Making the best of multidisciplinary care for patients with malignant fungating wounds: A qualitative study of clinicians' narratives.

BACKGROUND: Malignant fungating wounds occur in advanced cancer patients, often in the last 6 to 12 months of life, when malignant cells breach the skin, causing a non-healing wound. Little is known about the perspectives of clinicians who treat these patients or how collaboration is facilitated among different specialties. OBJECTIVE: To understand the experiences and perceived roles of clinicians who treat patients with malignant fungating wounds from a multidisciplinary perspective. DESIGN: A qualitative study using narrative interviews was conducted and data was analyzed to identify themes that encompass the experiences of clinicians who treat patients malignant fungating wounds and put these experiences in a temporal context. SETTING/SUBJECTS: Ten clinicians who treat patients with malignant fungating wounds (n = 10) from various metropolitan research hospitals were interviewed. The clinicians were of different disciplines, including physicians and nurses, and different specialties, including palliative care, oncology, and wound care. RESULTS: Three themes emerged that described how clinicians of varying disciplines and specialties understood their roles and navigated the transition from curative to palliative care for patients with malignant fungating wounds: (1) making the best of fragmented care (2) collaboration between oncology and wound care (3) transitioning from curative to palliative care. CONCLUSION: Findings of the study present a timeline of clinical care for patients, with different specialties taking the lead at different points in clinical time. Recognizing when collaboration between specialties is essential, as well as when communication fails, or clinicians have differing perspectives is important to facilitate the best care possible for patients.

On Hymenoplasty.

Some traditional cultural practices assure expected wedding night bleeding, to help preserve the honor of all parties.

Cultural explanations of psychotic illness and care-seeking of family caregivers in Java, Indonesia.

The cultural understanding of illness among caregivers of first-episode psychotic persons is a crucial issue. Not only does it influence caregivers' care-seeking behavior and length of time until receiving medical treatment (known as the 'duration of untreated psychosis' or DUP), but it also predicts the outcome of the illness. This article aims to explore cultural understanding and care-seeking behavior among caregivers of psychotic patients in Java, Indonesia. Data for this article have been taken from two studies conducted by our research group in Yogyakarta, Indonesia. Methods of data collection include surveys, case studies, ethnographic fieldwork, and in-depth interviews. Results of analyses, within and across studies, indicate that caregivers have employed diverse cultural explanatory models in order to understand psychotic illness. Local cultural beliefs, including possession and forms of black magic, were among the most common initial concepts held by family members in relation to psychosis. This echoes broader cultural beliefs in Java. However, it was not uncommon for caregivers to also understand illness in psychological terms (such as frustration, disappointment, and stress) and attached medical explanations. Caregivers' understanding of illness also changed over time following the changing course of the illness. Both models of illness and the rapidity of care-seeking are also related to the acuteness of onset. This article concludes that it is important for mental health providers, as well as those designing systems of care, to understand the diversity and changing nature of caregivers' cultural understanding of psychotic illness.

Determinants of tetanus, diphtheria and poliomyelitis vaccinations among Hajj pilgrims, Marseille, France.

BACKGROUND: It has been observed that Muslim pilgrims departing France for Mecca have low national immunization rates against tetanus, diphtheria and poliomyelitis (TdP). Our purpose is to identify immigration, socio-economic and socio-cultural determinants of vaccination coverage against TdP. METHODS: A cross-sectional survey study was conducted in late 2006 among 580 pilgrims in preparation who attended the Infectious and Tropical Medicine ward in Hôpital Nord at Marseille to receive their N. meningitidis vaccine required for travel to Mecca. RESULTS: Total vaccination rates for tetanus (18.9%), diphtheria (14.7%) and poliomyelitis (15.0%) were comparable. Pilgrim's characteristic lower socio-economic and social status, in addition to their unifying linguistic, cultural and religious identity defines them as a particularly disadvantageous group in France. French citizenship, higher level of education, better French fluency and no previous travel to country of origin were the strongest and most significant determinants of TdP vaccination status. CONCLUSION: These results suggest that the Muslim community in France is at risk from inequities of national preventive care efforts.

Narrative nuances on good and bad deaths: internists' tales from high-technology work places.

Public and professional discourses in American society about what constitutes a "good death" have flourished in recent decades, as illustrated by the pivotal SUPPORT study and the growing palliative care movement. This paper examines a distinctive medical discourse from high-technology academic medical centers through an analysis of how physicians who are specialists in internal medicine tell stories about the deaths of patients in their care. 163 physicians from two major academic medical centers in the United States completed both qualitative open interviews and quantitative attitudinal measures on a recent death and on the most emotionally powerful death they experienced in the course of their careers. A subsample of 75 physicians is the primary source for the qualitative analysis, utilizing Atlas-ti."Good death" and "bad death" are common in popular discourse on death and dying. However, these terms are rarely used by physicians in this study when discussing specific patients and individual deaths. Rather, physicians' narratives are nuanced with professional judgments about what constitutes quality end-of-life care. Three major themes emerge from these narratives and frame the positive and negative characteristics of patient death. Time and Process: whether death was expected or unexpected, peaceful, chaotic or prolonged; Medical Care and Treatment Decisions: whether end-of-life care was rational and appropriate, facilitating a "peaceful" or "gentle" death, or futile and overly aggressive, fraught with irrational decisions or adverse events; Communication and Negotiation: whether communication with patients, family and medical teams was effective, leading to satisfying management of end-of-life care, or characterized by misunderstandings and conflict. When these physicians' narratives about patient deaths are compared with the classic sociological observations made by Glaser and Strauss in their study A Time for Dying (1968), historical continuities are evident as are striking differences associated with rapid innovation in medical technologies and a new language of medical futility. This project is part of a broader effort in American medicine to understand and improve end-of-life care.