"Sweeping up after the parade": professional, ethical, and patient care implications of "turfing"

"Turfing" denotes a patient transfer or triage from one physician to another when the care of that patient feels more troublesome than it is worth. A widespread phenomenon in medical training programs, turfing appears to allocate patient care to meet physicians' rather than patients' needs. Although turfing reportedly causes inter-physician discord and inter-specialty stereotyping, its deeper consequences are poorly understood. Turfing is an interpersonal conflict masquerading as a medical issue. After examining turfing alongside other patient-related slang, I analyze the distinction between "the turf," a person, and "to turf," a practice. Several explanatory models from medical practice are explored in order to illuminate turfing's implications for medical professionalism, ethics, and patient care. I suggest that a physician's medical specialty or practice type--that is, professional culture--may link to that physician's degree of altruism. If so, then what it means fundamentally to be a physician might vary across medical specialties. Such a link calls for a new notion of cultural competence, one that physicians may apply not to patients but to each other.     

Languages of labor: negotiating the "real" and the relational in Indo-Fijian women's expressions of physical pain

Medical personnel in public clinics in Fiji routinely contend that state-funded medical resources are misallocated on patients who complain of, but do not actually experience, physical pain. Frequently, these patients are identified as being Indo-Fijian women (i.e., women of South Asian origin in Fiji). In this article, I examine clinical interactions between medical staff and female Indo-Fijian patients to demonstrate how "real" and 'unreal' pain are distinguished in the clinical setting and to indicate some of the roles clinical encounters play in community processes that ascribe alternative meanings to physical pain. Focusing on how both physicians and women patients foster certain interpretations of physical pain over others, I argue that the category of 'unreal' pain, as employed by Fiji's physicians, consists of pain that medical professionals consider to be induced by psychological or physical, work-related stresses. I then show how Indo-Fijian women engage in a complementary but distinct discourse that emphasizes links between physical labor and pain and suggests that, in some cases, expressions of physical pain are as much an idiom of pride as an idiom of distress.     

From "Rights" to "Ritual": AIDS Activism in South Africa

In this article, I investigate how the moral politics of HIV/AIDS activism in South Africa is contributing toward new forms of citizenship that are concerned with both rights-based struggles and with creating collectively shared meanings of the extreme experiences of illness and stigmatization of individual HIV/AIDS sufferers. I argue that it is precisely the extremity of the "near death" experiences of full-blown AIDS, and the profound stigma and "social death" associated with the later stages of the disease, that produce the conditions for HIV/AIDS survivors' commitment to "new life" and social activism. It is the activist mediation and retelling of these traumatic experiences that facilitates HIV/AIDS activist commitment and grassroots mobilization. It is also the profound negativity of stigma and social death that animates the activist's construction of a new positive HIV-positive identity and understanding of what it means to be a citizen–activist and member of a social movement.     

"Craziness" and "visions": experiences after a stroke.

For a stroke victim there may be at least three types of strange occurrences: incorrect saying, seeing, and thinking. To the patient only the third seems to be "crazy". After a stroke (left hemisphere), which mainly produced serious aphasia, I (the patient) felt crazy two or three times when someone said something I expected him to say. On the other hand, my initial aphasic "gibberish speech" and an occasional false vision did not seem crazy. In my case the vision is always a car or a child, seen on my extreme right, where I am otherwise blind from the stroke. I am always driving when it happens; in recent years this phenomenon occurs when I am tired or tense, or the light is poor. These rapid visions do not seem insane but merely physical problems in my eyes, much like ordinary people''s dreams.     

The medicalization of "nature" in the "artificial body": surrogate motherhood in Israel

In this article, I draw on anthropological and feminist scholarship on the body and the nature/culture divide as a framework for understanding the place of surrogate mothers in a conceptual ideology that connects motherhood with nature. I explore links between the medicalization of childbirth in Israel and the personal agency of surrogate mothers as relayed through interviews. Taking the patriarchal context of the Israeli surrogacy law of 1996 into consideration, I underscore surrogates' imaginative use of medical metaphors as tools for the subversion of surrogacy's threatening social connotations. By redefining the surrogate body as "artificial" and locating "nature" in the commissioning mother's body, surrogates adopt medical rhetoric to transform surrogacy from a transgressive act into an alternative route toward achieving normative Israeli national reproductive goals.     

