish voice disorders from one another. The second aim was to establish the face validity and reliability of the system as an effective diagnostic tool for the allocation of patients to different diagnostic groups for clinical and research purposes. After the Diagnostic Classification System for Voice Disorders (DCSVD) had been developed, it was used in an inter-rater reliability study for the independent assessment of 53 new consecutive patients referred to the Voice Analysis Clinics of three tertiary hospitals. There were three raters present for the assessment and diagnostic allocation of each patient. The high levels of inter-rater reliability suggest this may be a robust classification system that has good face validity and even at this early stage, strong construct validity.

Peyronie?s disease: an update of the medical management

Peyronie’s disease (PD) is characterised by penile plaque formation, pain, penile deformity and erectile dysfunction. It is a fibrotic disorder of the tunica albuginea with a poorly understood aetiology and epidemiology. PD may be classified into inflammatory (acute) and chronic stages. Medical treatment is usually instigated during the inflammatory phase of the disease. A review of the literature reveals a wide range of oral, intralesional and alternative therapies that are discussed in relation to established pathophysiological mechanisms of the disease. The advantages and disadvantages of each treatment are summarised. This review also discusses the ongoing therapeutic dilemmas of PD and suggests a treatment strategy based on an analysis of the urological literature.

Therapist dilemmas: A discussion paper

The aim of this paper is to act as a springboard to generate discussion between therapists about ethical dilemmas raised through their clinical work. It is hoped that this paper will provide a starting point for an interactive forum to encourage the discussion of ongoing practice issues and dilemmas. Two case examples are presented, one by each therapist, which grapple with therapeutic/ethical/legal issues within the settings of: (1) a Domestic Violence Project, and (2) a Community Mental Health Team.Therapists’ dilemmas have been highlighted by Lindsay and Clarkson (1999) and Dryden (1985). In our case examples the focus is upon ethical dilemmas. These include: giving information within the counselling role, supporting and containing a client if wider systems fail, role conflict within the therapeutic relationship, professional and ethical ‘mismatching’ within a team and managing personal feelings within the therapeutic relationship. For ease of reading the case examples are presented separately although there is a significant amount of overlap between them.