Lupine Publishers | Bewilderment amongst Neurologic and Fake Ailments: A Serious Culpability that needs Pedagogical Boost

 Lupine Publishers | LOJ Medical Sciences

Introduction

The incidence of medical mistakes in primary care is not rare and the probability of faults producing grave detriment is great. Medical negligence is a ‘tort’, or ‘civil wrong’. It is a ‘wrong’ resulting from a doctor’s carelessness. Simply put, negligence means failing to do something that should have been done as defined by current medical practice or doing something that a physician with a duty to care for the patient should not have done. Whereas about one percent of hospital admissions result in an adversative event due to negligence, faults are probably much more common, because these studies detect only errors that led to assessable adversative events occurring soon after the mistakes. Moreover, though after heart disease and cancer, medical mistake is the 3rd important reason of death in the USA, maybe the real problem in medical faults is not bad persons in health care; rather it is that good individuals are working in corrupt systems. Poor communiqué , blurred lines of power of doctors, nurses, and other care providers, incoherent recording systems, differences in healthcare provider teaching and practice , failure to recognize the frequency and significance of medical mistakes, overestimation of insufficient data, sleep deficiency and night shifts, doctor’s depression, fatigue, and burnout , unfamiliar settings, diverse patients, and time pressures have been accounted as vital causes of medical error. In the following article, some proven neurologic cases, which have been diagnosed in the beginning by at least one neurologist as conversion disorder and referred to psychiatric facilities, have been described. This article tries to give the reader an awareness regarding the aforesaid dilemma, in the ground of psychological medicine.

Background

Clinical forensic medicine is a term that has become widely used only in recent decades, though the phrase has been in use at least since 1951. The practitioners of clinical forensic medicine have been given many different names thru the years, but the term forensic physician has become more widely accepted. In broad terms, a forensic pathologist generally does not deal with living individuals, and a forensic physician generally does not deal with the deceased. However, worldwide there are doctors who are involved in both the clinical and the pathological aspects of forensic medicine. There are many zones where both clinical and pathological aspects of forensic medicine overlap, and this is reflected in the history and development of the specialty as a whole and its current practice [1]. The current data indicates that medical mistakes kill yearly around 180 000 individuals in hospitals and medical faults may be the fifth foremost reason of death in the United States of America. If these implications are exact, the present health care system can be accounted, as well, as a community health threat [1], and the existing scheme of medical negligence or misconduct does a poor job as regards the wellbeing of patients. Societal and economic powers are changing the structure of health care from the individual doctor to a union of health care specialists, categorized by liable medical groups [2]. On the other hand, enterprise accountability, joined with medical slip communication and corrective platforms, delivers the lawful agenda essential for the ‘patient-centered’ practice of medicine in current situation [3]. The word ‘error’ in medicine is utilized as a term for approximately all of the complications hurting the patients. Also, medical mistakes are often designated as human faults in healthcare [4]. Whether this label is ‘human error’ or ‘medical error’, one description used for it in medicine pronounces that it happens when a healthcare worker selects an unfortunate mode of care or incorrectly performs a proper technique of care. Anyway, a medical fault is an avoidable adversative consequence of care, whether or not it is hurtful or manifest to the patient. This might contain an erroneous or imperfect management or diagnosis of a behavior, syndrome, disease, infection, damage, or other illness [2].

According to a national survey in United Kingdom, each year, medical errors costing in excess of two billion ponds [5]. Another study has found that drug mistakes are among the most common medical errors, hurting as a minimum 1.5 million individuals each year. Likewise, medical faults, globally, affect at least one in ten patients [6]. According to the findings of a new study, after heart disease and cancer, medical mistake is the 3rd important reason of death in the USA. It deserves to be mentioned that The Institute of Medicine (IOM) released “To Err is Human,” in 2000, which stated that the real problem in medical faults is not bad persons in health care-it is that good individuals are working in corrupt systems that should be prepared safer [6]. Moreover, poor communiqué and blurred lines of power of doctors, nurses, and other care providers are among the causative issues [6]. Incoherent recording systems in a hospital may cause disjointed systems in which frequent handoffs of patients ends in lack of harmonization and mistakes [6]. Differences in healthcare provider teaching & practice and failure to recognize the frequency and significance of medical mistakes as well intensify the threat [7,8]. Then again, the supposed ‘July effect’ happens when firsthand residents come to training hospitals and instigating an upsurge in medication mistakes [9,10]. Jerome Groopman, author of ‘How Doctors Think’, has assumed that these are ‘cognitive pitfalls’, or biases which can cloud our judgment. For instance, a physician may overestimate the first data run into his head, influencing his decision. Another drawback is where stereotypical presumptions may skew intelligence [11].

Sleep deficiency has also been mentioned as a causal reason in medical mistakes [11]. According to a study, being awake for above twenty four hours could cause medical interns to ‘double’ or ‘triple’ the number of avoidable medical faults, involving those that had caused harm or decease [11]. Similarly, night shifts are connected with poorer surgeon performance through laparoscopic surgeries [11]. Doctor’s risk factors consist of depression, fatigue, and burnout [12]. Issues related to the clinical setting, too, include unfamiliar settings, diverse patients, and time pressures [11]. All of the following case examples, which have been chosen in this regard, have been diagnosed primarily and unreasonably, by at least one neurologist as conversion disorder and referred to psychiatric facilities. This article tries to give the reader awareness about the aforesaid dilemma, in the ground of psychological medicine. Names, dates and locations have been omitted totally to keep the confidentiality of the cases.

Case 1

A 42 years old male driver had been referred by his general physician to a neurological clinic after observing some tremors in the upper limbs of the patient. The patient had been visited due to sleep problems and nervousness. According to the patient, his problems had been started a few weeks after his divorce from his wife, which had been occurred one year earlier due to various financial and family problems. The care of children also had been transported to him. While the primary prescription of fluoxetine, 20- 40 milligram per day, could only mitigate some of the psychological symptoms like anxiety and dysphoria, the aforesaid tremor got worse, which had not respond to 30 milligram propranolol per day, too. So, he had been referred to a neurologist for further analysis. After primary checkup and based on the personal and family history, since no specific finding was evident at clinical exam, he had been prescribed a series of drugs, in accompany with the aforesaid fluoxetine, like Primidone, 500 milligram per day and Trihexyphenidyl 6 milligram per day, with the primary diagnosis of essential familial tremor, which could be aggravated, too, by means of psychological stresses and maybe small amounts of antipsychotis (Perphenazine, 4-8 milligram per day which had been prescribed by the GP due to his aggressiveness). After another six months, due to intensification of tremor that had interfered with some of his daily activities, and also his anxiousness he had been referred to a consultant psychiatrist. In the initial examination, in addition to a relatively fluctuating tremor, between fine and course, depending on the situation of the limbs, some mild rigidity as well was palpable in the proximal muscles of the upper limb, without any evident cogwheel or clasp-knife rigidity. Due to lack of obvious concern in him regarding his earlier divorce or similar worries, absence of strong or insistent relationship between tremor and psychosocial stresses, unexplained mild rigidity of the proximal muscles of the upper limbs in spite of discontinuation of antipsychotic, and no satisfactory response to the abovementioned medications, so he was referred again for another neurologic evaluation. This time, due to low serum ceruloplasmin level (17 mg/dl), low serum copper (55 microgram/dl), and increased urinary copper excretion (150 microgramm Cu in 24 h) , presence of copper deposition in Descemet’s membrane (Kayser-Fleischer rings) in slit-lamp examination, and slightly enlarged lateral and third ventricles, widened cerebral and cerebellar sulci, and hypodensity of posterior parts of lenticular nuclei in CT Scan , plus bilateral, symmetrical signal hyperintensities in the Basal ganglia, Midbrain, Pons, and Thalamus in T2-weighted MRI, the diagnosis of Wilson’s disease (Hepatolenticular Degeneration) had been suggested for him and thus transferred to a neurologic clinic for further investigation and management.

