Loss Of Dignity Research Articles

Alternative US History in Philip Dick’s Novel The Man in the High Castle (1962) and Philip Roth’s Novel The Plot Against America (2004)

The paper gives a comparative analysis of Philip K. Dick’s novel The Man in the High Castle (1962) and Philip Roth’s novel The Plot Against America (2004) focusing on the role of the US national cultural mythology, primarily the American Dream, in the time of trials. Both works belong to the genre of alternative history with elements of dystopia and autobiography. The genre, plot and narrative peculiarities of these novels and the TV series The Man in the High Castle (2015–2019) are compared, namely: the alternative historical background of events, the subjective and objective factors of possibility of the World War II alternative retrospective suggested by the authors, the plot and narration in the novels. The alternative background (the success of a totalitarian Nazi project in the USA) is detailed in both novels, but Dick’s reality (the US occupation by the Axis countries and loss of national dignity) is more tragic than Roth’s reality, which shows a temporary deviation from the right course of his country that does not lead to the loss of independence. The structure of these works differs: multicultural polyphony with three worlds, six storylines and seven focalizers in Dick’s novel and linearity with a single focalizer and a focus on “The Jewish question” in Roth’s book, but both authors succeed in showing a convincing picture of a possible decline of humanistic and democratic projects. On the basis of such analysis, the problems of novels, in particular, the pitfalls of the American Dream are considered: mass consciousness, lack of critical thinking, consumerism, populism, pursuit of success, anti-Semitism, racism, xenophobia, over-enthusiasm for the “melting pot” concept, etc. The main method of restoring the American Dream for both authors is the proof by contradiction: by displaying global history through the local, they are gradually debunking totalitarian projects, which at first may seem very attractive, because they are based on the best myths and expectations of the mass society.

How right is right-based mental health law?

Human rights’ frameworks are increasingly being recognized in general, and mental health in particular. Human rights can thus act as powerful catalysts for change in areas such as mental health care that has historically suffered from stigma, discrimination, and loss of dignity of patients. Mental health law in India has evolved over the past few decades, in keeping with improved delivery of care, societal changes, and increasing awareness of a person's human rights and privileges. The new Mental Healthcare Act, 2017 has shifted the focus to a rights-based approach to provide treatment, care, and protection of a person with mental illness compared to previous Mental Health Act 1987. This dynamic shift is to align, harmonize, and fulfill the requirements of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). This article reviews the existing international human rights model of disability and recovery, and the Mysore Declaration, and does a critical review of UNCRPD.

Exploitation without Exchange

Extant accounts of exploitation typically focus on either an exchange or interaction between persons, or on exploitative systems (i.e., global capitalism). We propose a new account of exploitation that focuses instead on the benefits an exploiter enjoys which are had at the expense of another, the exploited party. This account is developed by considering the benefits enjoyed by consumers (e.g., inexpensive sweatshop-made goods) and the manner in which those benefits are produced (e.g., the loss of dignity suffered by sweatshop workers). On our account, an exploitative relationship need not involve any interaction or exchange between exploiter and exploited. Neither is exploitation a property of systems or institutions. Instead, we argue that a consumer who buys a shirt produced under near slave-like conditions engages in a moral wrong by exploiting the worker who made it even though the two may be far-removed in space and time.

Value Сhanges in Contemporary Emigrant Literature: To Have or to Be?