Biographics art "I know me": image generation aiming at EEG control by biofeedback

"I know me" is an interactive artwork that produces images based on EEG measurements from human participants. Although artists have previously made some interactive image works, we considered using human physiological information as input because it reflects human feelings better. In this research we were interested in information about human's mental states, such as anger or sadness. Brain activity was observed with EEG, subjected to Fourier analysis and converted into an animation based on a Lissajous curve.We generated images corresponding to alpha or beta waves activity in real time and showed them to the observer. The observer understood his own mental condition from looking at the images, and could potentially control his own mental state with this interactive device.     

Women and affliction in Maharashtra: A hydraulic model of health and illness

The anthropological literature on spirit possession cults offers a distinction between voluntary possession or mediumship and involuntary possession or illness. Fieldwork was carried out in a Mahanubhav healing temple. Contradictory interpretations of trance and affliction were found to be held by the different temple inhabitants.Beliefs about the nature of spiritual affliction, its epidemiology and aetiology vary according to gender, family structure and position within the family. One manifestation of affliction is thought to be madness. However, the experience of mental affliction is very varied, for example, the number of family members accompanying an afflicted person, the amount of money made available for treatment, the length of treatment, as well as the less tangible but equally important aspects of treatment such as the degree of empathy and concern felt, all vary according to the afflicted person's gender and status within the family. The inferiority of women's position in society and their precarious belonging in their husband's family comes to the fore in cases of mental illness. The greater shame attaching to women's mental illness means that more women seek temple treatment alone and that the level of family support and involvement is less for women. Recently married women and older childless women fare particularly badly in the division of concern and responsibility for the afflicted. In Maharashtra the recognition and experience of mental affliction varies according to the stage of family development and, most importantly, according to the gender of the patient.The material on which this paper is based was originally presented in Venice in September 1988 at the 10th European Conference for Modem South Asian Studies. An earlier version of this paper will be included in the Proceedings of that conference, Gender, Caste, and Power in South Asia— Social Status and Mobility in Transitional Societies, forthcoming, Manohar Publishers, New Delhi.     

Wording effects and the factor structure of the Hospital Anxiety & Depression Scale in HIV/AIDS patients on antiretroviral treatment in South Africa

Background

Given the immense burden of HIV/AIDS on health systems in sub-Saharan Africa and the intricate link between HIV/AIDS and mental health problems, health care providers need a valid and reliable instrument to assess mental health rapidly. The Hospital Anxiety and Depression Scale (HADS) may constitute such an instrument. The aims of this study were to: (1) examine the factor structure of the HADS in a population of South African HIV/AIDS patients on antiretroviral treatment (ART); and (2) identify and control the disturbing influence of systematic wording effects in vulnerable respondent groups.

Methodology/Principal Findings

The translated scale was administered to 716 HIV/AIDS patients enrolled in the public sector ART program in South Africa. A combined confirmatory factor analysis and correlated-traits-correlated-methods framework was used to determine the preferred factor structure of the HADS, while controlling for the disturbing influence of systematic wording effects. When assessing the structure without a negative wording factor, all three factor structures displayed an acceptable fit to the data. The three-factor solution best fitted the data. Addition of a method factor significantly improved the fit of all three factor solutions. Using χ² difference testing, Razavi''s one-factor solution displayed a superior fit compared to the other two factor solutions.

Conclusions

The study outcomes support the use of the HADS as a valid and reliable means to screen for mental health problems in HIV/AIDS patients enrolled in a public-sector ART program in a resource-limited context. The results demonstrate the importance of evaluating and correcting for wording effects when examining the factor structure of the screening instrument in vulnerable patient groups. In light of the inter-relationships between HIV/AIDS and mental health problems and the scarcity of adequate screening tools, additional studies on this topic are required.     

Association between Body Mass Index and Health-Related Quality of Life: The "Obesity Paradox" in 21,218 Adults of the Chinese General Population

Background

There was no consistent recognition of the association between high or low body mass index (BMI) and health related quality of life (HRQL). The aim of this research was to study the association between BMI and HRQL in Chinese adults, and to further explore the stability of that association in the subgroup analysis stratified by status of chronic conditions.