Case 2

A 38 years old man had been hospitalized in the psychiatric ward due to aggressiveness, suspiciousness, disturbed sleep and some movement problems. When he was 18-year-old, he had been diagnosed as a case of bipolar I disorder due to similar profile of symptoms, except than movement problems, which had been started since two years ago. During the last two decades a number of neuroleptics, mainly first-generation antipsychotics, mood stabilizers like lithium and valproate, and benzodiazepines had been prescribed for him. One year ago he was hospitalized again in another psychiatric hospital for his increasing movement problems, which had been assigned to his antipsychotic medications, and had been treated by dopaminergic drugs like Levodopa – Carbidopa (Sinemet) (750-1000 milligram per day), Amantadine (200 milligram per day), and also Trihexyphenydil (6 milligram per day). The aforesaid problem had been diagnosed as medication induced movement disorder (pseudo-parkinsonism) by a consultant neurologist. But there was lack of effectiveness and worsening of the problem. After the recent admission and disregard to the past and present psychiatric history of anxiety, depression, impulsiveness, dis-inhibition, suspiciousness or paranoid delusions, in the clinical examination a mild-moderate fluctuating rigidity and tremor in the upper and lower limbs was evident, which had made clumsiness and unsteady gait, respectively. Also, there were some problems regarding swallowing solid foods and talking fluently. Also, a fixed stare with a smiling expression and drooling was evident. So, another neurologic consultation had been requested by his psychiatrist; this time also, the antipsychotic induced movement disorder had been confirmed, once more, by the second consultant neurologist, who, moreover, proposed tardive Parkinsonism as a probable differential diagnosis. Due to lack of effectiveness of the aforesaid treatments, in spite of discontinuation of prescribed antipsychotic (Quetiapine 75 milligram per day), Electroconvulsive therapy (ECT) was started, which stopped after five sessions, due to existence of mild fever and lack of significant effect. Nonetheless, due to refractoriness of the movement symptoms against the recommended treatments, their fluctuating course and persistence in spite of discontinuation of neuroleptics, atypical emergence and persistence of the primary psychopathology, and a long gap (18 years) between the first prescription of neuroleptics and subsequent emergence of movement symptoms, an additional neurologic consultation had been requested for the patient. This time, a suspicious serum ceruloplasmin level (23 mg/dl), low serum copper (76 microgram/ dl), and increased urinary copper excretion (153 microgram Cu in 24 h) had been found. MRI scan, too, had showed decreased signal intensity (hypodensity) in the Striatum and superior Colliculi and increased signal intensity in the Midbrain Tegmentum (except for red nucleus) and in the lateral Substantia Nigra (reticular zone). So, diagnosis of Wilson’s disease (Hepatolenticular Degeneration) had been suggested for him and transferred to a neurologic facility for further investigation and management.

Case 3

A forty seven years old father with a at least five percent weight loss in the last year, in spite or normal appetite and sleep, had been examined by an internist, but the primary laboratory examinations and clinical checkups, including thyroid analyses and computed tomographic scan (CTS), had not proved any specific medical diagnosis. So due to slight restlessness, increasing feeling of tiredness and loss of energy in comparison with before, nervousness, irritability and decrease in attentiveness had been referred to a psychiatrist for analysis regarding psychological problems. In the mental state examination, and in addition to the abovementioned complaints, a slight forgetfulness, disturbance in concentration, negative thoughts, minor disturbance of conduct, history of enuresis during childhood, and a past history of mixed anxiety and depressive disorder after his father’s death, were as well detected, which in sum concluded to a diagnosis of mild to moderate major depressive disorder for the present episode of illness. But the primary medicinal management with fluoxetine, 20- 60 mg per day in a two months period, was not effective. So after a consultation with an associate neurologist and based on newly detected anomia, verbal perseveration, small time disorientation, trivial mood swings, score of 17 in Mini Metal State Examination (MMSE), and history of some head traumas with decrease of consciousness in the past, the diagnosis turned to pre-senile dementia and the aforesaid psychiatric complaints had been classified as secondary symptoms due to that. So, treatment with Rivastigmine, 3-6 mg per day, in addition to fluoxetine, started. But ineffective outcomes after another two months and the progressive course of the ailment resulted in an additional consultation with another teammate neurologist. After a new clinical inspection and detection of trivial fasciculation in upper limbs, muscle atrophy and weakness in upper extremities in Electromyogram (EMG), and atrophy of the frontal and/or temporal lobes in Magnetic Resonance Imaging (MRI), the diagnosis turned to Fronto-Temporal Degeneration (FTD) with motor neuron disease (FTD/MND) , and the patient transferred to a neurologic facility .

Case 4

A 23 years old man had been hospitalized due to restlessness, aggressiveness, decreased sleep, increased libido, delusion of grandeur, and obsession. The incessant and fluctuating course of the problems had been started from around four years ago with a series of psychiatric hospitalizations and managements. He had been diagnosed as a case of bipolar mood disorder, schizophrenia, and schizoaffective, or schizo-phreniform disorder during different periods and treated with a series of mood stabilizers, like lithium and sodium valproate, and also antipsychotics, and benzodiazepines. But during the past few years, he was never completely symptomfree, in spite of relative compliance with the prescriptions. During his recent admission, a dystonic reaction, as well, appeared in the neck which was resistant against anticholinergic drug (Biperidene, 6 milligram per day) and decreasing the dosage of antipsychotic (Risperidone). So, he had been referred to a consultant neurologist, who diagnosed medication induced movement disorder, in addition to the formerly diagnosed primary psychiatric disorder, and added Trihexyphenidyl (6-12 milligram per day, instead of Biperidene) and Amantadine (100-200 milligram per day) to the previous prescriptions. After two weeks of current treatment, due to persistence of dystonic reaction, and also lack of suitable response of psychiatric symptoms to prescribed medications, particularly their fluctuating course, firm delusion of grandeur and impaired judgment in spite of the apparently intellectual insight (IV/V) and normal cognitive & sensorium parameters, another neurologic consultation had been asked for the patient. So, based on the extensive bilateral and symmetrical calcifications in the basal ganglia, thalamus, and cerebellum, in CT Scan and MRI, and ruling out Hyperparathyroidism and Pseudo-Hypoparathyroidism , as major differential diagnostic considerations in the evaluation for treatable causes of diffuse subcortical calcifications , the primary diagnosis changed to Idiopathic Basal Ganglia Calcification or Bilateral Striato-Pallido-Dentate Calcification (Fahr’s disease) and the patient transferred to a neurologic facility for further investigation.

Discussion

The Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association 1994, 2000) contains current standard psychiatric diagnostic nomenclature used for clinical diagnosis, treatment, and research. The development and adoption of DSM diagnoses have been accompanied by a great deal of controversy [12]. Nevertheless, DSM diagnoses are generally accepted and relied on in clinical and research venues, as well as many other venues for which the nomenclature was not intended, including insurance companies, managed care companies, and the courts. The more significant question raised by the acceptance and reliance of the legal system on DSM is whether DSM diagnoses provide an adequate understanding of psychological states for forensic purposes. Legal determinations, whether civil or criminal, typically revolve around issues of impairment [12]. A DSM diagnostic category is not directly relevant to such determinations. Diagnosis and impairment are not equivalent. No diagnosis carries specific information regarding level of impairment or information about whether an impairment associated with that diagnosis is relevant to the legal issue under examination by the court. The use of categorical DSM diagnosis in litigation may result in the examiner missing the most important aspect of the forensic evaluation: the assessment of impairment or legally relevant behavior [12].

Medical negligence is a ‘tort’, or ‘civil wrong’. It is a ‘wrong’ resulting from a doctor’s carelessness. Simply put, negligence means failing to do something that should have been done as defined by current medical practice or doing something that a physician with a duty to care for the patient should not have done [13]. Medical error has been defined as the failure of a planned action to be completed as intended (an error of execution), an unintended act (either of omission or commission) or one that does not achieve its intended outcome, a deviation from the process of care that may or may not cause harm to the patient, or the use of a wrong plan to achieve an aim (an error of planning). Also, patient maltreatment from medical mistake can occur at the individual or system level. Todays, the categorization of faults is getting bigger to better classify avoidable causes and happenings [14]. While about one percent of hospital admissions result in an adversative event due to negligence, faults are probably much more common, because these studies detect only errors that led to assessable adversative events occurring soon after the mistakes [14]. Though independent review of doctors’ management policies proposes that decision-making could be enhanced in fourteen percent of admissions, many of the profits would have late expressions [14]. Even this amount may be an underestimate [14]. Medical faults are connected with inexpert doctors and nurses, innovative techniques, complex or urgent care, and extremes of age. Unfortunate communiqué, unreadable handwriting, inappropriate documentation, insufficient nurse-topatient proportions, and alike named drugs are similarly identified to contribute to the problem [15].