The author of the article, based on the method of imagological analysis, discusses the competing scenarios of a contemporary person’s existence – to have and to be, which emerge in their especially relevant forms in the contemporary prose by Lithuanian and Latvian emigrants.The prevailing economic causes of emigration determine the predominance of having in the contemporary emigration literature. Consumption as an impetus for happiness is more typical of former societies of lack, who do not yet understand the imagological nature of such happiness – the illusiveness of possessing. In the social structure of the host countries, Lithuanian and Latvian emigrants are usually the disadvantaged class, and therefore their desire to flaunt externally, to demonstrate their superiority by externals, is eminently obvious. They strengthen their symbolic power and self-realization by displaying themselves wearing demonstrative emblems in the form of expensive items, cars, and bright makeup. The article identifies other contemporary changes of values that have emerged in the literature written by emigrants: the shredded concept of freedom, loss of dignity and self-worth for the sake of money, and imperatives of bondage (dog imagotopics). The tendencies of such behavior (distorted conception of power, dominance, prestige, dignity, and freedom) unveil the general common problems of post-Soviet societies, revealing the erosion of existence, the distorted values, and sometimes the reverse of these two social forms, when possessing finds itself in the place of being. The new egoistical ideals of freedom, which contemporary emigrants cling to, testify to endangered social thinking, the weakening of the national mentality, and the entrenching self-centeredness.The model of being, which is alternative to having, is less frequent in the narratives of emigration, and usually manifests itself as a companion of academic emigration. The paradigm of being focuses on cultural rather than material or physical property, as well as on active self-realization and inner personal development.

Dying Patient and Family Contributions to Nurse Distress in the ICU.

Caring for patients at the end of life is emotionally taxing and may contribute to burnout. Nevertheless, little is known about the factors associated with emotional distress in intensive care unit (ICU) nurses. To identify patient and family factors associated with nurses' emotional distress in caring for dying patients in the ICU. One hundred nurses who cared for 200 deceased ICU patients at two large academic medical centers in the Northeast United States were interviewed about patients' psychological and physical symptoms, their reactions to those patient experiences (e.g., emotional distress), and perceived factors contributing to their emotional distress. Logistic regression analyses modeled nurses' emotional distress as a function of patient symptoms and care. Patients' overall quality of death (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.31-7.25), suffering (OR, 2.34; CI, 1.03-5.29), and loss of dignity (OR, 2.95; CI, 1.19-7.29) were significantly associated with nurse emotional distress. Some 40.5% (79 of 195) of nurses identified families' fears of patient death, and 34.4% (67 of 195) identified families' unrealistic expectations as contributing to their own emotional distress. Patients' emotional distress, physical distress, and perceived quality of death are associated with nurse emotional distress. Unrealistic family expectations for the patient may be a source of nurse emotional distress. Improving patients' quality of death, including enhancing their dignity, reducing their suffering, and promoting acceptance of an impending death among family members may improve the emotional health of nurses.

Health and dignity of Palestine refugees at stake: a need for international response to sustain crucial life services at UNRWA

The UN Sustainable Development Goals affirm equality and dignity as essential to the enjoyment of basic human rights, including the right to the highest attainable standard of physical and mental health, which promotes global solidarity among all people, including refugees. The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has provided support to Palestine refugees in Jordan, Lebanon, Syria, the Gaza Strip, and the West Bank since the 1950s. Today, however, conflict and violence, occupation, high levels of poverty, and other social determinants of health jeopardize the wellbeing of Palestine refugees. Health concerns include non-communicable diseases, mental health conditions, and access to hospital care. Additionally, UNRWA is continuing to face a severe funding crisis. Using a historical and health policy perspective, this Health Policy examines UNRWA strategies that facilitate continuous provision of health-care services for Palestine refugees. Given the increasingly volatile environment faced by this population, a multifaceted international response is needed to enable UNRWA to deliver sustainable services to Palestine refugees and avert further loss of life, dignity, and hope, pending a just and lasting solution to their plight in accordance with applicable international law and UN General Assembly resolutions.

