"I'm Going to Be Good to Me": Exploring the Role of Shame and Guilt in Patients With Type 2 Diabetes

OBJECTIVE

People with type 2 diabetes are likely to experience shame or guilt as they navigate through their disease. Previous research has shown that feelings of shame and guilt often exist within the clinician-patient relationship, often as a result of the complex care regimen required to achieve treatment goals. The purpose of this qualitative study was to explore patients' experiences of shame and guilt in type 2 diabetes management and the impact their clinicians have on these experiences.

METHODS

Semistructured interviews were used to explore patients' experiences with shame and guilt. Interviews were audio-recorded, transcribed, and coded using directed content analysis. Demographic data were also obtained.

RESULTS

We completed 20 interviews with people with type 2 diabetes (65% Black, 70% female). Participants exhibited feelings more consistent with guilt than with shame. All participants discussed how their clinicians affected these feelings. Patients who expressed feelings of guilt were able to recognize opportunities for behavior change without experiencing global devaluation, in which they linked their actions to an unchangeable aspect of their identity or personality, often describing their guilt as motivating of change. Unlike guilt, when patients experienced shame, they often exhibited global devaluation, in which they blamed their personality, experienced hopelessness, and increased maladaptive behaviors.

CONCLUSION

Our findings highlight a notable difference between shame and guilt in the context of type 2 diabetes management. We believe that incorporation of an understanding of these nuances, along with ideal responses to both shame and guilt, will enhance clinicians' ability to provide high-quality patient-centered care to people with diabetes.

Overtraining Syndrome as a Complex Systems Phenomenon

The phenomenon of reduced athletic performance following sustained, intense training (Overtraining Syndrome, and OTS) was first recognized more than 90 years ago. Although hundreds of scientific publications have focused on OTS, a definitive diagnosis, reliable biomarkers, and effective treatments remain unknown. The present review considers existing models of OTS, acknowledges the individualized and sport-specific nature of signs/symptoms, describes potential interacting predisposing factors, and proposes that OTS will be most effectively characterized and evaluated via the underlying complex biological systems. Complex systems in nature are not aptly characterized or successfully analyzed using the classic scientific method (i.e., simplifying complex problems into single variables in a search for cause-and-effect) because they result from myriad (often non-linear) concomitant interactions of multiple determinants. Thus, this review 1) proposes that OTS be viewed from the perspectives of complex systems and network physiology, 2) advocates for and recommends that techniques such as trans-omic analyses and machine learning be widely employed, and 3) proposes evidence-based areas for future OTS investigations, including concomitant multi-domain analyses incorporating brain neural networks, dysfunction of hypothalamic-pituitary-adrenal responses to training stress, the intestinal microbiota, immune factors, and low energy availability. Such an inclusive and modern approach will measurably help in prevention and management of OTS.

Distinguishing Low and High Water Consumers-A Paradigm of Disease Risk

A long-standing body of clinical observations associates low 24-h total water intake (TWI = water + beverages + food moisture) with acute renal disorders such as kidney stones and urinary tract infections. These findings prompted observational studies and experimental interventions comparing habitual low volume (LOW) and high volume (HIGH) drinkers. Investigators have learned that the TWI of LOW and HIGH differ by 1-2 L·d-1, their hematological values (e.g., plasma osmolality, plasma sodium) are similar and lie within the laboratory reference ranges of healthy adults and both groups appear to successfully maintain water-electrolyte homeostasis. However, LOW differs from HIGH in urinary biomarkers (e.g., reduced urine volume and increased osmolality or specific gravity), as well as higher plasma concentrations of arginine vasopressin (AVP) and cortisol. Further, evidence suggests that both a low daily TWI and/or elevated plasma AVP influence the development and progression of metabolic syndrome, diabetes, obesity, chronic kidney disease, hypertension and cardiovascular disease. Based on these studies, we propose a theory of increased disease risk in LOW that involves chronic release of fluid-electrolyte (i.e., AVP) and stress (i.e., cortisol) hormones. This narrative review describes small but important differences between LOW and HIGH, advises future investigations and provides practical dietary recommendations for LOW that are intended to decrease their risk of chronic diseases.