The same problem exists as well as regards the mental illnesses. For example, patients with ‘dissociative identity disorder’ typically have past psychiatric histories that encompass three or more separate mental disorders and prior treatment failures [16]. The skepticism of some physicians about the legitimacy of ‘dissociative identity disorder’ may similarly increase its misdiagnosis [16]. As an additional example, female sexual dysfunction occasionally used to be identified as female hysteria. Or else, food allergies have been repeatedly misdiagnosed as anxiety disorder . Likewise, investigations have found that bipolar mood disorder has often been misdiagnosed as major depressive disorder [16]. While the misdiagnosis of schizophrenia is as well a common problem, there may be long delays before getting an accurate diagnosis [16]. For the same reason, the DSM- Five field trials have included ‘test-retest reliability’, which involved different clinicians doing independent assessments of the same patient - a new method for studding diagnostic trustworthiness [16]. Anyway, back to medical illnesses, according to a meta-analysis the five most usually misdiagnosed diseases are cardiovascular disease, myocardial infarction, infection, neoplasm and pulmonary emboli [17]. On the other hand, while doctor acquaintance with this data is variable [18], faults can have an intensely negative emotional influence on the physicians who commit them [19]. As has been stated before, some researchers believe that adversative consequences from medical mistakes generally do not occur owing to isolated faults and essentially reflect system difficulties [20]. Such an idea is frequently referred to as the ‘Swiss Cheese Model’. This is the impression that there are strata of safeguard for patient and clinicians to avoid errors from happening. So, even if a physician or nurse makes an unimportant fault, this is exposed before it really jeopardizes patient safety (for example, pharmacologist checks the medications and corrects the slip). Such mechanisms include: Systematic safety methods, practical modifications, training programs, and persistent specialized progress courses [21]. On the other hand, medical and, particularly, neurological illnesses happen repeatedly among patients with conversion disorders. What is naturally seen in these co-morbid medical or neurological disorders is an expansion of symptoms arising from the original biological lesion. Somatization disorders, anxiety disorders and depressive disorders are particularly famous for their relationship with conversion disorder. Meanwhile, studies of patients admitted to a psychiatric hospital for conversion disorder, later, disclose that 25% to 50% have a clinically noteworthy mood disorder or schizophrenia. Similarly, personality disorders, too, often accompany conversion disorder, principally the passive-dependent type (9 to 40 percent of cases) and the histrionic type (in 5 to 2 1 percent of cases). The identification of conversion disorder necessitates that clinicians find an obligatory and important link between the source of the neurological symptoms and psychological dynamics, though the symptoms should not result from the factitious disorder or malingering. No doubt, one of the major difficulties in identifying conversion disorder is the problem of absolutely exclusion a medical ailment. Parallel nonpsychiatric medical disorders are common in hospitalized patients with conversion disorder, and evidence of a present or preceding neurological illness or a systemic disease affecting the brain has been reported in 18% to 64 % of such patients. As has been stated before, an estimated 25 to 50 percent of patients classified as having conversion disorder eventually receive diagnoses of non-psychiatric medical or neurological disorders that could have produced their prior symptoms. Accordingly, a systematic neurological and medical workup is necessary in all cases. Neurological disorders [e.g., dementia and other degenerative diseases], basal ganglia disease and brain tumors should be considered in the differential diagnosis. For example, weakness may be confused with multiple sclerosis, poly-myositis, acquired myopathies, or myasthenia gravis. Similarly, optic neuritis can be misdiagnosed as conversion disorder blindness. Other illnesses that may cause perplexing symptoms are Creutzfeldt-Jakob disease, Guillain-Barre syndrome, early neurological manifestations of acquired immunodeficiency syndrome (AIDS) and periodic paralysis. While conversion disorder symptoms occur in schizophrenia, depressive illnesses, and anxiety disorders, these other disorders are related with their specific distinct symptoms that sooner or later make differential diagnosis probable. In both factitious disorder and malingering, the symptoms are under conscious, voluntary control [13]. Because somatoform disorders are positioned at the crossroad between somatic and mental sicknesses, their differential diagnosis tends to be relatively all-encompassing.

However, there are numerous characteristics of these illnesses that can assist the differential diagnosis. For example, the presentation of rather ambiguous and multiple physical symptoms originating from several organ systems should usually propose a somatoform disorder instead of a somatic ailment. As the number of somatic symptoms rises [irrespective of whether they are pathologically clarified or inexplicable], so does the probability that those persons will meet criteria for a psychiatric illness, not a medical sickness. The following features can help in deciding whether idiopathic somatic symptoms may have a psychiatric etiology: 1- The symptoms co-exist with important psychiatric illnesses such as depression or panic disorder, 2- The symptoms strictly occur after traumatic events, 3- The symptoms lead to psychological “gratification” or “secondary gain”, 4- The symptoms characterize anticipated personality traits (coping mechanism)], 5- The symptoms become inflexible, join a conglomerate of other symptoms, and express such approaches as overuse of medical facilities and disappointment with medical care. The more of the abovementioned features that are present, the more likely it is that symptoms can be categorized as somatoform symptoms. In general, differential diagnosis from other psychiatric disorders is also difficult because many of the somatic symptoms may be related to a psychiatric disorder such as depression (e.g., pain symptoms), anxiety (e.g. cardiorespiratory and gastrointestinal symptoms), or even psychotic disorders (somatic delusions). Nevertheless, the existence of a great level of idiopathic somatic symptoms has to be considered even if they appear in the context of what is viewed as another primary disorder such as depression or anxiety because they probably affect symptom strictness, management outcome and level of incapacity [22].

Anyhow, careful medical examination, based on adequate clinical skills and knowledge, is necessary for diagnosis or ruling out of medical problems. Enhanced educational curriculums in medical schools, improvement of skills and knowledge of medical students in the field of ‘somatic symptom disorder’ and consultation-liaison psychiatry, guideline modifications, continuous post-graduation education and system modifications possibly will help to decline the percentage of medical errors [23]. Though no one has considered the total expenses of misdiagnosis of medical illnesses, it is clear that, if the mistake in diagnosis results in the deceases of patients, then the cost is tremendously high. Consequently, it may be wise that the diagnosis of conversion disorder not be seen as an absolute choice between biological vs. psychological symptomatology. However, if the diagnosis of conversion disorder is assumed, the clinician is recommended to prudently monitor current symptomatology to guarantee discovery of a biological pathology.

Conclusion

The incidence of medical mistakes in primary care is not rare and the probability of faults producing grave detriment is great, of which most could be taken as avoidable or fixable, if management could be started almost immediately or at least not too late. Sufficient attention to detailed process of development of patient’s symptoms, their intensity, duration, priority and fluctuation, and, moreover, vigilant medical checkup and thorough documentation of findings are helpful issues for further lessening of medical and diagnostic faults. So, a rigorous work and all-inclusive approach is compulsory for improvement of patient’s safety in primary care clinics. This may contain enhanced educational core curriculums in medical colleges, with an improved emphasis on psychological medicine, strengthening the validity and reliability of available diagnostic criteria, constant post-graduate training, and organizational amendments or revisions based on periodic re-evaluations. Supplementary studies respecting the prevalence, etiology, cultural or societal issues, student, faculty or facility related aspects, curriculum efficiency, and objective self-monitoring mechanisms certainly will help to reduce the problem.

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Lupine Publishers | Calligraphic Handwriting Effects on Type A Personality of Hypertensive Patients

 Lupine Publishers | Journal of Complementary & Alternative Medicine

Background

Hypertension is one of the most common worldwide diseases afflicting humans. It is a serious condition that can lead to coronary heart disease, heart failure, stroke, kidney failure, and other health problems (National Institutes of Health, 2008). People who have hypertension can take steps to control it and reduce their risks for related health problems. Key steps include following a healthy lifestyle, having ongoing medical care, and following the treatment plan that the doctor prescribes. Most people who have hypertension will need lifelong treatment. Despite progress in prevention, treatment, and control of high blood pressure, hypertension remains a major public health challenge Whelton, et.al [1].

The etiology of hypertension is multifactorial, involving genetic factors, biophysiological processes, daily experiences throughout life. Some psychosocial factors, such as the Type A behavior pattern, anxiety, and depression, also play a significant role in the etiology of hypertension, which is supported by many epidemiological investigations Krantz, et.al.[2]; Markovitz, et.al.[3]; Spicer et.al. [4]. Yan et.al. [5] followed 3,308 adults with normal blood pressures, ages 18 to 30 years, for fifteen years for the development of high blood pressure. This study gives strong support to the role of psychological characteristics in the development of high blood pressure.

Chinese Calligraphic Handwriting (CCH) is a WHO Fancourt et.al. [6] recognized effective treatment. Its training can enhance the practitioner’s cognitive abilities, relax his bodily conditions, and stabilize his emotions. Its practice in general can also lead to serene, stable, comfortable, and quiet emotional states. These changes are indicated by the participant’s physiological changes. For example, their heart rate slows down, blood pressure decreases, and digital pulse volume also increases with corresponding reduction in EMG. In addition, greater control of breathing takes place during brush writing than do their normal resting breathing, etc. Kao et.al.[7].