Hukum Menjual Hak Suara Pada Pemilukada Dalam Perspektif Fiqh Siyasi Sunni

Secara faktual, kondisi politik yang muncul saat ini benar-benar sarat dengan kepentingan politik, politik uang menjadi tren di setiap Pilkada Langsung (Pemilukada); hak suara diperdagangkan. Praktek “money politic” telah terjadi di banyak daerah. Pelanggaran ini sangat cemas karena digunakan sebagai alat untuk menang dalam pemilihan langsung. Akibatnya, hak pilih warga dibajak oleh kepentingan kandidat. Praktek “money politic” dapat terjadi selama kampanye dan sebelum pemungutan suara. Sayangnya, dalam beberapa kasus, petugas Pemilu juga terlibat dalam praktek tersebut. Lalu ada jual beli suara yang menyebabkan penipuan dalam menentukan dan menetapkan perolehan suara dan berpotensi bisa mengubah elektabilitas calon. Kerugian nyata “money politic” adalah hilangnya martabat hak suara warga negara. Hak suara hanya akan menjadi komoditas politik di tengah persaingan antar kandidat. Kedaulatan rakyat menjadi tidak berarti karena uang telah dimainkan di mana selanjutnya akan merugikan mereka. Sebuah posisi yang diperoleh dengan modal besar menjadi pembenaran untuk mendapatkan kembali modal apabila telah menduduki jabatan politik. Penipuan di Pemilu tidak hanya salah secara moral, tetapi bentuk pelanggaran hukum. Praktek jual beli dan suara di Pemilukada diklasifikasikan sebagai risywah yang sangat dilarang dalam Islam. Kata

The experiences of parents with children with disabilities travelling on planes: An exploratory study

Research into air travel for people with disabilities and complex care issues has seldom been investigated, with no research data that focusses solely on children. Qualitative interviews of a semi structured nature were carried out with seven parents of children with disabilities, who discussed their experiences as a parent and primary caregiver. There were multiple issues identified that are related to the design of the aircraft or the processes involved in the service. These included physical issues such as manual handling and accessing the toilet facilities; emotional issues including being separated from their wheelchair and the loss of dignity; and cognitive issues such as preparation for travel. Recommendations include access to suitable toilet facilities and a redesign of processes concerning seating on board the aircraft.

Non siamo tutti coraggiosi allo stesso modo

This article puts forward the hypothesis that courage varies accordingly with the dominant meanings through which people construct their own world. Delving into the model of family semantic polarities (Ugazio, 1998; 2012/13), the Authors identify different shades of courage within the semantics of freedom, goodness, power and belonging and illustrate and discuss them providing example from their clinical practice and from literature. The goals people aim at when acting courageously, the threats they feel and obstacles that entangle them are different in the four shades of courage discussed. The threat within the semantic of freedom is represented by the dangers the world is fraught with, in front of which the individual is constructed as vulnerable. Autonomy is the purpose, since losing autonomy means to lose value in front of oneself and the family. Fear is thereby the obstacle. Facing the world alone is the paramount shade of courage within this semantic. Breaking the siege of guilt is the principal shade of courage within the semantic of goodness. Being brave within this semantic means to trespass the boundaries established by a moral code perceived as oppressive. Consequently, the threat is to become corrupt and the obstacle is guilt, whereas the aim is to feel alive. Winning alone is the prevalent shade of courage within the semantic of power. It requires overcoming the need of approval (obstacle) and facing others’ envy in order to gain one-upmanship (aim). Within the semantic of belonging, being courageous means accepting the fate of a stray dog in order to retain the dignity. Exclusion and loneliness are the threat whereas the hope to be love and included is the obstacle, since it may led to the loss of dignity.

The role of perceived dignity and control in the wish to hasten death among advanced cancer patients: A mediation model.

The objective of the study is to test a model in which perceived loss of dignity and control are proposed, along with symptoms of depression and functional impairment, as risk factors for the wish to hasten death (WTHD) in advanced cancer patients. This was a cross-sectional study of 193 patients in an oncology unit. Outcome measures included perceived control, performance status, symptoms of depression, perceived dignity, and the WTHD. Structural equation modeling was performed. Structural equation modeling showed that perceived loss of control (-0.402) and functional impairment (-0.21) were risk factors for perceived loss of dignity. Loss of control (-0.385) and functional impairment (-0.283) were also risk factors for symptoms of depression. Perceived loss of dignity and symptoms of depression were the most proximal determinants of the WTHD, on which they had a direct, positive, and significant effect (0.246 and 0.209, respectively). Therefore, both symptoms of depression and perceived loss of dignity independently predicted the WTHD and mediated the effects of perceived loss of control and functional impairment on this wish. The hypothesized model provides evidence for the impact of the four aforementioned factors on the WTHD. Our results suggest that personalized care plans which are able to enhance the sense of dignity and control among advanced cancer patients could help to reduce the likelihood or intensity of a WTHD.