Methods

A total of 21,218 adults aged 18 and older were classified as underweight, normal weight, overweight, class I obese, and class II obese based on their BMI. HRQL was measured by the SF-36 Health Survey. The independent impact of each BMI category on HRQL was examined through standard least squares regression by comparing the difference of SF-36 scores and the minimum clinically important differences (MCID), which was defined as 3 points.

Results

Compared to the normal weight, the class I obese was significantly associated with better HRQL scores in the mental component summary (MCS) (75.1 vs. 73.4, P<0.001). The underweight had the lowest score in both the physical components summary (PCS) (75.4 vs. 77.5, P<0.001) and mental components summary (MCS) (71.8 vs. 73.4, P<0.001). For the MCID, the HRQL score was reduced by more than 3 points in the physical functioning for the class II obese (D=-3.43) and the general health for the underweight (D=-3.71). Stratified analyses showed a similar result in the health subjects and chronic conditions, and it was significant in the chronic conditions.

Conclusions

The class I obese showed the best HRQL, especially in the mental domain. The worst HRQL was found in the underweight. The class II obese reduced HRQL in the physical functioning only. “Obesity paradox” was more obvious in the participants with chronic conditions.     

Rubinstein-Taybi syndrome: Clinical profile of 11 patients and review of literature

BACKGROUND:

Rubinstein-Taybi syndrome (RSTS) is a rare congenital neurodevelopmental disorder, characterized by postnatal growth deficiency, typical dysmorphic features, broad thumbs and toes, and mental retardation. Very few cases are reported in literature from developing countries. Diagnosis is often delayed due to non-familiarity with the characteristic features of this syndrome.

AIMS:

To report 11 cases of RSTS and to review the current literature.

SETTINGS AND DESIGN:

Retrospective study conducted in genetic and metabolic unit of a tertiary care teaching hospital in north India over a period of 3½ years.

MATERIALS AND METHODS:

11 patients with diagnosis of RSTS were identified, and their case sheets were reviewed.

RESULTS:

Developmental delay was presenting complaint in 10 patients, and seizure in 1 case. 7 patients had microcephaly (head circumference below −3 SD), and a prominent beaked nose was seen in 9 patients. The intelligence quotient (IQ) varied from 22-62 in 7 patients who had mental retardation. The most notable features in hands were broadness, shortening, and flattening of the distal phalanx of thumbs or great toes. Additionally, we also noted webbing of neck, microphthalmia, and pachygyria (on MRI brain) in 1 patient each.

CONCLUSIONS:

The diagnosis of RSTS is primarily clinical and based on characteristic phenotype that is often combined with a variety of somatic anomalies. An early diagnosis facilitates appropriate genetic counseling and in planning the management.     

The "Moi-peau"

To construct a coherent identity, humans must distinguish what belongs to the external, perceived world from what belongs to their own inner world and the inner world of other individuals. Based on the theory developed by S. Freud and on work by ethologists, a number of psychoanalysts (J. Bowlby, R.A. Spitz, D.W. Winnicott, etc.) have underlined the importance of early tactile exchanges with the mother if a child is to become an autonomous individual who feels secure within what he or she perceives to be sound and reliable mental and physical boundaries. More recently, other psychoanalysts (E. Bick, W.R. Bion, etc.) have studied the fantasized mental structures that form the limits between an individual's inner mental space and the external world (including other individuals). As part of this theoretical psychoanalytical movement, Didier Anzieu, a French psychoanalyst, started to develop the concept of the "Moi-peau" in 1974. The "Moi-peau" designates a fantasized reality that a child uses during its early development to represent itself as "me", based on its experience of the body surface. The child, enveloped in its mother's care, fantasizes of a skin shared with its mother: on one side the mother (the outer layer of the "Moi-peau"), and on the other side the child (the inner layer of the "Moi-peau"). These two layers must separate gradually if the child is to acquire its own me-skin. D. Anzieu's work allowed dermatologists and other specialists, such as pediatricians, to focus on the quality of early tactile exchanges between a mother and her child, including the child with a chronic skin disorder. It also helped dermatologists to recognize patients with "borderline" states, which are particularly frequent in dermatology (ereutophobia, dysmorphophobia, tattooing, self-mutilation, artefacta dermatitis). These borderline patients are adults who, as a result of their mental conflicts, adopt defense mechanisms derived from both neurotic and psychotic functioning. Their complaints reflect difficulties with the solidity of their mental and physical limits: their real skin is metaphorically linked to the fantasized mental structure that delimits the individual mental space. Among other clinical characteristics, they have a "pathology of action" and frequently attack their own skin, paradoxically, in order to test the solidity and reliability of their own limits. Finally, D. Anzieu's work encouraged dermatologists to use psychotherapeutic approaches in parallel to classical dermatologic approaches, when necessary, and helped them better understand how psychoanalysts work with patients who have not yet acquired their own "Moi-peau". As a result, D. Anzieu was among the first to reconcile dermatologists and psychoanalysts.     