Furthermore, long-term calligraphic practice can exert a subtle effect on one’s personality Kao et.al.[8]; Henry et.al.[9]. To examine the effects of calligraphic activities on the traits of human personality, we studied the relationship between CCH writing experience and traits of personality by the factors from the 16- Personality Factors (16 PF) was administrated to in practising adults and children. Results showed that CCH training can shape and change children and adults’ personality to a more mature state, including being more emotionally stable, conscientious, self-sufficient, controlled and with heightened learning ability. On basis of the above observations, we carried out an experiment to see if CCH training would be able to clinically treat hypertensive patients who were comorbid with both the trait of introversion and the traits of Type A personality. We expected that the CCH training would lead to significant reduction in the subjects’ blood pressure to be indexed by the Systolic and Diastolic blood pressures.

Method

Type A behaviour questionnaire is originated in the fifties, developed by Friedman et.al.[10] and was used for evaluating special types of behaviour of the patients with coronary heart disease. The Chinese version of the scale was revised by Zhang [11]. Type A personality refers to “a complex pattern of behaviors and emotions that includes an excessive emphasis on competition, aggression, impatience, and hostility.”.

It includes three dimensions: TH score indicates the sense of time rush, sense of tight timing and quick work etc.; CH score indicates competitive, strong desire to outshine others, having vigilance, hostility, and impatience etc. The classes of Type A behaviour are defined according to the total scores: Total score > 35 is Type A behaviour, scores between 28~34 is Type A-, score of 27 is the middle type, scores between 20~26 is type B-, and total score <19 is type B. Only when the subjects’ total scores were more than 27 would they be eligible to participate in the experiment. That is all the 20 participants were of Type A or Type A- personality. The experimental group of 10 patients practiced calligraphy for 30 minutes while the control group of 10 patients sat quietly for the same duration.

Results

Results showed that the post-writing decrease in blood pressure averaged 10.50 Hg. for the experimental group. The more salient decrease, averaged at 22 mmHg, was observed for the systolic blood pressure of the patients with Type A- personality. A significant post-writing reduction in systolic blood pressure was found (F=14.14; p<0.05) for the experimental group. While the post-writing reduction in systolic blood pressure was found for both the Type A and the Type A- patients, the drop in Type Apatients was significantly greater than in Type A patients (F=5.89; p<0.05). The patients in the control group showed no change in blood pressure between the two measurements.

Figure 1: Changes of blood pressure pre- and post-writing in experimental group.

Figure 2: Changes of blood pressure of pre- and post-writing in control group.

Discussions

Results of the present study offer evidence for the therapeutic effects of brush handwriting on blood pressure reduction, particularly the systolic pressure, in patients with hypertension. Another significant finding is that after calligraphy handwriting, individuals with type A- behaviour showed greater reduction in systolic pressure than individuals with type A behaviour, which further disclosed the internal relationship among blood pressure, personality traits and calligraphic conduct. There can be two explanations for different blood pressure rectification effects of calligraphic conduct on individuals with type A- and type A personality. Firstly, type A individuals showed rather stable psychological tension elements and thus significant therapeutic effect would not occur only through once, or twice short-term calligraphic practice. That is, more calligraphy practice is needed for people with type A behaviors to achieve significant reduction in blood pressure. Secondly, type A- individuals, in terms of personality elements, include more non- type A personality features, or comprises with a certain proportion of type B personality features. Therefore, when conducting calligraphy, they are easier to relax nervous emotions, and regulate blood pressure. When conducting calligraphy, individuals can achieve a state like that generated by qigong and meditation-“entering into quietness”. They relax psychological tension, reduce body’s awakening level of the central nervous system, raise the activity level of non- central nervous system, regulate functions of internal organs, such as cardiovascular system etc., and finally, reduce heart rate and blood pressure. Hypertension has become such a common disease these days and psychological factors are playing an increasingly important role on the onset and course of hypertension. Calligraphy therapy, as an innovative, effective technique for emotion stability, stress reduction and general health improvement Kao, [12]; Goan [13]; Goan et.al.[14], can be applied widely to those suffering from psychosomatic diseases. In sum, short-term calligraphic practice seems to produce a more immediate effect on stable introverted individuals and type A- personality individuals than unstable extroverted or type A individuals.

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Lupine Publishers | Resistance of Neisseria gonorrhoeae on oral and mucosa : A Review Article

 Lupine Publishers | Journal of Pediatrics and Neonatology

Abstract

Introduction: Gonorrhea is one of the four most common sexually transmitted diseases worldwide. Globally, the highest incidence of gonorrhea cases is in the African and Western Pacific regions (including China, Indonesia and Australia). Gonorrhea is a sexually transmitted disease caused by the bacteria Neisseria gonorrhoeae. These bacteria are gram-negative bacteria in the form of diplococci located intracellularly from PMN cells. Infection from Neisseria gonorrhoeae can be transmitted by sexual intercourse or vertical transmission at the time of delivery. In children, infection can occur as a result of sexual abuse by an individual infected with Gonorrhea or it can also occur from touching items contaminated with N. gonorrhoeae bacteria.

Discussion: Gonococcal infection occurs by invading the mucosa, so that gonococcal infection can occur in many places. Gonococcal infection can occur in male and female external genitalia, anorectal, pharynx and eyes. There can be a local infection in the genital area (most common), infection in the abdominal cavity (peritonitis), infection around the liver (perihepatitis), meningitis, endocarditis, dermatitis, arthritis and can spread to the bloodstream and cause a Disseminated Gonococcal Infection (DGI) which can spread systemically. The manifestations of gonococcal infection in the female external genitalia can be asymptomatic but may also include periurethral edema and urethritis. There may be a purulent discharge from the cervix but it does not represent vaginitis, dysuria or painful urination, dyspareunia or pain during sexual intercourse and lower abdominal pain. There can also be a vulvovaginitis, bartolin abscess, and in gonococcal infections that are not treated properly, a complication can occur in the form of pelvic inflammatory disease (PID), characterized by lower abdominal pain, increased body discharge from the vagina and urethra, dysuria and intermenstruals. bleeding accompanied by signs of peritonitis, endocervicitis, endosalfingitis and endometritis, causing a deep pelvic or lumbar pain. Currently, the resistance rate of Neisseria gonorrhoeae to antibiotics is increasing rapidly. This condition is not good for prognosis.

Conclusion: The administration of dual therapy with this drug regimen is expected to increase the cure rate so that it can prevent more serious complications and reduce the possibility of resistance to cephalosporins.

Keywords: Gonorrhoea; Resistance; Oral Management

Introduction

Gonorrhea is an infectious disease of the mucosa caused by gram-negative cocci bacteria Neisseria gonorrhoeae which can be transmitted through sexual or perinatal contact. This infection occurs co-infection with Chlamydia trachomatis [1,2]. Gonorrhea can occur in men or women, generally at productive age, but infection by bacteria in women is asymptomatic. This infection can also occur in newborns due to vertical media from the mother during labor. Most gonorrhea manifests as infection of the genital tract, but it can also cause pharyngitis, proctitis and conjunctivitis in certain groups. Clinical findings of conjunctivitis were found in infants with a history of perinatal infection[1-3]. Gonococcal infection is the most common cause of urethritis in men, who experience complaints of pus from the genitals. In women, gonococcal infection causes cervicitis, but this condition manifests asymptomatically so that patients present after a pelvic inflammatory disease (PID), infertility, ectopic pregnancy, or a chronic pelvic inflammation. Diagnosis of a gonococcal infection is done by taking pus from the genitalia, rectum, oropharynx or eye secretions in conjunctivitis gonorrhea and doing a gram examination, where an image of gramnegative diplococcal bacteria can be found in PMN cells, which is confirmed by culture on gonococcal selective media such as Martin. -Lewis medium and Thayer-Martin medium [1,4].

The management of gonorrhea is done by administering antibiotics with a recommended treatment regimen using Ceftriaxone 250 mg IM in a single dose, plus offering Azithromycin 1 gram orally in a single dose. In patients with cephalosporin allergy, an alternative therapeutic regimen can be used using a single dose of Gentamycin 240 mg IM and Azithromycin 1 g orally as a single dose [1,2,4,5]. Currently, the resistance rate of Neisseria gonorrhoeae to antibiotics is increasing rapidly. The high rate of Gonorrhea resistance to the penicillin, tetracycline and quinolone classes has made this drug class no longer accepted for use as a Gonorrhea therapy in most countries in the world. Even in some countries, it has been found that Gonorrhea resistance to cephalosporin therapy creates the 3rd that is given orally[6,7].