PMU115 - AN INVESTIGATION OF ISSUES IN THE TRANSLATION AND COMPREHENSION OF THE TERMS SELF-CONSCIOUS AND EMBARRASSED IN PATIENT REPORTED OUTCOME (PRO) MEASURES

Identifying problematic terminology and proposing solutions for improved translation is critical to increasing PRO content validity and the quality of respondent data. We examined patients’ comprehension of the terms self-conscious and embarrassed, which have considerable semantic overlap and frequently appear together in PROs. Self-conscious can be defined as uncomfortable or intense awareness of being observed or of how one is perceived, while embarrassed connotes more negative qualities of feeling shame or distress and loss of dignity, but is also frequently defined as uncomfortable self-consciousness. RWS Life Sciences translated and harmonized three PROs containing items on self-consciousness and embarrassment into 40 languages for 50 countries across three translation projects (for 72 total translations). The harmonized questionnaires underwent in-person cognitive interviews with atopic dermatitis and head & neck cancer patients. We extracted patient demographic and item comprehension information, as well as feedback regarding comprehension problems, from 356 interviews. Patients (n = 356) were aged 11-95 years, with length of education from 0-20 years (mean = 11.9). Comprehension problems with self-conscious and embarrassed were noted in 12 / 39 languages (31%), 14 / 50 countries (28%), 17 / 72 translations (24%), and accounted for 55% of the total number of comprehension errors across all debriefing sessions. Patients reported that self-conscious and embarrassed were difficult to separate conceptually, and suggested that only one of the concepts was necessary. Patients also had difficulty comprehending / paraphrasing self-conscious itself, and were frequently unable to provide alternative translations. Patients demonstrated considerable difficulty interpreting the terms self-conscious and embarrassed in three PROs. We attribute this to their semantic overlap and co-occurrence in contexts where they are intended to assess different constructs. We recommend greater effort to differentiate self-conscious and embarrassed in PROs containing both in order to improve comprehensibility and translations of both terms.