Development of the Aboriginal Communication Assessment After Brain Injury (ACAABI): A screening tool for identifying acquired communication disorders in Aboriginal Australians

PURPOSE

Acquired communication disorders (ACD), following stroke and traumatic brain injury, may not be correctly identified in Aboriginal Australians due to a lack of linguistically and culturally appropriate assessment tools. Within this paper we explore key issues that were considered in the development of the Aboriginal Communication Assessment After Brain Injury (ACAABI) - a screening tool designed to assess the presence of ACD in Aboriginal populations.

METHOD

A literature review and consultation with key stakeholders were undertaken to explore directions needed to develop a new tool, based on existing tools and recommendations for future developments.

RESULT

The literature searches revealed no existing screening tool for ACD in these populations, but identified tools in the areas of cognition and social-emotional wellbeing. Articles retrieved described details of the content and style of these tools, with recommendations for the development and administration of a new tool. The findings from the interview and focus group views were consistent with the approach recommended in the literature.

CONCLUSIONS

There is a need for a screening tool for ACD to be developed but any tool must be informed by knowledge of Aboriginal language, culture and community input in order to be acceptable and valid.

Missing voices: Profile and extent of acquired communication disorders in Aboriginal and non-Aboriginal adult stroke survivors in Western Australia using linked administrative records

Background

Limited data exist on the extent of specific functional sequelae, including acquired communication disorder, among Aboriginal stroke survivors, making planning of multidisciplinary services difficult.

Aims

To obtain estimates of the extent and profile of acquired communication disorder in Aboriginal and non-Aboriginal adult stroke survivors in Western Australia and investigate potential disparities in receiving in-hospital speech pathology services among survivors with acquired communication disorder.

Methods

Stroke cases surviving their first stroke episode during 2002–2011 were identified using Western Australia-wide person-based linked hospital and mortality data, and their five-year comorbidity profiles determined. The mid-year prevalence of stroke cases with acquired communication disorder was estimated for 2011. Regression methods were used to investigate determinants of receiving speech pathology services among acquired communication disorder cases.

Results

Of 14,757 stroke survivors aged 15–79 years admitted in 2002–2011, 33% had acquired communication disorder (22% aphasia/dysphasia) and 777 (5.3%) were Aboriginal. Aboriginal patients were more likely to be younger, live remotely, and have comorbidities. A diagnosis of aphasia was more common in Aboriginal than non-Aboriginal patients 15–44 years (p = 0.003). A minimum of 107 Aboriginal and 2324 non-Aboriginal stroke patients with acquired communication disorder lived in Western Australia in 2011. Aboriginal status was not associated with receiving in-hospital speech services among acquired communication disorder patients in unadjusted or adjusted models.

Conclusions

The relative youth, geographical distribution, high comorbidity prevalence, and cultural needs of Aboriginal stroke patients with acquired communication disorder should inform appropriate service design for speech pathology and rehabilitation. Innovative models are required to address workforce issues, given low patient volumes.

“Good Girls”

Women’s participation in slut shaming is often viewed as internalized oppression: they apply disadvantageous sexual double standards established by men. This perspective grants women little agency and neglects their simultaneous location in other social structures. In this article we synthesize insights from social psychology, gender, and culture to argue that undergraduate women use slut stigma to draw boundaries around status groups linked to social class—while also regulating sexual behavior and gender performance. High-status women employ slut discourse to assert class advantage, defining themselves as classy rather than trashy, while low-status women express class resentment—deriding rich, bitchy sluts for their exclusivity. Slut discourse enables, rather than constrains, sexual experimentation for the high-status women whose definitions prevail in the dominant social scene. This is a form of sexual privilege. In contrast, low-status women risk public shaming when they attempt to enter dominant social worlds.

Imaging features of ductal plate malformations in adults

Ductal plate malformations, also known as fibrocystic liver diseases, are a group of congenital disorders resulting from abnormal embryogenesis of the biliary ductal system. The abnormalities include choledochal cyst, Caroli's disease and Caroli's syndrome, adult autosomal dominant polycystic liver disease, and biliary hamartoma. The hepatic lesions can be associated with renal anomalies such as autosomal recessive polycystic kidney disease (ARPKD), medullary sponge kidney, and nephronophthisis. A clear knowledge of the embryology and pathogenesis of the ductal plate is central to the understanding of the characteristic imaging appearances of these complex disorders. Accurate diagnosis of ductal plate malformations is important to direct appropriate clinical management and prevent misdiagnosis.