Discussion

Gonorrhea is one of the four most common sexually transmitted diseases worldwide. In 2015, the World Health Organization (WHO) estimated that around 357 million new infections from one of the four infectious diseases occurred each year [8]. In an epidemiological study based on data collected from 2005 to 2012, it was found that the global incidence of gonorrhea in women was 0.8%, while in men, it was found that the global incidence of gonorrhea was 0.6% of the worldwide population in 2012, so that if converted In total, there were 26,819,000 cases of gonorrhea worldwide in men and women aged 15-49 years, where there were 19 cases per 1000 women and 24 cases per 1000 men based on World Bank data in 2012 [9,10]. Globally, the highest incidence of gonorrhea cases is in the African and Western Pacific regions (including China, Indonesia and Australia). There are several potential causes for the increased incidence of Gonorrhea globally. One possible cause of this is the increasing prevalence of HIV infection in developing countries. Improvements in diagnostic capabilities and case reporting systems in several countries can also contribute to increasing the incidence of Gonorrhea globally [3].

Gonorrhea is a sexually transmitted disease caused by the bacteria Neisseria gonorrhoeae. These bacteria are gram-negative bacteria in the form of diplococci located intracellularly from PMN cells. Infection from Neisseria gonorrhoeae can be transmitted by sexual intercourse or vertical transmission at the time of delivery. These bacteria mainly attack the columnar epithelium of the host, so that all mucous membranes can be infected by these bacteria[1,2]. There are many factors that influence N. gonorrhoeae bacteria on their virulence and pathogenicity. Fili help the attachment of bacteria to the mucosal surface thereby contributing to the resistance that occurs by preventing ingestion and destruction of bacteria by neutrophils. Opacity-associated (Opa) protein increases the adhesion between gonococcal bacteria and phagocytes, thereby increasing the ability of bacteria to invade host cells and can cause a decreased immune response [4].

Clinical Manifestation

Manifestations of gonococcal infection in male external genitalia can be urethritis, which is the most common manifestation of Gonorrhea in male external genitalia, balanoposthitis, balanitis, prostatitis, epididymitis, vesiculitis or cystitis, often characterized by a purulent and thick body body, sometimes accompanied by complaints of pain when urinating or dysuria. The manifestations of gonococcal infection in the female external genitalia can be asymptomatic but may also include periurethral edema and urethritis. There may be a purulent discharge from the cervix but it does not represent vaginitis, dysuria or painful urination, dyspareunia or pain during sexual intercourse and lower abdominal pain. In gonococcal infection that is not treated properly, a complication can occur in the form of pelvic inflammatory disease (PID) [1,5]. Anorectal manifestations include proctitis accompanied by pain and a purulent fever. In some cases complaints of burning or pain during defecation, tenesmus, and blood in the stool may also be found. Gonorrhea diagnosis is done by taking anamnesis and physical examination that leads to a gonococcal infection and finding an intracellular gram-negative diplococcal image from the results of gram staining of the secretions or body fluids of a patient suspected of a gonococcal infection and the growth of N. gonorrhoeae from culture results. The differential diagnosis of a gonorrhea urethritis includes urethritis caused by genital herpes, urethritis due to C. trachomatis, urethritis due to Ureaplasma urealyticum, urethritis due to Trichomonas vaginalis, bacterial vaginosis, Reiter’s syndrome [11].

The manifestations of gonococcal infection in the male external genitalia can be in the form of urethritis which is the most common manifestation of Gonorrhea in male external genitalia, balanoposthitis, balanitis, prostatitis, epididymitis, vesiculitis or cystitis. This condition is often characterized by the presence of a body discharge that varies from clear and clear to purulent and thick, sometimes accompanied by complaints of pain during urination or dysuria. In some cases, edema may also be found in the external urethral meatus, prepuce or penis. Gonorrhea manifestations of the pharynx occur due to sexual exposure to oral-genital contact. It can also occur as a result of an inoculation after holding an infected limb or object and then putting the hand in the mouth. In this condition, there is erythema of the pharynx, mild sore throat, and often an infection of the genitalia is also found [1,2]. There is a hyperemic pharynx and swelling of the tonsils and there is a purulent white discharge on the wall of the pharynx. It is important to dig for the coitus suspectus with orogenital sexual intercourse and to do a throat swab to check with gram stain or for culture (Figure 1).

Figure 1: Gonorrhea of the pharynx (Pharyngitis Gonorrhea).

Gonorrhea manifestations in the eye may include conjunctivitis, palpebral edema, chemosis and profuse and purulent discharge. In some cases, this gonococcal infection can even cause a corneal ulcer to perforate which can lead to permanent blindness. In neonates, ophthalmia neonatorum can occur, which is a bilateral conjunctivitis condition characterized by eye pain, conjunctival hyperemia, and the presence of purulent secretions[1]. Diagnosis of gonorrhea is carried out by taking anamnesis and physical examination that leads to a gonococcal infection and finding an intracellular gramnegative diplococcal image from the gram stain of the secretions or body fluids of a patient suspected of a gonococcal infection. However, because the sensitivity is low, a negative gram test result is not sufficient to rule out a diagnosis of gonorrhea, so it is necessary to have another gram-test or a culture examination done. Swab culture examination of the infected area is currently. The standard for diagnosis of Gonorrhea, which is very useful especially in cases with unclear clinical picture, when there is a condition of failure of therapy or when it is difficult to extract the history of the disease. However, empiric therapy can be done first considering the culture results take 24-48 hours [2,4].

Gonorrhea Resistance

Antibiotic resistance, especially in the case of Gonorrhea, is a threat in reducing the consequences of sexually transmitted diseases worldwide. Based on data from WHO, the incidence of gonorrhea infection that is resistant to antibiotics is increasing every year. This is of particular concern to public health observers, especially for the prevention of infertility in women [8]. Gonorrhea is currently still one of the four largest sexually transmitted diseases worldwide that can be cured. However, in recent years, Gonorrhea has become increasingly resistant to antibiotics that were previously sensitive, which has led to fears that Gonorrhea will not cure. Gonorrhea with multiple drug resistance (MDR) was reported by more than 36 countries in the world in 2015 [9-10]. Untreated gonorrhea can lead to more severe complications, such as female infertility, complications in pregnancy and blindness in newborns who are infected during pregnancy. the delivery process [12]. Resistance of Neisseria gonorrhoeae to penicillin and tetracyclines was first discovered in Asia in 1970. The high rate of resistance to quinolones (Ciprofloxacin) emerged since mid-2000. Recent data shows that there is an increase in resistance and failure of Neisseria gonorrhoeae treatment against third generation cephalosporins given orally. Several serotypes of N. gonorrhoeae that have been associated with failed cephalosporin therapy have also been shown to have resistance to other antibiotics and have been classified as multi-drug resistant gonococci [13].

Therapeutic Management

Initially, the therapeutic regimen given in cases of gonorrhea can be done by providing single therapy using cephalosporins. However, due to the resistance of these bacteria to oral cephalosporins as monotherapy, dual therapy using ceftriaxone and azithromycin is recommended as the standard therapy for gonorrhea cases worldwide, especially in the United States. Dual therapy with ceftriaxone and azithromycin should be given simultaneously on the same day and under direct supervision. Since most N. gonorrhoeae infections are co-infected with C. trachomatis, the principle of dual therapy is also considered quite effective because basically azithromycin is a class of antibiotics given to C. trachomatis infections [14]. In recent years, gonorrhea has become increasingly resistant to previously sensitive antibiotics, which has led to fears of incurable gonorrhea. Gonorrhea with multiple drug resistance (MDR) was reported by more than 36 countries in the world in 2015. Untreated gonorrhea can lead to more severe complications, such as female infertility, complications in pregnancy and blindness in newborns who are infected during pregnancy. childbirth process. Due to the resistance of these bacteria to oral cephalosporins as monotherapy, dual therapy using ceftriaxone 250 mg IM single dose and azithromycin 1 g PO single dose is recommended as the standard therapy in cases of gonorrhea worldwide. The administration of dual therapy with this drug regimen is expected to increase the cure rate so that it can prevent more serious complications and reduce the possibility of resistance to cephalosporins [15,16].

