Why do women consent to surgery, even when they do not want to? An interactionist and Bourdieusian analysis

The 'informed consent' process has been placed at the centre of bioethical and policy discourses about how the autonomy and rights of patients can best be protected. Although there has been critical analysis of how the process functions in relation to participation in research and particular ethical 'dilemmas', there has been little examination of the routine business of consenting to medical procedures. Evidence is now beginning to emerge that people may consent to surgery even when reluctant to do so. In this paper, we develop an analysis informed by Bourdieusian and interactionist social theory of the accounts of 25 British women who consented to surgery in obstetrics and gynaecology. Of these, nine were ambivalent or opposed to having an operation. When faced with a consent form, women's accounts suggest that they rarely do anything other than obey professionals' requests for a signature. Women's capacity to act is reduced as they become enmeshed in the hospital structure of tacit, socially imposed rules of conduct. However, the interactionist account of power operating through the social rules of particular situated encounters, and the sanctions associated with rule-breaking, may not provide a sufficiently powerful explanation for why women submit to surgery they are opposed or ambivalent towards. Bourdieu's concepts of habitus, capital and symbolic power/violence offer a potentially more elaborated account, by showing how the practical logic that women apply in the field of surgery confers a 'sense of place' relative to professionals. Women experience deficits in capital, intensified by their physical vulnerability in critical situations, that severely constrain their ability to exercise choice. This work demonstrates the weakness of the consent process as a safeguard of autonomy. Far from reinforcing autonomy, the process may reinforce rather than disrupt passivity, but more generally our findings raise the question of the extent to which autonomy is an illusory goal.     

Screening of the eight BBS genes in Tunisian families: no evidence of triallelism

PURPOSE: To study Bardet-Biedl syndrome (BBS) in the Tunisian population and determine the presence of triallelism in the eight identified BBS genes. METHODS: DNA samples were collected from 19 consanguineous Tunisian families with BBS. Genome-wide scans were performed with microsatellite markers in 12 families, and two-point linkage analyses were performed. Direct sequencing was used to screen patients with BBS for mutations in all eight identified BBS genes. RESULTS: Mutations in the BBS genes were identified in nine families. In addition, a large consanguineous family (57004) showed linkage to the BBS7 locus, although no mutation was identified. Five novel mutations were present in the nine families: one in BBS2 (c.565C>T, p.ArgR189Stop), one in BBS5 (c.123delA, p.Gly42GlufsX11), one in BBS7 (g.47247455_47267458del20004insATA, p.Met284LysfsX7), and two in BBS8 (c.459+1G>A, p.Pro101LeufsX12 and c.355_356insGGTGGAAGGCCAGGCA, p.Thr124ArgfsX43). CONCLUSIONS: All families in which mutations were identified show changes in both copies of the mutant gene, and inheritance patterns in all families are consistent with autosomal recessive inheritance excluding any evidence of triallelism in the BBS genes in Tunisia.     

Q fever endocarditis: a case report

Do we bring back the observation of a patient aged of 42 years having a mitro-aortic valvulopathy who present since 3 months a level III dyspnea, a fever to 39 degrees C, a change of the general state and a splenomegaly. To the chest x-ray we note a pulmonary parenchymatous focus. Echocardiography puts in evidence a mitral illness to stenosis predominance and an aortic illness complicated of a graft bacterial with an abscess of the mitro-aortic trigone. Haemocultures were negative and the serology of the Rickettsia was positive. The diagnosis of infective endocarditis to Coxiella Burnetii is kept and is the patient put under Doxycycline 200 mg/j, Hydroxychloroquine 2 cp/j and Ofloxacine 400 mg/j. Will the two first antibiotics be pursued to the 18th month. The patient benefited, after 20 days of three antibiotics therapy, of a duplicate aortic and mitral replacement with simple following.     

Isolated skin recurrence following salvage mastectomy for intramammary recurrence (after initial breast conservation therapy): is it a fatal event?

Aims

The authors analyzed the outcome of patients with Isolated Skin Recurrence After Salvage Mastectomy (ISRASM) performed after conservative treatment for breast carcinoma, taking into account initial tumor characteristics, intramammary recurrence (first recurrence) characteristics, local skin recurrence (second recurrence) characteristics, and the type of treatment at each stage of the breast cancer continuum.