Coexistence of hepatitis B surface antigen (HBs Ag) and anti-HBs antibodies in chronic hepatitis B virus carriers: influence of "a" determinant variants

In chronic hepatitis B (CHB), the persistence of hepatitis B surface antigen (HBs Ag) is sometimes associated with antibodies (Ab) to HBs (anti-HBs). To assess the hypothesis of the selection of HBs Ag immune escape variants in CHB patients, the variability of the HBV S gene was determined for patients persistently carrying both HBs Ag and anti-HBs antibodies and patients solely positive for HBs Ag. We selected 14 patients who presented both markers (group I) in several consecutive samples and 12 patients positive for HBs Ag only (group II). The HBs Ag-encoding gene was amplified and cloned, and at least 15 clones per patient were sequenced and analyzed. The number of residue changes within the S protein was 2.7 times more frequent for group I than for group II patients and occurred mostly in the "a" determinant of the major hydrophilic region (MHR), with 9.52 versus 2.43 changes per 100 residues (P = 0.009), respectively. Ten patients (71%) from group I, but only three (25%) from group II, presented at least two residue changes in the MHR. The most frequent changes in group I patients were located at positions s145, s129, s126, s144, and s123, as described for immune escape variants. In CHB patients, the coexistence of HBs Ag and anti-HBs Ab is associated with an increase of "a" determinant variability, suggesting a selection of HBV immune escape mutants during chronic carriage. The consequences of this selection process with regard to vaccine efficacy, diagnosis, and clinical evolution remain partially unknown.     

Quantum-like brain: "Interference of minds"

We present a contextualist statistical realistic model for quantum-like representations in physics, cognitive science, and psychology. We apply this model to describe cognitive experiments to check quantum-like structures of mental processes. The crucial role is played by interference of probabilities for mental observables. Recently one such experiment based on recognition of images was performed. This experiment confirmed our prediction on the quantum-like behavior of mind. In our approach "quantumness of mind" has no direct relation to the fact that the brain (as any physical body) is composed of quantum particles. We invented a new terminology "quantum-like (QL) mind." Cognitive QL-behavior is characterized by a nonzero coefficient of interference lambda. This coefficient can be found on the basis of statistical data. There are predicted not only cos theta-interference of probabilities, but also hyperbolic cosh theta-interference. This interference was never observed for physical systems, but we could not exclude this possibility for cognitive systems. We propose a model of brain functioning as a QL-computer (there is a discussion on the difference between quantum and QL computers).     

The Misuse of Chayanov: "Chayanov's Rule" and Empiricist Bias in Anthropology

Sahlins's "Chayanov's Rule"–the more consumers each worker has to support the more work each worker does-has characterized Chayanov's analysis for most anthropologists. I examine the relationship between the consumer/worker ratio and product per worker for the Shan community of Thongmakhsan in northwestern Thailand. Since there is no systematic relationship between these variables even when the population is divided into production strategy groups, I go on to examine the relationship between Sahlins's "Chayanov's Rule" and Chayanov's own analysis. In conclusion I raise the issue of the continuing identification of Chayanov with "Chayanov's Rule" and consider a number of possible reasons for this.     

Intergrading between members of the "regularis group" of toads in South Africa

The mating calls of three members of the " regularis group" of toads (Anura: Bufonidae) that are sympatric in part of South Africa are examined. A naturally occurring population of hybrid toads from Pretoria (South Africa) has previously been described as representing an intergrading between Bufo garmani Meek and Bufo rangeri Hewitt. Examination of the mating calls of these toads provides little evidence of intergrading between Bufo rangeri and Bufo garmani , and indicates the involvement of Bufo regularis Reuss in the hybridization. The mating calls of the hybrids are varied, and are structurally intermediate between those of the parental species. Mating call parameters are found to be useful in separating forms that are difficult to distinguish on morphological grounds alone. They are further found to be a sensitive non-morphological means of ascertaining the affinities of naturally occurring hybrid toads.     

