An explanatory factor analysis of a brief self-report scale to detect neurocognitive impairment among HIV-positive men who have sex with men and transgender women in Peru

Neurocognitive impairment (NCI) has been associated with poor clinical outcomes in various patient populations. This study used exploratory factor analysis (EFA) to examine the factor structure of the existing 95-item Neuropsychological Impairment Scale (NIS) to create a suitable NCI screening instrument for people living with HIV (PLH). In Lima, Peru, 313 HIV-positive men who have sex with men (MSM) and transgender women (TGW) prescribed antiretroviral therapy (ART) completed the NIS using computer-assisted self-interviews (CASI). The EFA used principal axis factoring and orthogonal varimax rotation, which resulted in 42 items with an 8-factor solution that explained 51.8% of the overall variance. The revised, 8-factor, Brief Inventory of Neurocognitive Impairment for Peru (BINI-P) showed a diverse set of factors with excellent to good reliability (i.e., F₁ α?=?0.92 to F₈ α?=?0.78). This EFA supports the use of the BINI-P to screen for NCI among Spanish-speaking, HIV-positive MSM and TGW. Future research should examine the effectiveness of the BINI-P in detecting NCI in clinical care settings and the impact of NCI on HIV health-related outcomes, including linkage and retention in care, ART adherence and HIV risk behaviors.     

Dissolving the Explanatory Gap: Neurobiological Differences Between Phenomenal and Propositional Knowledge

The explanatory gap and theknowledge argument are rooted in the conflationof propositional and phenomenal knowledge. Thebasic knowledge argument is based on theconsideration that ``physical information' aboutthe nervous system is unable to provide theknowledge of a ``color experience' (Jackson,1982). The implication is that physicalism isincomplete or false because it leaves somethingunexplained. The problem with Jackson'sargument is that physical information has theform of highly symbolic propositional knowledgewhereas phenomenal knowledge consists in innateneurophysiological processes. In addition totheir fundamental epistemological differences,clinical, anatomical, pathological and brainimaging studies demonstrate that phenomenal andpropositional knowledge are fundamentallydifferent neurobiological processes. Propositional knowledge is phylogeneticallynew, highly symbolic, culturally acquired,exclusively human and expressible in differentnatural and artificial languages. By contrast,phenomenal knowledge (i.e.: knowingwhat-it-is-like to see a color) consists inqualitative experiences and phenomenal conceptsthat provide an internal, language-independentreference to the properties of objects and theneeds of the organism. Language andpropositional knowledge are exclusively humanattributes implemented in specific regions ofthe dominant hemisphere. This contrastssharply with the phylogenicallysensory areas that are common to animals andhumans, which implement qualitativeexperiences. Experiences are hard-wiredneurobiological processes that can neither betransmitted nor re-created through thesymbolism of propositions. Thus, I concludethat the fallacy in the explanatory gap and inthe knowledge argument is a fallacy ofequivocation that results from ignoringfundamental neurobiological differences betweenphenomenal and propositional knowledge.     

Conceptions of dementia in a multiethnic sample of family caregivers

Understanding variability in conceptions of dementia in multiethnic populations is important to improve care and guide research. The objectives of this study were to describe caregiver conceptions of dementia using a previously developed typology and to examine the correlates of conceptions of dementia in a multiethnic sample. This is a cross-sectional study conducted in Boston and the San Francisco Bay area. Participants were a convenience sample of 92 family dementia caregivers from four ethnic/racial groups: African-American, Anglo European-American, Asian-American, and Latino. In-depth, qualitative interviews explored the caregivers' ideas about the nature and cause of dementia (i.e., explanatory models). Explanatory models of caregivers were categorized as biomedical, folk, or mixed (folk/biomedical). Quantitative analyses examined the association between ethnicity and other caregiver characteristics, and explanatory model type. Overall, 54% of caregivers, including 41% of Anglo European Americans, held explanatory models that combined folk and biomedical elements (i.e., mixed models). For example, many families attributed Alzheimer's disease and related dementias to psychosocial stress or normal aging. Ethnicity, lower education, and sex were associated with explanatory model type in bivariate analyses. In multiple logistic regression analysis, minority caregivers (P<.02) and those with less formal education (P<.02) were more likely to hold mixed or folk models of dementia. Although minority and nonminority caregivers often incorporated folk models into their understanding of dementia, this was more common in minority caregivers and those with less formal education. Further research on cross-ethnic differences in a larger, more-representative sample is needed.     

Pro-anorexia, weight-loss drugs and the internet: an "anti-recovery" explanatory model of anorexia

This paper explores the online "pro-anorexia" underground, a movement that supports those with anorexia and adopts an "anti-recovery" perspective on the disease. While encouraging a "healthy" diet to sustain an anorexic way-of-life, the movement also recommends the radical use of weight-loss pharmaceuticals to pursue and maintain low body weight, in contrast to their conventional use to treat obesity. Using ethnographic and interview data collected from participants in the "Anagrrl" website and online forum, we analyse the pro-anorexia (or "pro-ana") movement in terms of its underlying "explanatory model" of the disease, and contrast it with medical, psychosocial, sociocultural and feminist models that encourage a "normalisation" of body shape and weight. We suggest that for participants in pro-ana, anorexia represents stability and control, and Anagrrl offers support and guidance for those who wish to remain in this "sanctuary". We discuss the pro-anorexia movement's use of the internet to facilitate resistance to medical and social theories of disease, and its subversion of pharmaceutical technologies.     

Study control,violators, inclusion criteria and defining explanatory and pragmatic trials

Important differences between explanatory and pragmatic studies were originally argued by Schwartz and Lellouch. Three important differences between the two types of study involve study control, study violators and inclusion criteria. It was originally argued that explanatory studies are highly controlled, and pragmatic studies may be looser and more like 'real life'. It was argued that an explanatory study should only analyse those receiving treatment, and a pragmatic study would analyse all randomized patients. Explanatory trials are said to use homogeneous groups, and pragmatic studies have less selection (better generalizability). Some suggestions are put forward to update the original distinctions between these two attitudes for future study design. Poor study control is undesirable (but might be necessary) and should not be welcomed as pragmatic. The intention-to-treat strategy is now considered as standard for nearly all trials. Homogeneity is a red herring for studies in humans. Inclusion criteria should be minimized and they should not be used to justify claims of representativeness. Routine criticism of randomized controlled trials for being unrepresentative is unwarranted. We should accept that most trials in humans are 'explanatory'. The division line should be moved, so that pragmatic studies are in the domain of non-therapeutics and complex treatments.     

包容多元———医学人文的胸襟与路径

“包容多元”已逐渐成为当今社会的核心价值取向之一,医疗领域中同样需要提倡。在向医生求助之前,病人都会对自身疾病以及即将接受的治疗有预测、担忧和期待,而这一切都与病人的背景有关———他们文化背景多样、受教育水平与社会经济地位多样、人生哲学多样。医生和其他医务工作者只有理解和接纳,作出诊断,结合患者意愿进行治疗,方能体现医学人文的胸襟,铺平医学人文关怀的路径。