Finding autonomy in birth

Over the last several years, as cesarean deliveries have grown increasingly common, there has been a great deal of public and professional interest in the phenomenon of women 'choosing' to deliver by cesarean section in the absence of any specific medical indication. The issue has sparked intense conversation, as it raises questions about the nature of autonomy in birth. Whereas mainstream bioethical discourse is used to associating autonomy with having a large array of choices, this conception of autonomy does not seem adequate to capture concerns and intuitions that have a strong grip outside this discourse. An empirical and conceptual exploration of how delivery decisions ought to be negotiated must be guided by a rich understanding of women's agency and its placement within a complicated set of cultural meanings and pressures surrounding birth. It is too early to be 'for' or 'against' women's access to cesarean delivery in the absence of traditional medical indications--and indeed, a simple pro- or con- position is never going to do justice to the subtlety of the issue. The right question is not whether women ought to be allowed to choose their delivery approach but, rather, taking the value of women's autonomy in decision-making around birth as a given, what sorts of guidelines, practices, and social conditions will best promote and protect women's full inclusion in a safe and positive birth process.

A different story on "Theory of Mind" deficit in adults with right hemisphere brain damage

BACKGROUND: Difficulties in social cognition and interaction can characterise adults with unilateral right hemisphere brain damage (RHD). Some pertinent evidence involves their apparently poor reasoning from a "Theory of Mind" perspective, which requires a capacity to attribute thoughts, beliefs, and intentions in order to understand other people's behaviour. Theory of Mind is typically assessed with tasks that induce conflicting mental representations. Prior research with a commonly used text task reported that adults with RHD were less accurate in drawing causal inferences about mental states than at making non-mental-state causal inferences from control texts. However, the Theory of Mind and control texts differed in the number and nature of competing discourse entity representations. This stimulus discrepancy, together with the explicit measure of causal inferencing, likely put the adults with RHD at a disadvantage on the Theory of Mind texts. AIMS: This study revisited the question of Theory of Mind deficit in adults with RHD. The aforementioned Theory of Mind texts were used but new control texts were written to address stimulus discrepancies, and causal inferencing was assessed relatively implicitly. Adults with RHD were hypothesised not to display a Theory of Mind deficit under these conditions. METHODS #ENTITYSTARTX00026; PROCEDURES: The participants were 22 adults with unilateral RHD from cerebrovascular accident, and 38 adults without brain damage. Participants listened to spoken texts that targeted either mental-state or non-mental-state causal inferences. Each text was followed by spoken True/False probe sentences, to gauge target inference comprehension. Both accuracy and RT data were recorded. Data were analysed with mixed, two-way Analyses of Variance (Group by Text Type). OUTCOMES #ENTITYSTARTX00026; RESULTS: There was a main effect of Text Type in both accuracy and RT analyses, with a performance advantage for the Theory of Mind/mental-state inference stimuli. The control group was faster at responding, and primed more for the target inferences, than the RHD group. The overall advantage for Theory of Mind texts was traceable to one highly conventional inference: someone tells a white lie to be polite. Particularly poor performance in mental-state causal inferencing was not related to neglect or lesion site for the group with RHD. CONCLUSIONS: With appropriate stimulus controls and a relatively implicit measure of causal inferencing, this study found no "Theory of Mind" deficit for adults with RHD. The utility of the "Theory of Mind" construct is questioned. A better understanding of the social communication difficulties of adults with RHD will enhance clinical management in the future.

Optimization of CT colonography technique: a practical guide

In this article we provide practical advice for optimizing computed tomography colonography (CTC) technique to help ensure that reproducible, high-quality examinations are achieved. Relevant literature is reviewed and specific attention is paid to patient information, bowel cleansing, insufflation, anti-spasmodics, patient positioning, CT technique, post-procedure care and complications, as well as practical problem-solving advice. There are many different approaches to performing CTC; our aim is to not to provide a comprehensive review of the literature, but rather to present a practical and robust protocol, providing guidance, particularly to those clinicians with little prior experience of the technique.

