'Conditional candour' and 'knowing me': an interpretive description study on patient preferences for physician behaviours during end-of-life communication

OBJECTIVE: To understand patients' preferences for physician behaviours during end-of-life communication.

METHODS: We used interpretive description methods to analyse data from semistructured, one-on-one interviews with patients admitted to general medical wards at three Canadian tertiary care hospitals. Study recruitment took place from October 2012 to August 2013. We used a purposive, maximum variation sampling approach to recruit hospitalised patients aged ≥55 years with a high risk of mortality within 6-12 months, and with different combinations of the following demographic variables: race (Caucasian vs non-Caucasian), gender and diagnosis (cancer vs non-cancer).

RESULTS: A total of 16 participants were recruited, most of whom (69%) were women and 70% had a non-cancer diagnosis. Two major concepts regarding helpful physician behaviour during end-of-life conversations emerged: (1) 'knowing me', which reflects the importance of acknowledging the influence of family roles and life history on values and priorities expressed during end-of-life communication, and (2) 'conditional candour', which describes a process of information exchange that includes an assessment of patients' readiness, being invited to the conversation, and sensitive delivery of information.

CONCLUSIONS: Our findings suggest that patients prefer a nuanced approach to truth telling when having end-of-life discussions with their physician. This may have important implications for clinical practice and end-of-life communication training initiatives.

Socialized credit and the working-class family economy: a comparative history of Britain and France 1900-2000

This paper provides a comparative analysis of working class consumer credit in Britain and France from the early twentieth century through to the 1980s. It indicates a number of similarities between the two nations in the earlier part of the period: in particular, in the operation of doorstep credit systems. For the British case study, we explore consumer finance offered by credit drapers (sometimes known as tallymen) whilst in France the paper explores a similar system that functioned in the coalmining communities around the city of Lens. Both methods operated on highly socialised relationships that established the trust on which credit was offered and long-term creditor/borrower relationships established. In the second part of the paper, we analyse the different trajectories taken in post-war France and Britain in this area of working class credit. In France this form of socialized credit gradually dwindled due to factors such as ‘Bancarisation’, which saw the major banks emerge as modern bureaucratized providers of credit for workers and their families. In contrast, in Britain the tallymen (and other related forms of doorstep credit providers) were offered a new lease of life in the 1960s and 1970s. This was a period during which British credit providers utilised multiple methods to evade the hire purchase controls put in place by post-war governments. Thus, whilst the British experience was one of fragmented consumer loan types (including the continuation of doorstep credit), the French experience (like elsewhere in Europe) was one of greater consolidation. The paper concludes by reflecting on the role of these developments in the creation of differential experiences of credit inclusion/exclusion in the two nations and the impact of this on financial inequality.

Impact of Syncope on Quality of Life: Validation of a Measure in Patients Undergoing Tilt Testing

INTRODUCTION AND OBJECTIVES: Recurrent syncope has a significant impact on quality of life. The development of measurement scales to assess this impact that are easy to use in clinical settings is crucial. The objective of the present study is a preliminary validation of the Impact of Syncope on Quality of Life questionnaire for the Portuguese population. METHODS: The instrument underwent a process of translation, validation, analysis of cultural appropriateness and cognitive debriefing. A population of 39 patients with a history of recurrent syncope (>1 year) who underwent tilt testing, aged 52.1 ± 16.4 years (21-83), 43.5% male, most in active employment (n=18) or retired (n=13), constituted a convenience sample. The resulting Portuguese version is similar to the original, with 12 items in a single aggregate score, and underwent statistical validation, with assessment of reliability, validity and stability over time. RESULTS: With regard to reliability, the internal consistency of the scale is 0.9. Assessment of convergent and discriminant validity showed statistically significant results (p<0.01). Regarding stability over time, a test-retest of this instrument at six months after tilt testing with 22 patients of the sample who had not undergone any clinical intervention found no statistically significant changes in quality of life. CONCLUSIONS: The results indicate that this instrument is of value for assessing quality of life in patients with recurrent syncope in Portugal.

