Doing patient-centredness versus achieving public health targets: A critical review of interactional dilemmas in ART adherence support.

Anti-retroviral Therapy (ART) transformed HIV into a chronic disease but its individual and public health benefits depend on high levels of adherence. The large and rising number of people on ART, now also used as prevention, puts considerable strain on health systems and providers in low and middle as well as high-income countries, which are our focus here. Delivering effective adherence support is thus crucial but challenging, especially given the promotion of patient-centredness and shared decision making in HIV care. To illuminate the complexities of ART adherence support delivered in and through clinical encounters, we conducted a multi-disciplinary interpretative literature review. We reviewed and synthesized 82 papers published post 1997 (when ART was introduced) belonging to three bodies of literature: public health and psychological studies of ART communication; anthropological and sociological studies of ART; and conversation analytic studies of patient-centredness and shared decision-making. We propose three inter-related tensions which make patient-centredness particularly complex in this infectious disease context: achieving trust versus probing about adherence; patient-centredness versus reaching public health targets; and empowerment versus responsibilisation as 'therapeutic citizens'. However, there is a dearth of evidence concerning how precisely ART providers implement patient-centredness, shared-decision making in practice, and enact trust and therapeutic citizenship. We show how conversation analysis could lead to new, actionable insights in this respect.

Eliciting the smoker's agenda: implications for policy and practice.

Existing health promotion messages and advice on smoking cessation focus upon the negative aspects of continuing to smoke and contrast these to the benefits of giving up. Benefits of cessation are invariably linked to reduced risks of illness and disease with the process of cessation framed as a largely positive and certainly a health enhancing one. In this paper we present an analysis of data from a cross-sectional, exploratory study in the city of Aberdeen, Scotland, undertaken with 54 people, aged 18-44, who are or have been smokers. The multiple and often contradictory agendas of everyday life, smoking and health are explored. Participants spoke of the dangers of smoking and the potential benefits of giving up as these are considered by health promotion and medical research. However, many smokers experienced a number of benefits from smoking (such as socialising with others and breaks from boredom), and health and social problems with the process of cessation (for example, weight gain, stress, colds, flu). Participants appeared to query the validity of the risks of continuing to smoke and yet indicate a range of health and social difficulties in giving up. The authors assert that an acknowledgement of the attractive, pleasurable aspects of smoking may be seen as unacceptable and irresponsible but this could well provide an opportunity to relate to the everyday and multiple practices of smoking and smokers themselves as illuminated by this research.

[Pericardial C-reactive protein. A marker of agonal cardiac disease ?]. / La protéine C-réactive péricardique. Un marqueur de la souffrance cardiaque agonique?

We studied the influence of the agonal period on the concentrations of acute phase proteins in biological fluids obtained from 26 autopsy cases. We found significant differences for C-reactive protein concentrations in serum and in pericardial fluid, between short and long agonies. The other acute phase proteins studied (alpha-1 antitrypsin, alpha-2 macroglobulin, haptoglobin) failed to show any significant difference in serum and pericardial fluid levels between the two types of agony. The increase in C-reactive protein level in the pericardial fluid is attributed to an "agonal pericarditis" which may result from an agonal myocardial necrosis. Our results could be of interest in forensic medicine.