Risks, values, and decision making surrounding pregnancy

Assessing, communicating, and managing risk are among the most challenging tasks in the practice of medicine and are particularly difficult in the context of pregnancy. We analyze common scenarios in medical decision making around pregnancy, from reproductive health policy and clinical care to research protections. We describe three tendencies in these scenarios: 1) to consider the probabilities of undesirable outcomes alone, in isolation from women's values and social contexts, as determinative of individual clinical decisions and health policy; 2) to regard any risk to the fetus, including incremental risks that would in other contexts be regarded as acceptable, as trumping considerations that may be substantially more important to the wellbeing of the pregnant woman; and 3) to focus on the risks associated with undertaking medical interventions during pregnancy to the exclusion of demonstrable risks to both woman and fetus of failing to intervene. These tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.

Whose deaths matter? Mortality, advocacy, and attention to disease in the mass media

Diseases capture public attention in varied ways and to varying degrees. In this essay, we use a unique data set that we have collected about print and broadcast media attention to seven diseases across nineteen years in order to address two questions. First, how (if at all) is mortality related to attention? Second, how (if at all) is advocacy, in the form of organized interest group activity, related to media attention? Our analysis of the cross-disease and cross-temporal variation in media attention suggests that who suffers from a disease as well as how many suffer are critical factors in explaining why some diseases get more attention than others. In particular, our data reveal that both the print and the broadcast media tend to be much less attentive to diseases that disproportionately burden blacks relative to whites. We also find a positive link between the size of organizational communities that take an interest in disease and media attention, though this finding depends on the characteristics of those communities. Finally, this study also reveals the limitations of relying on single-disease case studies-and particularly HIV/AIDS-to understand how and why disease captures public attention. Many previous inferences about media attention that have been drawn from the case of AIDS are not reflective of the attention allocated to other diseases.

Preventing errors in the outpatient setting: a tale of three states

Although error in medicine has received sustained policy attention recently, the problem of error in the outpatient setting has been relatively neglected. In this paper we review what is known about the incidence and nature of error-related adverse events in physicians' offices, ambulatory care facilities, and surgicenters. We then analyze policies to improve outpatient safety in New Jersey, New York, and Florida, three states that took very different paths toward this goal. Their experience suggests that accreditation, combined with particular attention to ensuring anesthesia safety, can improve quality of care for outpatients. These actions are best accomplished through proactive legislation and the development of regulations, rather than reactive responses to adverse events.

Investigations of Amavadin

The development of the understanding of the co-ordination chemistry and the properties of Amavadin, the chemical form in which vanadium is accumulated by the Amanita genus of mushrooms, is reviewed.

Fetal alcohol syndrome: the origins of a moral panic

Since its discovery almost 30 years ago, the fetal alcohol syndrome (FAS) has been characterized in the USA, as a major threat to public health. In part because FAS resonated with broader social concerns in the 1970s and 1980s about alcohol's deleterious effect on American society and about a perceived increase in child abuse and neglect, it quickly achieved prominence as a social problem. In this paper, we demonstrate that, as concern about this social problem escalated beyond the level warranted by the existing evidence, FAS took on the status of a moral panic. Through examples taken from both the biomedical literature and the media about drinking during pregnancy, we illustrate the evolution of this development, and we describe its implications, particularly how it has contributed to a vapid public policy response.

Diagnosing moral disorder: the discovery and evolution of fetal alcohol syndrome

The diagnosis of fetal alcohol syndrome (FAS) was invented in 1973. This paper investigates the process by which a cluster of birth defects associated with exposure to alcohol in utero came to be a distinct medical diagnosis, focusing on the first ten years of the medical literature on FAS. Fetal alcohol syndrome was "discovered" by a group of American dysmorphologists who published the first case reports and coined the term FAS. However, the nature of the diagnosis and its salient symptoms were determined collectively over time by the medical profession as a whole. The paper traces the natural history of the diagnosis in the U.S. through five stages: introduction, confirmation and corroboration, dissent, expansion, and diffusion. FAS serves as an example of the social construction of clinical diagnosis; moral entrepreneurship plays a key role and the medical literature on FAS is infused with moral rhetoric, including passages from classical mythology, philosophy, and the Bible. FAS is a moral as well as a medical diagnosis, reflecting the broader cultural concerns of the era in which it was discovered, including a greater awareness of environmental threats to health, the development of fetal medicine, an emphasis on "the perfect child," and a growing paradigm of maternal-fetal conflict.