Indices and Implications of Emotional Underarousal for Persons with a History of Head Trauma

We examined the role of altered emotional functioning across the spectrum of injury severity (mild head injury [MHI], moderate/severe traumatic brain injury [TBI]), its implications for social behaviours, and the effect of modifying arousal and its relation to cognitive performance. In the first study (N = 230), students with self-reported MHI endorsed engaging in socially unacceptable and erratic behaviours significantly more often than did those with no MHI. We did not find significant differences between the groups in the measure of emotional intelligence (EI); however, for students who reported a MHI, scores on the EI measure significantly predicted reports of socially unacceptable behaviours such that lower scores predicted poorer social functioning, accounting for approximately 20% of the variance. Also, the experience of postconcussive symptoms was found to be significantly greater for students with MHI relative to their peers. In the second study (N = 85), we further examined emotional underarousal in terms of physiological (i.e., electrodermal activation [EDA]) and self-reported responsivity to emotionally-evocative picture stimuli. Although the valence ratings of the stimuli did not differ between students with and without MHI as we had expected, we found evidence of reduced and/or indiscriminate emotional responding to the stimuli for those with MHI which mimics that observed in other studies for persons with moderate/severe TBI. We also found that emotional underarousal followed a gradient of injury severity despite reporting a pattern of experiencing more life stressors. In the third study (N = 81), we replicated our findings of emotional underarousal for those with head trauma and also uniquely explored neuroendocrine aspects (salivary cortisol; cortisol awakening response [CAR]) and autonomic indices (EDA) of emotional dysregulation in terms of stress responsivity across the spectrum of injury severity (MHI [n = 32], moderate/severe TBI [n = 9], and age and education matched controls [n = 40]). Although the manipulation was effective in modifying arousal state in terms of autonomic and self-reported indices, we did not support our hypothesis that increased arousal would be related to improved performance on cognitive measures for those with prior injury. To our knowledge, this is the only study to examine the CAR with this population. Repeated measure analysis revealed that, upon awakening, students with no reported head trauma illustrated the typical CAR increase 45 minutes after waking, whereas, students who had a history of either mild head trauma or moderate/severe TBI demonstrated a blunted CAR. Thus, across the three studies we have provided evidence of emotional underarousal, its potential implications for social interactions, and also have identified potentially useful indices of dysregulated stress responsivity regardless of injury severity.

Perfectionist Philosophy as a (an Untaken) Way of Life

I am honored to respond to Paul Guyer’s elaboration on the role of examples of perfectionism in Cavell’s and Kant’s philosophies. Guyer’s appeal to Kant’s notion of freedom opens the way for suggestive readings of Cavell’s work on moral perfectionism but also, as I will show, for controversy. There are salient aspects of both Kant’s and Cavell’s philosophy that are crucial to understanding perfectionism and, let me call it, perfectionist education, that I wish to emphasize in response to Guyer. In responding to Guyer’s text, I shall do three things. First, I shall explain why I think it is misleading to speak of Cavell’s view that moral perfectionism is involved in a struggle to make oneself intelligible to oneself and others in terms of necessary and sufficient conditions for moral perfection. Rather, I will suggest that the constant work on oneself that is at the core of Cavell’s moral perfectionism is a constant work for intelligibility. Second, I shall recall a feature of Cavell’s perfectionism that Guyer does not explicitly speak of: the idea that perfectionism is a theme, “outlook or dimension of thought embodied and developed in a set of texts.” Or, as Cavell goes on to say, “there is a place in mind where good books are in conversation. … [W]hat they often talk about … is how they can be, or sound, so much better than the people that compose them.” This involves what I would call a perfectionist conception of the history of philosophy and the kinds of texts we take to belong to such history. Third, I shall sketch out how the struggle for intelligibility and a perfectionist view of engagement with texts and philosophy can lead to a view of philosophy as a form of education in itself. In concluding these three “criticisms,” I reach a position that I think is quite close to Guyer’s, but with a slightly shifted emphasis on what it means to read Kant and Cavell from a perfectionist point of view.

Subtle Cognitive Deficits in Adults With a Previous History of Sydenham's Chorea During Childhood

Objective. To evaluate the neuropsychological profile and health-related quality of life (HRQOL) of adults who had rheumatic fever (RF) during childhood with and without Sydenham's chorea (SC).Methods. Three groups of patients were assessed: adults who had RF with SC during childhood (SC group), adults who had RF without SC during childhood (RF group), and controls (CT group). A range of neuropsychological tests looked at several cognitive domains. HRQOL was measured through a Brazilian version of the Short Form 36 (SF-36) health survey.Results. Twenty patients were included in the SC group, 23 patients in the RF group, and 19 patients in the CT group. The 3 groups were homogeneous regarding sex (P = 0.078), age (P = 0.799), schooling (P = 0.600), socioeconomic status (P = 0.138), intelligence quotient (P = 0.329), and scores for anxiety (P = 0.156) and depression (P = 0.076). The SC group demonstrated inferior performance in tests that assessed attention (Digit Span Forward [ P = 0.005], Corsi Block Forward [ P = 0.014]), speeded information processing (Trail Making A [ P = 0.009], Symbol Search [ P = 0.042]), and executive functions and working memory (Corsi Block Backward [ P = 0.028]), and higher scores for attention deficit scale (P = 0.030) when compared with the RF and CT groups. They also showed a tendency toward lower scores in the physical aspects, vitality, emotional aspects, and mental health domains of the SF-36. The RF group had a lower score for the general health domain than the CT group (P = 0.030).Conclusion. Patients who had SC during childhood can exhibit inferior performance in tasks that evaluate attention, speeded information processing, executive functions, and working memory in adult life. Therefore, there is indirect evidence of the persistence of dysfunction in cerebral circuits involved with the basal ganglia. They also presented a worse self-evaluation in HRQOL that was not related to cognitive impairments.