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Lupine Publishers | Varied clinical and Oral Presentation of Beckwith – Wiedemann Syndrome - Report of a Case from Saudi Arabia

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Beckwith – Wiedemann syndrome is congenital, genetic and epigenetic pathologies with low prevalence and diverse clinical presentations. It is characterized by triad of omphalocele, macroglossia and gigantism. This syndrome has been widely studied with a current emphasis on improvement of prenatal diagnostic techniques and a multidisciplinary approach towards treatment. We report a case of BWS from Saudi Arabia, with unique presentations and misleading history which delayed diagnosis, due to cultural and religion constraints.

Keywords:Congenital; Epigenetic; Genetic; Prenatal

Introduction

Genetic and epigenetic changes or a human genomic imprinting disorder is characterized by phenotypic variability which might shows its occurrence either as sporadic or inherited. The pathology presents wide range of effect on psychological and social wellbeing of patients and families. One such congenital, multigenic, multisystem human genomic imprinting disorder with complex molecular etiology and variable complex phenotype is Beckwith – Wiedemann Syndrome (BWS). Beckwith-Wiedemann Syndrome is most common overgrowth syndrome described by Beckwith in 1963 and Wiedemann in 1964 with similar findings. It is rare congenital deformity with low prevalence but at same time have high prevalence within genetic abnormalities of overgrowth [1]. The presentation of triad features of omphalocele (exomphalos), macroglossia and gigantism was described earlier as EMG syndrome which now is referred as Beckwith – Widemann Syndrome. The incidence of BWS reported is approximately 1:13700 births and the major cause is thought till date is genetic and epigenetic defects within the chromosome 11p15.5 regions [2].

BWS presents wide array of clinical manifestations such as congenital abdominal wall defects as hernia (exomphalos), gigantism, macroglossia, nevus flammeus, ear pits/hearing loss, midface hypoplasia, cardiac anomalies, hemihypertrophy, genitourinary anomalies and musculoskeletal abnormalities. To standardize the diagnostic criteria various attempts have been made to classify the major and minor criteria. Elliot et al described the diagnosis of BWS with the presence of either three major features (abdominal wall defect, macroglossia, gigantism) or two major and three minor features (ear pits, nevus flammeus, hemi hyperplasia, nephromegaly, neonatal hypoglycemia) [3]. In spite of diverse clinical presentations of BWS, most of the cases do not show characteristic features at birth but develop later in life. Also, children with BWS have significantly increased risk of cancer during early childhood which need strict follow up and monitoring. Here, we present a case of BWS with unique dental and medical presentation and its differential diagnosis with literature review.

Case Report

A 5-year-old female patient, accompanied by her mother, presented to the dental unit with complaint of decay tooth in upper front region of mouth. Extra oral examination revealed dysmorphic features, coarse facies and developmental problems (Figure 1). Intra oral examination of hard tissue showed high arched palate, decayed teeth in relation to 51, 52, 55, 61, 62, 74, 75, 84,85. Oral soft tissue examination revealed macroglossia, enlargement of fungiform papillae and mild loss of filiform papillae (Figure 2). Speech and feeding difficulty were noticed due to macroglossia. History revealed she is the youngest 7th child born out of consanguineous marriage in 30th week by cesarian section. She has a chronic history of constipation for 9 months of age. She passes hard stool once in every 8 to 10 days, by spending long time in washroom. It is associated with decrease in appetite and abdominal pain. She was given Movicol (half the adult dose) twice a day for constipation without any medical prescription. She was also tried with lactulose, glycerin suppository and mineral oil. Under medical supervision fleet enema and contrast enema were performed to relieve constipation and to rule out Hirschsprung disease.

Figure 1: Photograph showing dysmorphic features and hypertelorism.

Figure 2: Macroglossia with enlarged fungiform papillae and loss of filiform papillae.

Other medical findings noticed omphalocele, ear pits, large child at 90th centiles, large rounded eyes with hypertelorism, abdominal soft lax, enlargement of kidney, distention of left renal pelvis with significantly distended urinary bladder, abnormal anatomy of the colon located in left abdomen and partial colonic non – rotation with no evidence of obstruction (Figure 3). Based on the clinical and past medical history a diagnosis of Beckwith – Wiedemann Syndrome (BWS) was made. Series of laboratory investigation were reviewed which presented negative urine examination, alpha – fetoprotein, karyotype, microarray and methylation analysis for BMS. Patient was advised for gene analysis and targeting testing for parents. The gene analysis of CDKN1C gene showed heterozygous alteration consistent with BWS but targeting gene tests were refused by parents. Panoramic radiograph was advised considering the patient chief complaint, which revealed multiple developing permanent tooth buds, protrusion of anterior teeth, open bite and increase in mandibular dimension (Figure 4). Under preventive measures the patient was treated for the decayed teeth and is under follow up from past 6 months.

Figure 3: Photograph showing abdominal wall defect with surgical scar.

Figure 4: Panaromic radiograph showing multiple developing permanent tooth buds, open bite and increased mandibular dimension.

Discussion

Diagnostic criteria for BWS is still a matter of research due to its varied clinical presentations and overlapping features with other various conditions. The presence of major and minor findings is generally helpful in establishing the clinical diagnosis (Table 1). The oral findings as mentioned in the literature and observed in our case has been tabulated in Table 2 [4,5]. The incidence of BWS is difficult to assess in Saudi Arabia, as most of the cases goes undiagnosed and unnoticed. Also attributed to its diverse clinical presentation and difficulty in diagnosing. In the present case, features of macroglossia, macrosomia, omphalocele, abdominal wall defect (treated immediately after birth and surgical scar observed clinically), Renal involvement, ear crease, high arched palate, open bite and increased mandibular dimension, leads to the diagnosis of BWS. Various molecular mechanisms and alterations have been involved in BWS such as abnormal methylation of H19DMR, loss of imprinting of IGF2, chromosomal rearrangements, loss of imprinting of LIT1, uniparental disomy of 11p15 and CDKN1C mutations [2]. The full gene analysis of CDKN1C gene profile were suggestive of BWS in our case and the alteration is thought to be located in the allele inherited from the mother. Parental testing was advised which was refused by the parents. There are various endocrine and overgrowth syndromes that was considered in the differential diagnosis. These included Simpson-Golabi-Behmel syndrome (mutation in X-linked gene, GPC3), Perlman syndrome (Increased risk of neonatal mortality), Costello syndrome (missense mutation in HRAS), Sotos syndrome (Mutation in NSD1) and Mucopolysaccharidosis type IV (lysosomal storage disorder) [6]. Oral findings like macroglossia of BWS needs differentiation from other lesions like lymphangioma, idiopathic muscular hypertrophy, hemangioma, rabdomyomas, amyloidosis, cretinism and acromegaly.

Table 1: Presenting major and minor features of BWS.

Table 2: Oral findings of BWS.

The overall risk of BWS for tumor development/malignancies is estimated to range from 4 – 21%. The tumors reported with BWS are mainly embryonal tumors such as Wilms tumor, hepatoblastoma, rabdomyosarcoma, adrenocortical carcinoma and neuroblastoma [7]. The prenatal diagnosis with current technology is increasing representing an important tool to determine some features of BWS before birth. In our case, parents were highly orthodox and refuse to share the detailed prenatal and ultrasonic reports. Few misguided information’s were given by mother which was later clarified with the reports from the subsequent medical hospitals. Patient’s parents were advised for periodic follow up with genetic counselling and the possibility of surgical interventions in the medical units, but they refused to follow and changed the hospitals every time. Hence, an effort was put forward to retrieve the information’s related to the patient while giving her the primary treatment for which she reported to our dental unit. This suggest the need of awareness required in the country like Saudi Arabia, where most of the cases goes unreported/unnoticed or parent’ consent not given or the cultural and religion barriers that prevent reporting such cases. Though the patient was treated with dental fillings, the follow up of the patients is been restricted by the family members.

Conclusion

Beckwith – Wiedemann Syndrome patients usually grow and do well despite being at increased risk of childhood cancer. Hence, strict follow up, awareness of parents and cancer screening is mandatory. Families, physicians and dentists should determine screening schedule including abdominal ultrasound in every three months, blood test to measure alpha-fetoprotein in every six weeks, dental check-up in every six months and other symptomatic treatment schedule as and when required.