Viewpoint

hallway care, trafficking, abuse: hallway care, trafficking, abuseOne common adage we learn in medical school is that 80 percent of a diagnosis can be made from a careful medical history and physical exam. The remaining 20 percent, as often taught, is comprised of the myriad laboratory, radiographic, and advanced diagnostic testing available. If this statement is, in fact, true, then the prevalent practice of caring for patients in the hallways of our emergency departments is directly challenging our ability to provide the best care. Hallway care for emergency department patients has been a necessary reality for decades. Recently, rising demands for care from patients with otherwise insufficient health care access coupled with the increasingly common practice of boarding admitted patients in the ED have exacerbated the problem of having too many patients with too few resources for care. Hallway corridors and shared spaces, which used to serve as improvisational care areas reserved for unusually high utilization periods, have now become part of the daily routine in many emergency departments. Our survey study conducted with 409 emergency clinicians showed that 72 percent of respondents reported providing care in ED hallways at least sometimes. (Emerg Med J 2018;35[7]:406; http://bit.ly/2ARAubQ.) Our study further corroborates the common-sense assessment that caring for patients in the hallway is suboptimal and compromises the emergency physician's ability to practice the fundamental diagnostic skills of a detailed medical history and thorough physical exam. Ninety percent of those who practice in the hallway altered their history-taking, while 56 percent altered their physical exam. This then led to delays or failures in diagnoses related with these alterations in the history (35%) and exam (41%). These challenges put the emergency physician right between the rock of providing rising volumes of high-quality care and the hard place of increased limitations to carry out even the most basic practices of emergency medicine. Basic patient care challenges aside, this reality also has implications for other important motivations for emergency physicians. Many of us chose to pursue emergency medicine because of the ability to care for those at the margins of society, the most vulnerable and disenfranchised who have nowhere else to turn for help besides our emergency departments. Attempting to provide care in crowded ED hallways further subjects these vulnerable patients to violations of privacy, loss of dignity, and worse communication. Emergency physicians and staff have often been identified as the front-line defenders against traditionally hidden evils such as human trafficking, domestic violence, and child abuse. Our importance in recent years has also been solidified in challenges involving substance abuse and mental health. Alarmingly, our study identified that each of these issues was negatively affected among those who provide care in the hallway and who reported delays or failures in diagnoses. Approximately 12 percent reported clinical failures related to child abuse, eight percent related to human trafficking, and 37 percent to domestic abuse. Despite these alarming figures, we suspect these are underestimates because of these cases' hidden nature. This will remain a substantial portion of our practice unless some pretty drastic changes are made in our health care delivery model. Legislators, hospital administrators, inpatient care clinicians, and the rest of the care continuum need to recognize the reality that our compromised ability to provide patient care in the appropriate setting will necessarily lead to worse quality of care and outcomes. Inadequate access to care, inpatient boarding in the ED, and prolonged length of stay in the hospital all lead to the downstream effects we have described. We have tolerated this extrinsic factor as status quo in providing care in the emergency department for far too long. It's what we have known since the start of training. But as this practice becomes increasingly prevalent, let's pay attention to the challenges it poses and the mistakes for which we are set up. We ought to recognize that this goes beyond a convenience or comfort factor. Our patients deserve better.

Advance Directives for Refusing Life-Sustaining Treatment in Dementia.

Aid-in-dying laws in the United States have two important restrictions. First, only patients who are terminally ill, defined as having a prognosis of six months or less to live, qualify. Second, at the time the patients take the lethal medication, they must be competent to make medical decisions. This means that an advance directive requesting aid in dying for a later time when the patient lacks decision-making capacity would be invalid. However, many people are more concerned about avoiding living into severe dementia for years-a time when they will lack decision-making capacity-than they are about preventing suffering or the loss of dignity or autonomy for a few months at the end of life. Gillian Bennett is an example of someone determined not to live into severe dementia. She opted for preemptive suicide in 2014, explaining why in a letter she posted online: "Every day I lose bits of myself, and it's obvious that I am heading toward the state that all dementia patients eventually get to: not knowing who I am and requiring full-time care." A major problem with Bennett's solution, however, is that the individual is likely thereby to be giving up some "good time." A legal alternative to preemptive suicide is to create an advance directive stating the circumstances under which one wants not to receive any lifesaving or life-sustaining treatment, even the most basic and noninvasive. This option is our focus in this paper: how to create effective advance directives to avoid living into severe dementia. To be relevant to progressive dementia, the directive would need to state what kinds of care should be withheld and when. At the same time, advance directives for severe dementia face serious challenges. Before addressing these, we review the normative force of directives themselves.

‘Doing Dignity Work’: Indian Security Guards’ Interface with Precariousness

Increasing global competition has intensified the use of informal sector workforce worldwide. This phenomenon is true with regard to India, where 92% of the workers hold precarious jobs. Our study examines the dynamics of workplace dignity in the context of Indian security guards deployed as contract labour by private suppliers, recognising that security guards’ jobs were marked by easy access, low status, disrespect and precariousness. The experiences of guards serving bank ATMs were compared with those working in large reputed organisations. The former reported loss of dignity though their inherent self-worth remained partially intact, whereas the latter reclaimed dignity despite the precarious working conditions and the absence of unions. Guards from large reputed organisations evolved strategies by which they took advantage of the client’s vulnerabilities, developed ‘thick’ relationships at work and immersed themselves in 'doing dignity work' to ensure that they are not disposable. ‘Doing dignity work’ was a visible device which involved actions that met or went beyond the norms laid down by the client and was used by security guards to limit the extent of their precariousness. Since the opportunity to reclaim dignity was facilitated by large reputed clients’ adherence to legal regulations, we see implications of the study for the moral economy.