Natural history of Peucetia flava (Araneae, Oxyopidae): seasonal density fluctuation, phenology and sex ratio on the glandular plant Rhyncanthera dichotoma (Melastomataceae)

The seasonal density fluctuation, phenology and sex ratio of Peucetia flava (Oxyopidae) on Rhyncanthera dichotoma (Melastomataceae) were investigated during a year in a swamp in southeastern Brazil. Peucetia flava displayed an unusual non-seasonal life cycle and the population size varied little over the year. The density of Peucetia spiders increased with the increase in abundance of leaves and number of arthropods adhered to glandular trichomes on R. dichotoma leaves. Our findings suggest that seasonal density fluctuation of Peucetia may be influenced by foraging site availability (i.e. leaves) and prey supply (i.e. arthropods adhering to glandular trichomes). The unusual seasonal stability of P. flava may be related to the type of habitat in which this spider occurs (swamp), because of the constant input of allochthonous resources from the water source, i.e. aquatic insects that migrate to the terrestrial environment.

The amphibian tree of life

The evidentiary basis of the currently accepted classification of living amphibians is discussed and shown not to warrant the degree of authority conferred on it by use and tradition. A new taxonomy of living amphibians is proposed to correct the deficiencies of the old one. This new taxonomy is based on the largest phylogenetic analysis of living Amphibia so far accomplished. We combined the comparative anatomical character evidence of Haas (2003) with DNA sequences from the mitochondrial transcription unit HI (12S and 16S ribosomal RNA and tRNA(Valine) genes, 2,400 bp of mitochondrial sequences) and the nuclear genes histone H3, rhodopsin, tyrosinase, and seven in absentia, and the large ribosomal subunit 28S (approximate to 2,300 bp of nuclear sequences; ca. 1.8 million base pairs; x ($) over bar = 3.7 kb/terminal). The dataset includes 532 terminals sampled from 522 species representative of the global diversity of amphibians as well as seven of the closest living relatives of amphibians for outgroup comparisons.

From cytoplasm to environment: The inorganic ingredients for the origin of life

Early in its history, Earth's surface developed from an uninhabitable magma ocean to a place where life could emerge. The first organisms, lacking ion transporters, fixed the composition of their cradle environment in their intracellular fluid. Later, though life adapted and spread, it preserved some qualities of its initial environment within. Modern prokaryotes could thus provide insights into the conditions of early Earth and the requirements for the emergence of life. In this work, we constrain Earth's life-forming environment through detailed analysis of prokaryotic intracellular fluid. Rigorous assessment of the constraints placed on the early Earth environment by intracellular liquid will provide insight into the conditions of abiogenesis, with implications not only for our understanding of early Earth but also the formation of life elsewhere in the Universe. Copyright © 2013, Mary Ann Liebert, Inc. 2013.

Quality of life in patients with Charcot-Marie-Tooth disease type 1A

Avaliou-se o comprometimento funcional de pacientes com Charcot-Marie-Tooth provenientes da duplicação 17p11.2-p12 (CMT1A), utilizando o SF-36, que é um questionário para medir a qualidade de vida. Vinte e cinco pacientes de ambos os sexos com idades ≥10 anos e diagnóstico molecular de CMT1A foram selecionados. Idade, sexo, condições sociodemográficas e profissionais foram pareados com o Grupo Controle (sem histórico familiar de neuropatia). Os resultados mostraram que o maior impacto da CMT1A na qualidade de vida ocorreu nos domínios social e emocional dos pacientes avaliados. A capacidade funcional também tende a ser significativamente afetada, enquanto outros indicadores de deficiência física foram preservados. Por fim, os aspectos sociais e emocionais dos pacientes acometidos por CMT1A costumam ser negligenciados na assistência médica prestada aos pacientes brasileiros, e devem ser melhor compreendidos a fim de oferecer uma assistência global à saúde, resultando em adequada qualidade de vida.