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Lupine Publishers | Moral Judgments as Speech Acts: A Re-Evaluation

 Lupine Publishers | Scholarly Journal of Otolaryngology

Introduction

Elsewhere I tried to show that Nietzsche has a Human solution to “Is vs. Ought” problem [1]. His notion of causality as free will is Human causality, viz., habit; his picture of the mind is epiphenomenal, with clear Human traces as he rejected noumenal self and “I” as a given; he takes “Is” to be type-facts, facts about what character one is, and “Ought” to be the second-nature of human beings as build upon the type-facts. And the communal feeling of a natural being, viz. feeling of responsibility given the causality of free will, links “Is” with “Ought” just as Mounce claimed Hume meant them to do. At this point, it seems to be the case that Nietzsche is of the firm conviction that the problem can be traced back to a specific feeling of the moral subject, viz. the feeling that s/he is the cause of his/her own actions. Moral subjects achieve the causality in the second sense of the term Hume uses via socialization and they become moral subjects along the way. And the bridge between the I-sentences and the O-sentences are the inter-subjective constraints that train them into the moral feeling of responsibility. Indeed, this is the familiar process of moral education, punishment and reward. As for causality, Nietzsche believes that “[w]e has combined our feeling of will, out feeling of ‘freedom,’ our feeling of responsibility and our intention to perform an act, into the concept cause’…” [2]. It is just an explanatory schema human beings project on the chaos of events to satisfy their need for an answer, facing the unfamiliar and the unknown. The origin of the concept can be traced back to our belief that we cause things, that we have free will. Freedom as causa sui, however, is the power of things-in-themselves which, Nietzsche avers, are not nonexistent. It is not a metaphysically necessary relation, but a feeling that human beings are free in their actions. Accordingly, the problem Nietzsche and Hume deals with can be seen as a question pertaining to account of free actions prescribed by the O-sentences, rather than the shift between the copula “is” and the modal operator “ought,” under the light of the belief that some facts, connected by causal links in the I-sentences, must justify free actions prescribed by the O-sentences. “Ought” as a performative, is to express causa sui, freedom in moral action, but when the expression of moral action prescribed by an O-sentence must express the moral freedom, the expression of the action is free from “Is” as well. Since, if utterance of the O-sentences can be seen as a moral action, it is a free action too. Hence the problem of “Is vs. Ought.” Nietzsche seems to provide the answer in the I-sentences that express the type-facts, i.e., facts about the natural needs of diverse human beings. In the next part, I will elaborate on this suggestion.

The Rules of “Ought”

Hume, in the mainstream reading of the infamous passage in Treatise [3], seems to express his disavowal of any metaphysically necessary link between the two, i.e., the moral and the factual, sets of judgments. I tried to show that Nietzsche follows his footsteps too. Their analysis in fact remains worth of studying, since any argument that assumes a necessary relation between the I-sentences and the O-sentences must find a solution to the problem of freedom. The relation of causality may be replaced by some other relation assumed to be metaphysically necessary but if moral actions expressed by the O-sentences are subject to the necessity among the facts expressed by the I-sentences, the problem would persist. The unperceivable shift between the two set of judgments, therefore, cannot be accounted by the metaphysically necessary relations between the facts, since the actions then would lose the crucial character which renders them moral. Since their time, however, philosophers have come up with other alternative accounts of the O-sentences. More crucially, they offered some brand-new ways of conceiving the relation between the judgments and the facts, such as speech-acts who not only describe but also constitute actions.

“

As Austin notes, what we have to study is not the sentence, but the issuing of an utterance in a speech situation. Our question is not, what does the sentence mean? but What happens? What does the speaker mean? or perhaps, how is the world altered by the occurrence of this utterance?” [4]. The world alters when somebody utters an O-sentence, since chances are there that one’s interlocutor may act as prescribed by the O-sentence. The O-sentence can then be taken as analogous to a command, then. “More frequently the point of an utterance is to evoke some particular action as a response ... When someone obeys a command, his action, of course,is a response to the command, not something caused by it.” That is to say, one appeals to the feeling of causa sui in uttering an O-sentence, since one believes that one’s interlocutor has freedom and control over his actions to change the course of the events as prescribed by it. Given that “[t]here must exist an accepted conventional procedure having a certain conventional effect, that procedure to include the uttering of certain words by certain persons in certain circumstances” [5], the use of the O-sentences must have such a conventional procedure as well. Supposing that utterance of an O-sentence is an “act of uttering a sentence which is a performative to perform an act (e.g. to give an order, or make a promise)” (Holdcroft, 1974, p. 3) the factual preconditions of uttering an O-sentence adumbrate the correct inferential procedure of a moral argument: like in “Jones ought to pay back, because he promised to do so.” In this vein, “the way in which in entailment one proposition entails another is not unlike the way in which “I promise” entails “I ought”: it is not the same, but it is parallel [6].”

It is parallel, since at the most basic level, there are factual preconditions of uttering any sentence, whether it is performative or not. If those preconditions are not satisfied, then the sentence is not functional and the speech-act unhappy. Since the O-sentences as performatives have a function, i.e., to indicate that the interlocutor has control over his/her actions, the preconditions for the fulfillment of the function may solve the way out of the “Is vs. Ought” problem. I shall not go into the question if those are the truth-conditions of the sentences, and the question about their truth values is irrelevant in this context since in the sense I take them to be as injunctions, they do not have truth values: “A moral judgment of and centrally serves as a kind of injunction, spoken aloud or in one’s heart, to others or to oneself, to behave or not to behave in a certain way. As such, it has no truth value...” [7]. When they take on other functions, i.e., not taken as injunctions, they may or may not have truth values, but I shall not broach it in this discussion. Nietzsche tried to show how “Ought” to enter into our language in a quite complex history of a natural being. It was introduced, he speculated, to satisfy the socio-political needs in language games of responsibility, or more precisely to render a natural being moral. Thus “Ought” to be not only used to express the moral behavior of a life form, but it also constitutes the rules of moral behaviour, and it is the moral action par excellence. In my reading, the socio-political institutions induced the belief in the causality of free will, building a language game, and then playing on the specific needs of them by punishment (inducing pain) and reward (inducing pleasure). The issue is that “Ought” to find its preconditions for its function –to make interlocutors responsible from their actions–in the sociopolitical context of natural needs. That is the context that provides the constitutive rules of “Ought” as a speech-act which expresses a new form of behaviour, viz. moral behaviour. Searle [7] defines the notion of “constitutive rules” as describing new possibilities of behaviour. A critique of Searle, Ransdell [8] he claims Searle’s definition does not consider the instances where one is not committed to the type of the behaviour. However, as I argued below, there is no exit-option in the moral language game. In the next part, I will put the conclusions I derived from the reading of Hume and Nietzsche into modern terms and explain further.

“Ought” Based on Constitutive Rules

To present some of the schemas and insights unavailable at the time of Nietzsche and Hume, I will present a review of the literature on the passage by Hume that formulated the problem for the first time. Dismissing some of the proposed accounts of the link in terms of “normal psychical function,” [9], of “reductive definition of some moral term” [10], and many others, I shall focus on only some, such as that of Hannaford [11], of MacIntyre [12], and of Searle [13], and the reason why is because those authors, engaging fruitful debates and laying original analyses of the question, seem to be the best representatives of the views they hold. Hannaford [11], adopts the perspective of “human behavior and needs” as the standpoint from which the “imperceptible” connection between I-sentences and O-sentences can be perceived as generating norms for endorsement of the conditions for free. Practices of a community. It is a vain move on the side of philosophers such as Kant, to disparage hypothetical judgments, he implies, for possibility conditions of moral discourse are the necessary conditions for free action: that is to say, once the value of free action is taken for granted, the moral judgments to the effect that one ought to respect them set off automatically, and other moral judgments are derivable from those. In other words, “[f]rom the knowledge of what is necessary to human action in general we can derive judgments of what we ought to do if we are to continue to engage in that action”. Such conditions, he further claims, are regulative functions of what it means to be a free member of a community of persons and yield, recursively on this quasiaxiomatic basis, particular O-sentences in particular situations that can be descriptively grasped by I-sentences.

As for the obvious objection that what Hannaford suggests is not a logical derivation in the strict sense of the term, he dismisses it on the ground that as “a normal and natural kind of derivation”, it does its job without having recourse to formal intricacies and being neutral against them. His implicit assumption that human beings, capable of moral action and consistent thought, can arrive at moral judgments by other means than strictly logical operations, given the conceptual relation between “Ought” as a prerequisite of moral action and the social-communal context of the action. Only and all moral agents capable of action can raise the question of what ought to be done, thus he claims, and only in the context of preceding moral dispute can agents make moral sense of an action, for, as in a Kantian understanding, the shift between the two sets of sentences are made possible by the universalized conditions of action in the community of free equals.