Zinc co-ordination in the DNA-binding domain of the yeast transcriptional activator PPR1

The structure of the native zinc form of the DNA binding domain in the yeast transcriptional activator PPR1 was investigated by extended X-ray absorption fine structure (EXAFS). By carrying out the EXAFS measurements at 11k we were able to demonstrate explicitly the proximity of the two zinc ions (Zn-Zn distance = 3.16 +/- 0.03 A) and the presence of bridging cysteine ligands. The results show that the six cysteine residues co-ordinate two zinc ions in a two-metal ion cluster. PPR1 is the first member of this class of protein for which such information has been obtained.

Neurasthenic fatigue, chemical sensitivity and GABAa receptor toxins

Following observation of fatigue syndromes in people who have been occupationally exposed to pesticides and insecticides which exert their toxicity through the GABAa receptor, we have formulated the hypothesis that fatigue syndromes in general may be secondary to altered sensitivity of the GABAa receptor. We discuss the possible involvement of organochlorine compounds which are widespread in the environment. Organophosphate compounds may have similar toxic effects through damaged cholinergic input to the dentate gyrus of the hippocampus where cholinergic and GABAergic transmission are closely linked.

A BMA secretary for quality. Interview by Richard Smith

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CREST syndrome: a variant of progressive systemic sclerosis, associated with interstitial pulmonary fibrosis and malignancy

We have described a patient who had a clinical picture of CREST syndrome and pulmonary interstitial fibrosis, and in whom adenocarcinoma of the lung developed over a four-year period. Despite absence in the literature of the association of lung carcinoma in patients with CREST syndrome, our case is an example of pulmonary fibrosis complicated by lung cancer without any evidence of other risk factors. We believe this to be the first report of such an association. Clinicians, therefore, must be aware that pulmonary interstitial fibrosis in patients with the CREST syndrome may represent a risk for lung cancer.

Lung function in sickle cell hemoglobinopathy patients compared with healthy subjects

Previous studies of lung function tests performed on patients with sickle cell disease have shown a restrictive ventilatory defect, usually a diffusion defect, and mild hypoxia at rest. The present study was undertaken to explain the pathophysiology of these changes and to extend these studies to include functional measurements not reported previously.Lung function studies were performed at rest and during treadmill walking on 66 patients with sickle cell anemia and on 16 healthy control subjects. Patients had restrictive ventilatory defects, decreased lung compliance, and uneven ventilation-perfusion ratios. These abnormalities caused an increased alveolar-arterial oxygen tension difference that caused hypoxemia. The diffusion defects were because of the sickle cell disease.Carboxyhemoglobin levels were increased in patients with sickle cell disease. This increase may be caused by a combination of factors, including increased cigarette smoking, hemolysis, and preferential survival of red blood cells that contain carbon monoxide and which do not sickle. During treadmill walking, the patients with sickle cell disease showed a decreased work tolerance caused by impaired oxygen delivery. The anaerobic threshold is reached sooner in patients with sickle cell disease and may also account for the limitations in work capacity of these patients.

Acquired functional asplenia in sarcoidosis

Sarcoidosis is a recently identified cause of functional asplenia that can be diagnosed by radionuclide imaging. A 31-year-old woman with a five-year history of histologically compatible sarcoidosis was found to have nonvisualization of the spleen on technetium 99m sulfur colloid (radiopharmaceutical) liver-spleen scan. This scintigraphic finding was accompanied by poikilocytosis and Howell-Jolly bodies in the peripheral blood smear. A subsequent gallium 67 citrate scan reflected an abnormal increase in concentration of activity in the spleen, suggesting an active inflammatory process.Based upon this constellation of findings, it was concluded that acquired functional asplenia is the result of reticuloendothelial cell replacement via infiltration of the spleen by epithelioid cell granulomas of active sarcoidosis. This case also illustrates the reversibility of functional asplenia of sarcoidosis following adrenocorticosteroid therapy. Functional asplenia in sarcoidosis is now found to have a recognizable radionuclide imaging pattern.