Prevalence and risk factors associated with wheezing in the first year of life

Objective: to investigate the prevalence and risk factors associated with wheezing in infants in the first year of life.Methods: this was a cross-sectional study, in which a validated questionnaire (Estudio Internacional de Sibilancias en Lactantes - International Study of Wheezing in Infants - EISL) was applied to parents of infants aged between 12 and 15 months treated in 26 of 85 primary health care units in the period between 2006 and 2007. The dependent variable, wheezing, was defined using the following standards: occasional (up to two episodes of wheezing) and recurrent (three or more episodes of wheezing). The independent variables were shown using frequency distribution to compare the groups. Measures of association were based on odds ratio (OR) with a confidence interval of 95% (95% CI), using bivariate analysis, followed by multivariate analysis (adjusted OR [aOR]).Results: a total of 1,029 (37.7%) infants had wheezing episodes in the first 12 months of life; of these, 16.2% had recurrent wheezing. Risk factors for wheezing were family history of asthma (OR = 2.12; 95% CI: 1.76-2.54) and six or more episodes of colds (OR = 2.38; 95% CI: 1.91-2.97) and pneumonia (OR = 3.02; 95% CI: 2.43-3.76). For recurrent wheezing, risk factors were: familial asthma (aOR = 1.73; 95% CI: 1.22-2.46); early onset wheezing (aOR = 1.83; 95% CI: 1.75-3.75); nocturnal symptoms (aOR = 2.56; 95% CI: 1.75-3.75), and more than six colds (aOR = 2.07; 95% CI 1.43-.00).Conclusion: the main risk factors associated with wheezing in Fortaleza were respiratory infections and family history of asthma. Knowing the risk factors for this disease should be a priority for public health, in order to develop control and treatment strategies. (C) 2013 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.

Psoriasis: correlation between severity index (PASI) and quality of life index (DLQI) in patients assessed before and after systemic treatment

BACKGROUND: Psoriasis is a chronic inflammatory disease of the skin that affects patients of all ages and both genders. The impact of the disease on quality of life is greater among patients with moderate to severe psoriasis. OBJECTIVE: to establish a correlation between the psoriasis area and severity index (PASI) and the Dermatology Life Quality Index (DLQI) based on a quality of life questionnaire adapted to the Brazilian context for patients with plaque psoriasis before and after systemic treatment. METHODS: This was a cross-sectional, descriptive study of psoriasis patients who did not undergo treatment or who manifested clinical activity of the disease. Patients were evaluated according to the PASI and the quality of life questionnaire adapted to the Brazilian context before and 60 days after systemic treatment. RESULTS: Thirty-five patients participated in the study. Twenty-six were men, with a mean age of 46 years. There was no correlation between the PASI and the quality of life questionnaire adapted to the Brazilian context, but there was a correlation between the PASI and some items of the quality of life questionnaire adapted to the Brazilian context, such as jobs involving public contact. CONCLUSION: The non-correlation between the PASI and the quality of life questionnaire adapted to the Brazilian context in this work may be associated with a history of chronic disease, which implies greater acceptance of the illness, or may be related to the low income and social status of the patients studied. The correlation observed among patients with careers involving public contact suggests that some professions are more impacted by the disease. It may be necessary to adapt the quality of life questionnaire to patients with a low income and cultural and social limitations. The small sample size (n=35 patients) and the short follow-up period of 60 days were some of the limitations of this work.

A Land-Use and Water-Quality History of White Rock Lake Reservoir, Dallas, Texas, Based on Paleolimnological Analyses

White Rock Lake reservoir in Dallas, Texas contains a 150-cm sediment record of silty clay that documents land-use changes since its construction in 1912. Pollen analysis corroborates historical evidence that between 1912 and 1950 the watershed was primarily agricultural. Land disturbance by plowing coupled with strong and variable spring precipitation caused large amounts of sediment to enter the lake during this period. Diatoms were not preserved at this time probably because of low productivity compared to diatom dissolution by warm, alkaline water prior to burial in the sediments. After 1956, the watershed became progressively urbanized. Erosion decreased, land stabilized, and pollen of riparian trees increased as the lake water became somewhat less turbid. By 1986 the sediment record indicates that diatom productivity had increased beyond rates of diatom destruction. Neither increased nutrients nor reduced pesticides can account for increased diatom productivity, but grain size studies imply that before 1986 diatoms were light limited by high levels of turbidity. This study documents how reservoirs may relate to land-use practices and how watershed management could extend reservoir life and improve water quality.

