"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.

Interactions of Gut Microbiota, Endotoxemia, Immune Function, and Diet in Exertional Heatstroke.

Exertional heatstroke (EHS) is a medical emergency that cannot be predicted, requires immediate whole-body cooling to reduce elevated internal body temperature, and is influenced by numerous host and environmental factors. Widely accepted predisposing factors (PDF) include prolonged or intense exercise, lack of heat acclimatization, sleep deprivation, dehydration, diet, alcohol abuse, drug use, chronic inflammation, febrile illness, older age, and nonsteroidal anti-inflammatory drug use. The present review links these factors to the human intestinal microbiota (IM) and diet, which previously have not been appreciated as PDF. This review also describes plausible mechanisms by which these PDF lead to EHS: endotoxemia resulting from elevated plasma lipopolysaccharide (i.e., a structural component of the outer membrane of Gram-negative bacteria) and tissue injury from oxygen free radicals. We propose that recognizing the lifestyle and host factors which are influenced by intestine-microbial interactions, and modifying habitual dietary patterns to alter the IM ecosystem, will encourage efficient immune function, optimize the intestinal epithelial barrier, and reduce EHS morbidity and mortality.

Missing Voices: Profile, Extent, and 12-Month Outcomes of Nonfatal Traumatic Brain Injury in Aboriginal and Non-Aboriginal Adults in Western Australia Using Linked Administrative Records.

OBJECTIVE: To investigate differences in the profile and outcomes between Aboriginal and non-Aboriginal Western Australians (WAs) hospitalized with traumatic brain injury (TBI). SETTING: WA hospitals. PARTICIPANTS: TBI cases aged 15 to 79 years surviving their first admission during 2002-2011. DESIGN: Patients identified from diagnostic codes and followed up for 12 months or more using WA-wide person-based linked hospital and mortality data. MAIN MEASURES: Demographic profile, 5-year comorbidity history, injury mechanism, injury severity, 12-month readmission, and mortality risks. Determinants of 12-month readmission. RESULTS: Of 16 601 TBI survivors, 14% were Aboriginal. Aboriginal patients were more likely to be female, live remotely, and have comorbidities. The mechanism of injury was an assault in 57% of Aboriginal patients (vs 20%) and transport in 33% of non-Aboriginal patients (vs 17%), varying by remoteness. One in 10 Aboriginal TBI patients discharged themselves against medical advice. Crude 12-month readmission but not mortality risk was significantly higher in Aboriginal patients (48% vs 36%). The effect of age, sex, and injury mechanism on 12-month readmission was different for Aboriginal and non-Aboriginal patients. CONCLUSION: These findings suggest an urgent need for multisectoral primary prevention of TBI, as well as culturally secure and logistically appropriate medical and rehabilitation service delivery models to optimize outcomes.

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.

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.

Mode of delivery: toward responsible inclusion of patient preferences.

Deciding when and how to incorporate patient preferences regarding mode of delivery is challenging for both obstetric providers and policymakers. An analysis of current guidelines in four clinical scenarios (prior cesarean, twin delivery, breech presentation, and maternal request for cesarean) indicates that some guidelines are highly prescriptive whereas others are more flexible, based on physicians' discretion or (less frequently) patient preferences, without consistency or explicit rationale for when such flexibility is permissible, advisable, or obligatory. Although patient-choice advocates have called for more patient-responsive guidelines, concerns also have been raised, especially in the context of discussions of cesarean delivery on maternal request, about the dangers of unfettered patient-preference-driven clinical decisions. In this article, we outline a framework for the responsible inclusion of patient preferences into decision making regarding approach to delivery. We conclude, using this framework, that more explicit incorporation of patient preferences is called for in the first three scenarios and indicate why expanding access to cesarean delivery on maternal request is more complicated and would require more data and further consideration.

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.

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.