Bronchial and transbronchial lung biopsy without fluoroscopy in sarcoidosis

Sixty-eight patients with a clinical diagnosis of sarcoidosis underwent flexible fiberoptic bronchial and transbronchial lung biopsies without the aid of fluoroscopy. Close observation of the normal respiratory excursions of the distal tracheobronchial tree and tactile sensations were found to be helpful in preventing pleural rupture. Sarcoidosis was histologically confirmed in bronchial or transbronchial tissue (or both) by this technique in 51 (76 percent) of 67 patients. Only a single pneumothorax and no significant bleeding resulted from this procedure. In the hands of experienced physicians, peripheral bronchial biopsies and transbronchoscopic lung biopsies are safe and accurate procedures even when performed in institutions where fluoroscopy is not immediately available.

Therapy of tuberculosis

Despite its great decline in recent years as a cause of death, tuberculosis remains a curable and preventable disease. Remarkable progress has been made in understanding the pathogenesis and management of both pulmonary and extrathoracic disease. With the availability of multiple bactericidal drugs the length of treatment has been considerably shortened, while maintaining the high cure rate and low relapse rate. With the transfer of the treatment from the sanitoriums and specialized hospitals to mainstream outpatient medicine, it is incumbent upon all physicians who treat tuberculous patients to understand the actions of each drug and the most effective combinations.

The lung in sickle cell disease: a clinical overview of common vascular, infectious, and other problems

Acute pulmonary complications of sickle cell anemia are sickle cell lung disease and bacterial pneumonias. Chronic abnormalities in lung function include a restrictive ventilatory defect and perhaps increased venous admixture to the pulmonary circulation. Coexisting sarcoidosis may complicate sickle cell anemia and interact to potentiate sickling. Sickle cell lung disease, or acute "chest syndrome," occurs with greatest frequency in adults, is due primarily to pulmonary infarction, and may lead to cor pulmonale. On the other hand, bacterial pneumonia due to Streptococcus pneumoniae occurs with greater frequency in infancy and childhood. Mycoplasma and other organisms may also cause pneumonia with protracted illness and slow resolution. Bacteremia and meningitis may be further complications, particularly in children. Precise diagnosis of the acute febrile pulmonary episode is often difficult. In adults the illness is commonly self-limited. However, a vigorous diagnostic approach is warranted in all severely ill patients.

Pulmonary interstitial changes following bone marrow transplantation

Observations of 20 consecutive bone marrow transplantation recipients disclosed two distinctive categories of pulmonary interstitial changes. Interstitial infiltrates occurring less than 14 days after transplantation were observed in 13 of 20 patients and are believed to represent pulmonary edema. A late pulmonary interstitial process, which appears more than 30 days following transplantation (median 57 days), was encountered in 10 of 14 patients with successful grafts; the late changes represent interstitial pneumonia, a common cause of morbidity and mortality following bone marrow transplantation. It is probably attributable to a combination of factors including the preparatory chemotherapy and radiotherapy, and delayed immunologic reconstitution following transplantation.

The cyclical variation in the percentage of ciliated cells in the normal human endometrium

The percentage of ciliated cells in the luminal and glandular epithelia of endometrial samples from sixty-eight normal women has been studied. Although the concentration of ciliated cells found in the luminal epithelium tended to lag behind and below those found in the glandular epithelium, no significant difference was found between the absolute percentages of ciliated cells in each site. The number of ciliated cells increased during the proliferative phase to reach a maximum of around 20%. This was maintained during the ovulatory phase, and then declined. The hormonal basis of this variation is discussed.

Observations on the three-dimensional structure of the nucleolar channel system of the human endometrial glandular cell

Nucleolar channel systems from human endometrial glandular cells have been subjected to three-dimensional analysis using a goniometer stage. The results are compatible with a secondary helical conformation of the constituent tubules and this idea has been incorporated into an improved model of the channel system.

The giant mitochondrion-endoplasmic reticulum unit of the human endometrial glandular cell

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