The History of the German-Russian Colony in Lincoln

Standing at the corner of Tenth and O streets in the city of Lincoln, Nebraska, any week-day morning between 7:30 and 8 o'clock, you may see pass by you from ten to twenty women with little black woolen shawls on their heads. Ask any citizen who they are, and ninety-nine times in one hundred he will tell you they are "Russians" who live down on the bottoms, that they are going out into the offices and homes to wash and scrub and clean house, and that their husbands are street laborers or work for the railroad. He may then grow confidential and tell you that he "has no use for these people", that "they are only half human", and that he "would just as soon see the Chinese come here as those people". As a matter of fact the greater part of his information is incorrect, partly through race prejudice but chiefly through ignorance of their history. These people, of whom there are about 4,000 in the city (Including "beet fielders"), are Germans, not Russians: they are Teutons, not Slavs; they are Lutheran and Reformed, not Greek Catholics. To be sure they and their ancestors lived in Russia for over one hundred years and they came here directly from the realm of the Czar whoso bona fide citizens they were—but they never spoke the Russian language, never embraced the Greek religion, never intermarried with the Russians, and many of their children never saw a Russian until they left their native village for the new home in America. They despise being called "Russians" just as an Italian resents "Dago"; a Jew, "Sheeny"; and a German, "Dutchman". Ask them where they came from and most of the children and not a few of the grown people will say, "Germany". If you pursue your questioning as to what part of Germany, they will tell you "Saratov" or "Samara" - two governments in the eastern part of Russia on the lower course of the Volga river. The misconceptions concerning the desirability of these German-Russians as citizens arise from their unprogressiveness as compared with those Germans who come to us directly from the mother country. During their century's sojourn in Russia they have been out of the main current of civilization, a mere eddy in the stream of progress. They present a concrete example of arrested development, The characteristics which differentiate them from other Germans are not due to an inherent lack of capacity but to different environment. Notwithstanding this, the German- Russians have some admirable qualities. They bring us large stores of physical energy and an almost unlimited capacity for work. The majority of them are literate although the amount of their education is limited. They are thrifty and independent, almost never applying for public aid. They are law abiding, their chief offenses being those which are traceable to their communal life in Russia. They are extremely religious, all their social as well as spiritual life being bound up in the church which they support right royally. To be sure, the saloon gets their vote (the prohibition vote among them is increasing); but "was not the first miracle that Christ performed the turning of water into wine? If they would shut up the shows (theaters), they wouldn't need to shut up the saloons". The object of this paper is to give the historical setting in which the German-Russians have lived as one means to a better understanding and appreciation of them by our own citizens.

Prior history of sexually transmitted diseases in women living with AIDS in Sao Paulo, Brazil

Objectives: To describe the epidemiological profile, risk behaviors, and the prior history of sexually transmitted diseases (STDs) in women living with acquired immunodeficiency syndrome (AIDS). Methods: Cross-sectional study, performed at the Centro de Referencia e Treinamento em DST/AIDS of Sao Paulo. The social, demographic, behavioral, and clinical data such as age, schooling, marital status, age at first sexual intercourse, number of sexual partners, parity, use of drugs, time of HIV diagnosis, CD4 count, and viral load determination were abstracted from the medical records of women living with AIDS who had gynecological consultation scheduled in the period from June 2008 to May 2009. Results: Out of 710 women who were scheduled to a gynecological consultation during the period of the study, 598 were included. Previous STD was documented for 364 (60.9%; 95% CI: 56.9%-64.8%) women. The associated factors with previous STDs and their respective risks were: human development index (HDI) <0.50 (ORaj = 5.5; 95% CI: 2.8-11.0); non-white race (ORaj = 5.2; 95% CI: 2.5-11.0); first sexual intercourse at or before 15 years of age (ORaj = 4.4; 95% CI: 2.3-8.3); HIV infection follow-up time of nine years or more (ORaj = 4.2; 95% CI: 2.3-7.8)]; number of sexual partners during the entire life between three and five partners (ORaj = 2.2; 95% CI: 1.1-4.6), and six or more sexual partners (ORaj = 3.9; 95% CI: 1.9-8.0%); being a sex worker (ORaj = 1.9; 95% CI: 1.1-3.1). Conclusions: A high prevalence of a prior history of STDs in the studied population was found. It is essential to find better ways to access HIV infection prevention, so that effective interventions can be more widely implemented. (C) 2012 Elsevier Editora Ltda. All rights reserved.