Development of tools to measure dignity for older people in acute hospitals.

Dignity is a concept that applies to all patients. Older patients can be particularly vulnerable to experiencing a loss of dignity in hospital. Previous tools developed to measure dignity have been aimed at palliative and end-of-life care. No tools for measuring dignity in acute hospital care have been reported. To develop tools for measuring patient dignity in acute hospitals. A large UK acute hospital. We purposively selected 17 wards where at least 50% of patients are 65years or above. Three methods of capturing data related to dignity were developed: an electronic patient dignity survey (possible score range 6-24); a format for nonparticipant observations; and individual face-to-face semi-structured patient and staff interviews (reported elsewhere). A total of 5,693 surveys were completed. Mean score increased from 22.00 pre-intervention to 23.03 after intervention (p<0.001). Staff-patient interactions (581) were recorded. Overall 41% of interactions (239) were positive, 39% (228) were neutral, and 20% (114) were negative. The positive interactions ranged from 17%-59% between wards. Quality of interaction was highest for allied health professionals (76% positive), lowest for domestic staff (22% positive) and pharmacists (29% positive), and intermediate for doctors, nurses, healthcare assistants and student nurses (40%-48% positive). A positive interaction was more likely with increased length of interaction from 25% (brief)-63% (longer interactions) (F[2, 557]=28.67, p<0.001). We have developed a simple format for a dignity survey and observations. Overall, most patients reported electronically that they received dignified care in hospital. However, observations identified a high percentage of interactions categorised as neutral/basic care, which, while not actively diminishing dignity, will not enhance dignity. There is an opportunity to make these interactions more positive.

The Impact of Living with Parkinson's Disease: Balancing within a Web of Needs and Demands.

This study explores the impact of living with Parkinson's disease (PD). Nineteen persons (11 women) aged 55–84 diagnosed with PD 3–27 years ago participated. Data were collected through semistructured interviews, which were recorded, transcribed verbatim, and analysed by qualitative content analysis. Four categories represented the impact of living with PD: “Changed prerequisites for managing day-to-day demands,” “Loss of identity and dignity,” “Compromised social participation,” and “The use of practical and psychological strategies.” There was a shift from an internal to an external locus of control in managing, control, competence, relatedness, and autonomy. According to self-determination theory, a shift towards extrinsically motivated behaviours may occur when these basic needs are thwarted, leading to compensatory strategies or needs substitutes with negative consequences on health and well-being. We suggest a needs-based approach as an important starting point to better understand the consequences of living with PD and to explore the means for people with PD to acquire an improved quality of life on their own terms. In conclusion, our findings suggest for a shift in focus, from a biomedical to a needs-based approach to understand the impact of living with PD and facilitate more person-centred care and person-centred outcome measurement.

Uroneurology

The function of the pelvic organs, including the lower urinary tract (LUT), is controlled by a complex network of nerves. This leaves patients with neurologic disease vulnerable to LUT and pelvic organ dysfunction. Physicians often come across urogenital complaints in their patients with neurologic disease, the symptoms of which can result in significant distress and loss of dignity and quality of life. Due to the health and economic burden that accompanies neurogenic pelvic organ dysfunction, it is important for clinicians to understand the common forms of dysfunction, essential investigations, and modes of management. This chapter covers bladder dysfunction from a physician’s perspective. Topics include neurologic control of the LUT, large bowel, and sexual functions; male and female sexual response; neurogenic bladder dysfunction and its management; diagnostic evaluation; management of neurogenic sexual dysfunction; management of erectile dysfunction; ejaculatory dysfunction; sexual dysfunction in women; and fecal incontinence. Figures illustrate efferent innervation of the LUT, neurologic detrusor overactivity, a urethral pressure profile in a patient with Fowler syndrome, an example bladder diary, an example bladder scan, and normal and obstructed flow patterns. Tables list common causes of injury at the suprapontine, suprasacral, and infrasacral levels and storage and voiding systems. This chapter contains 6 highly rendered figures, 2 tables, 53 references, 1 teaching slide set, and 5 MCQs.