Methods

Forty-two patients who had ISRASM between 1976 and 2007 were included in this retrospective study. Twenty-six factors were studied in univariate and multivariate analyses.

Results

Mean Overall Survival (OS) was 70.3 (±4.1) months. The 5-year OS rate was 66.6%. 31% of patients did not present any recurrence, 52% had locoregional recurrence and 14% metastatic recurrence following ISRASM. Univariate analysis showed that 4 prognostic factors were significantly related to OS and/or Disease-Free Survival (DFS): (1) initial chemotherapy after primary breast cancer (P = 0.09 and 0.01 respectively), (2) presence of emboli at the site of intramammary recurrence (first recurrence) (P = 0.02 and 0.03), (3) interval between first and second surgery of less than 3 years (P = 0.09 and 0.0003), and (4) inflammatory skin involvement at ISRASM (P = 0.005 and 0.17). Multivariate analysis showed that presence of emboli at the site of intramammary recurrence was significantly related to OS and that an interval between first and second recurrence of less than 3 years was significantly related to DFS.

Conclusion

Our results show that ISRASM affects a group of breast cancer patients with predominantly local rather than metastatic disease. Prognostic factors depend on characteristics at initial breast cancer, first recurrence and second recurrence. Evidence-based guidelines are still required for ISRASM management.     

Transfusion safety in francophone African countries: an analysis of strategies for the medical selection of blood donors

BACKGROUND: The goal of selecting a healthy blood donor is to safeguard donors and reduce the risks of infections and immunologic complications for recipients. STUDY DESIGN AND METHODS: To evaluate the blood donor selection process, a survey was conducted in 28 blood transfusion centers located in 15 francophone African countries. Data collected included availability of blood products, risk factors for infection identified among blood donor candidates, the processing of the information collected before blood collection, the review process for the medical history of blood donor candidates, and deferral criteria for donor candidates. RESULTS: During the year 2009, participating transfusion centers identified 366,924 blood donor candidates. A mean of 13% (range, 0%‐36%) of the donor candidates were excluded based solely on their medical status. The main risk factors for blood‐borne infections were having multiple sex partners, sexual intercourse with occasional partners, and religious scarification. Most transfusion centers collected this information verbally instead of having a written questionnaire. The topics least addressed were the possible complications relating to the donation, religious scarifications, and history of sickle cell anemia and hemorrhage. Only three centers recorded the temperature of the blood donors. The deferral criteria least reported were sickle cell anemia, piercing, scarification, and tattoo. CONCLUSIONS: The medical selection process was not performed systemically and thoroughly enough, given the regional epidemiologic risks. It is essential to identify the risk factors specific to francophone African countries and modify the current medical history questionnaires to develop a more effective and relevant selection process.     

Association Between C-Reactive Protein and Type 2 Diabetes in a Tunisian Population

The aim of this study was to investigate the association of CRP levels with type 2 diabetes (T2D) and its related variables in a sample of the Tunisian population. Our sample included 129 patients with T2D and 187 control subjects. Body mass index (BMI), plasma lipids, glucose, insulin, and CRP concentrations were measured for each participant. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. T2D was defined as a fasting plasma glucose (FPG) level ≥ 7.0 mmol/L, the use of anti-diabetic drugs, or both. Statistical analyses were performed using SPSS 11.5. A significant difference in mean values of BMI, plasma lipids, FPG, insulin, and HOMA-IR was observed between subjects with and without T2D. CRP level was significantly higher in subjects with T2D than those without (p = 0.023), and this result persisted even after adjustment for age, gender, BMI, smoking, and alcohol consumption. In both diabetes statuses, log CRP was significantly associated with FPG, insulin, and HOMA-IR. Subjects with elevated CRP levels (>5 mg/L) had an increased risk of T2D (OR = 2.02, 95% CI 1.18–3.46, p = 0.010) than those whose CRP levels were less or equal to 5 mg/L. Even after adjustment for potentially confounding factors, the risk of T2D was still increased in subjects with elevated CRP levels (OR = 1.91, 95% CI 1.08–3.36, p = 0.025). These results suggest that elevated CRP levels are independently associated with T2D.