Anaplastic thyroid carcinoma developed after treatment of "hot" thyroid nodule with radioiodine]

A case of 55 years old woman with "hot" right lobe toxic thyroid nodule, presenting with paroxysmal atrial fibrillation, and therefore treated with 131I 666MBq (18 mCi) is described. After six years she became pyrexic and suffered of severe cough proxyisms. The fine needle biopsy of the above nodule showed the presence of anaplastic thyroid carcinoma. Strumectomy followed by local radiotherapy resulted in complete disappearence of all symptoms. The microscopic of the removed thyroid tissue confirmed the above diagnosis. After 22 months' observation the patient remained in good general condition. The possible reasons for the development of the thyroid carcinoma in this case are discussed.     

Kind-Making, objectivity, and political neutrality; the case of Solastalgia

Politics and science, it is customarily and broadly assumed, should not mix. I investigate a purported "new mental illness" arising from psychological stress associated with environmental damage. Previous assessments have concluded that the diagnosis of "solastalgia", which is clearly intended to advance a political agenda, may thereby lack scientific validity. Building on work by Ian Hacking and Nelson Goodman, and drawing comparisons with the history of "political medicine"--in particular, the scientific study of Child Abuse and Sudden Infant Death Syndrome--I argue that the political consequences of such a diagnosis may plausibly help to justify it as a distinct objective scientific kind, by demarcating it from alternative classifications. That science should be objective, then, does not require that it be politically neutral.     

Paracoccidioidomycosis Mimicking Squamous Cell Carcinoma on the Dorsum of the Tongue and Review of Published Literature

Introduction

Paracoccidioidomycosis is a disease that is endemic to southern and southeastern Brazil, caused by the fungus Paracoccidioides brasiliensis. The most common clinical oral manifestation is the presence of multiple granulomatous ulcers with hemorrhagic dots, located mainly on the lips, palate, and buccal mucosa. However, the disease can manifest atypically as a single ulcer, mimicking oral squamous cell carcinoma (SCC) or tuberculosis.

Case report

A 65-year-old male patient presented with a complaint of a single ulcerated lesion on the dorsum of the tongue; the lesion had evolved over 6 months. The diagnostic hypotheses were SCC and oral manifestation of tuberculosis. An incisional biopsy was performed, and histopathological analysis of the specimen revealed pseudoepitheliomatous hyperplasia, a granulomatous structure of epithelioid histiocytes, multinucleated giant cells, and lymphocytes in the connective tissue. Grocott staining confirmed the presence of the fungus in the lesion, and a diagnosis was made of paracoccidioidomycosis. The patient was treated with 200 mg/day of itraconazole for 12 months and now shows no signs or symptoms of recurrence of the disease.

Conclusion

Correct diagnosis is essential for a successful therapeutic approach and resolution of the lesion.     

Evidence that a dodecamer duplication in the gene HOPA in Xq13 is not associated with mental retardation

A recent study suggested that a dodecamer duplication in exon 42 of the HOPA gene in Xq13 may be a significant factor in the etiology of X-linked mental retardation. In an effort to investigate this possibility, we determined the incidence of the dodecamer duplication in cohorts of non-fragile X males with mental retardation from three countries, cohorts of fragile X males from two countries, 43 probands from families with X-linked mental retardation and control cohorts from three countries. The duplication was found in 3.6-4.0% of male patients from two non-fragile X groups (Italy and South Carolina), in 1.2% from another non-fragile X group (South Africa), but in no male patients from families with X-linked mental retardation (South Carolina). The dodecamer duplication was also found in several white males with fragile X syndrome from France (5%) and South Africa (22.2%). Additionally, the duplication was found in 1.5% of South Carolinian newborn males, 2.5% South Carolinian male college students, 5% Italian male controls and 4.5% of the white South African controls. None of the black South African non-fragile X individuals with mental retardation, the fragile X or the control samples tested carried the duplication, suggesting that the duplication is rare in the black South African population. The incidence of the duplication was not significantly different between any of the groups in the study. Therefore, results of our studies in four different populations do not corroborate the findings of the previous study, and indicate that the HOPA dodecamer duplication does not convey an increased susceptibility to mental retardation.