Extracorporeal shock wave therapy for the healing and management of venous leg ulcers.

Leg ulcers are chronic wounds of the lower leg, caused by poor blood flow, that can take a long time to heal. The pooling of blood in the veins can damage the skin and surrounding tissues, causing an ulcer to form. Venous leg ulcers are associated with impaired quality of life, reduced mobility, pain, stress and loss of dignity. The standard treatment for venous leg ulcers is compression bandages or stockings. Shock wave therapy may aid the healing of these wounds through the promotion of angiogenesis (the formation and development of blood vessels) and reduction of inflammation, though this process is poorly understood at present. To assess the effects of extracorporeal shock wave therapy on the healing and management of venous leg ulceration. In April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. We applied no restrictions with respect to language, date of publication or study setting. We considered all published and unpublished randomised controlled trials (RCTs) assessing the effectiveness of extracorporeal shock wave therapy in the healing and management of venous leg ulceration. Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias of included studies, extract study data and rate the certainty of the evidence using GRADE. We found no RCTs that met the inclusion criteria for this review. We found no RCTs assessing the effectiveness of extracorporeal shock wave therapy in the healing and management of venous leg ulceration. The lack of high-quality evidence in this area highlights a gap in research and may serve to justify the need for further research and evidence to provide guidance concerning the use of this treatment option for this condition. Future trials should be of clear design and include concomitant use of the current best practice treatment, multilayer compression therapy. Recruitment should aspire to best represent patients seen in clinical practice and patient-related outcome measures should be included in study design.

\u2018When helpers hurt\u2019: women\u2019s and midwives\u2019 stories of obstetric violence in state health institutions, Colombo district, Sri Lanka

BackgroundThe paper explores how age, social position or class, and linguistic and cultural background intersect and place women in varying positions of control and vulnerability to obstetric violence in state health institutions in Colombo district, Sri Lanka. Obstetric violence occurs during pregnancy, childbirth and the immediate postpartum period; hence, it is violence that directly affects women. The authors aim to break the traditional culture of silence around obstetric violence and bring attention to the resulting implications for quality of care and patient trust in obstetric care facilities or providers.MethodsFive focus group discussions were held with 28 public health midwives who had prior experience working in labor rooms. Six focus group discussions were held with 38 pregnant women with previous childbirth experience. Additionally, 10 of the 38 women, whom felt they had experienced excessive pain, fear, humiliation, and/or loss of dignity as patients in labor, participated in individual in-depth interviews. An intersectional framework was used to group the qualitative data into categories and themes for analysis.ResultsObstetric violence appears to intersect with systems of power and oppression linked to structural gender, social, linguistic and cultural inequities in Sri Lanka. In our dataset, younger women, poorer women, and women who did not speak Sinhala seemed to experience more obstetric violence than those with relevant social connections and better economic positions. The women in our study rarely reported obstetric violence to legal or institutional authorities, nor within their informal social support networks. Instead, they sought obstetric care, particularly for childbirth, in other state hospitals in subsequent pregnancies.ConclusionsThe quality of obstetric care in Sri Lanka needs improvement. Amongst other initiatives, policies and practices are required to sensitize health providers about the existence of obstetric violence, and repercussions are required for abusive or discriminatory practices. The ethics of care should be further reinforced in the professional training of obstetric health providers.

‘The Thing that Really Gets Me Is the Future’: Symptomatology in Older Homeless Adults in the HOPE HOME Study

ContextThe homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults. ObjectivesTo characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults. MethodsWe conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis. ResultsWe found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use. ConclusionHomelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.