However, two objections could be raised at this point:

a) What philosophers have been pursuing for ages does not seem to be the Hannaford’s “natural derivation” of O-sentences via hypothetical judgment: Indeed, most would argue against him that judgments of this type, ones that establishes the means to do X given that one wills X, presupposes the value of moral action in a community. Hypothetical judgments may take off once it is presupposed that human beings value taking part in the sociomoral game but does not account for why they ought to take part. Indeed, that seems to be what is called “technical,” rather than purely moral, sense of ‘Ought’ that enables the natural derivation [14].

b) It is quite ambiguous to re-frame the question in terms of conditions of moral action that would emerge in communal debate, without having settled first the conditions of idealized moral debate: indeed, this may prove the foundationalist approach to the question as regressive, as some still other moral premises may be needed to do so, yet the I-sentences as they enter into Hannaford’s theoretical picture, provide no defensive strategy against it.

The vices aside, Hannaford’s analysis has virtues:

a) The derivation of O-sentences from I-sentences, he thus avers, may be achieved by extra-logical, yet semantical, operations on contextual, rather than sentential, level. Therefore, most of the philosophers perhaps looked for a strictly necessary relation on the propositional level in vain since Hume and Nietzsche.

b) Therefore, the objection (i) may indeed lose its force, provided that there is no exit-option in moral game: one may simply remind the famous remark of Aristotle and insist that one who is not in the game would be either a beast, or a god. Is it a water-proof argument? Hardly so, for one may believe that free conditions of actions are not realized in actual games of actual communities and cannot be reached by moral debate of the agents, but to be sure, burden of the proof lies not with the defender.

Interpreted as such, the riddle of Hume and Nietzsche has no formal solution, but like the renowned Gordian knot, it can be cut loose by recourse to the preconditions of free action which is the basis of moral causality and responsibility as the function of “Ought” implies. But as for the exact character of those conditions that render human agents capable of moral action and responsibility, Hannaford is silent, but MacIntyre [12] is not: such an approach to moral judgments discover, or ought to discover, as its focal point, he takes Hume to suggest, “a foundation in human needs, interests, desires, and happiness”. Hudson [15], in criticizing MacIntyre’s exegesis of the passage by Hume, claims: “it is undoubtedly the case that moral judgments are made in situations where we want, need, etc., and Hume is aware of this ; but it does not follow that he was, or thought he was, deducing ought from is. To say that a game is played in certain circumstances is not to say that the circumstances are part of the game.” But it seems obvious that rules are responses to the circumstances of a life form, a natural form of life that is subject to the constraints of the circumstances in moral action.

Austin’s [5] introduction of “performatives” is the following:

a) They do not ‘describe’ or ‘report’ or constate anything at all, are not ‘true or false’; and

b) The uttering of the sentence is, or is a part of, the doing of an action, which again would not normally be described as saying something.

Searle [13], following him, elaborates upon the rules of the performatives. He takes the so-called pejorative sense of ‘Ought’ as tautological with that of ‘obligation’ under the institutional facts therein, and therefore establishing a connection between the I-sentences and the O-sentences as the sup-species of the former. Therefore, he claims, if one acceded to play in the game of “obligation,” one has to play by the rules of the game, which is constitutive of it. In other words, a moral game like “obligation” is none other than its rules that constitutes it, i.e., institutional/ constitutional facts. Some believed all of this is irreparably wrong, as “Searle’s confusion, then, arises from his having conflated a question of entailment with a question of entitlement,” in the sense that the obdurate gap retains between the I-sentences and the O-sentences. Indeed, the objection would have a point to the effect that the institutional facts would always be divorced from the facts simpliciter, had the divorce could be rendered intelligible without recourse to the institutional facts of other speech-acts. “I suppose this amount to saying that judging, acknowledging, classifying someone else’s act as an ‘institutional act’ comprise themselves a distinct group of institutional acts [16].” Yet individuation of such facts must again resort to other language games or presume the preconditions of free action in order to account for the moral character of the action at stake-freedom. And the preconditions of free action for a form of life, viz., human form of life are quite wellestablished in terms of needs and interests. “That is not agreement in opinions but in form of life [17].”

“Is” in “Ought”

As I attempted to show above, Hannaford following the Kantian tradition finds the solution to the problem in preconditions of free action human beings feel that they are capable of. McIntyre elaborated and specified these conditions as needs, interests, desires and happiness as facts to be expressed by I-sentences. On the other hand, Austin and Searle held the mirror to the judgment side of the problem and gave some hints that moral judgments as expressed by O-sentences can be seen as speech-acts. That is to say, the O-sentences not only express those facts, but building upon them as the ineluctable preconditions of what they aim at, viz., free action, they constitute the moral facts. In fact, that is what my Human reading of Nietzsche implied as well. Conditions of free action, to be sure, relates to free will and causality of will as an inexplicable feeling that enters into the moral picture. If morality be intelligible and moral actions be possible after all, one may presume freedom of action in metaphysical terms as a necessary relation, too. Yet that is not to say that freedom will is to be taken as a tangible and observable causal relation that makes itself manifest in the action as Hume and Nietzsche put it. And if that relation is not possibly observable, it cannot be expressed by the I-sentences. If it cannot be expressed by them, then the formal gap between them and the O-sentences opens up. At this point, following Searle, I argue that the O-sentences comprise a sub-set of speech-acts. They do not only express moral facts, but also constitute them as moral. I believe Hume’s second definition of causality must come into the picture to account for freedom of action that enables the use of speech-acts as capable of articulating moral facts. Human beings feel that they are the cause of their actions. Indeed, as compatibilists argue, causality of free will and physical causality may be co-operating on human actions, though the former is not demonstrable by any means, since it is not observable, ostensible and determinable. In fact, to put it brashly, it makes no difference to the argument from free will at all that causa sui is indemonstrable. The gist of the matter is that unless one is willing to give up the whole edifice of morality and related institutions, which is Nietzsche’s point and aim, one is compelled to presume causality in the second sense.

Moreover, given the naturalistic fallacy, one cannot demonstrate moral properties and actions by the I-sentences. Thus, human beings need a second set of judgments, viz., the O-sentences, to express them. But then the problem is that, given that causality of will is indemonstrable as well, the odds are against the attempts to establish the necessary semantic connection between the I-sentences and the O-sentences, as the rules of the speech-game are centered on freedom, i.e., freedom from the factual constraints. It is in fact not a paradoxical situation where one is supposed to establish the necessity imposed by factual restraints when the game is designed to illustrate that one can get rid of them in free action. That a necessary connection is indemonstrable does not boil down to the conclusion that there is no such connection. The semantic necessity in question seems to be established by fixing the referent of the moral terms, though we may not demonstrate their semantic content. The notion of “fixing the referent” goes back to Kripke [18], who distinguished between the two functions of Sinn, viz. that of determining the semantic content and that of determining the referent. People in the past referred to the same natural object as we do to as a piece gold but did not know the factual restrictions on the speech-act at stake before they discovered physical properties of the element described by the semantic content of the term “gold.” Even then the necessary relation between the factual restrictions and the speech-act did hold. Analogously, we may never point to the necessary relation between the semantic content of the moral terms and operators and that of amoral ones, but that is no reason to deny that there may be necessary relations between the moral speech-acts and the amoral facts [19-25].

To conclude, my reading of Nietzsche via Hume put in sharp relief three points: the subjective feeling of human causality gives a sense of the necessary connection between the O-sentences and I-sentences. Human beings feel, after a long history of moral education, that they are the cause of their own actions and they act, on the beliefs expressed by the I-sentences and as prescribed by the O-sentences [26-32]. It is necessary for them to assume causality of will as natural and social beings in order to satisfy their needs, pursue their interests, and aim at happiness in the context of socio-political institutions. That in turn assumes they can cause the facts to change accordingly if these preconditions of free action are satisfied. The I-sentences in a moral argument thus can be seen as expressing the facts about their interest, needs, and happiness as the preconditions of free action[33-42]. However, causality of free will also implies freedom from factual constraints, whether in causal relations, or in any other metaphysically necessary relation, and that is why constitution of a distinct speech-act in the form of the O-sentences is inevitable, since the action of uttering an O-sentence is a moral one too [43-55]. Given that causality of free will is not demonstrable on the factual level, the factual speechacts, i.e., the I-sentences cannot convey the autonomy presumed in moral actions. The O-sentences on the other hand, given the shift of the logical operator from the copula “is” to “ought,” give a sense that moral action is divorced from the factual constraints. However, all that they demonstrate is the feeling that human beings cause their own actions. It is not a formal epistemological ground from which the O-sentences can be derived from the I-sentences. Yet, they act on the belief that they ought to cause the action prescribed by an O-sentence when it contributes to their interest, needs, and happiness [56-60].

Thus, in the feeling of causa sui, there is no gap to be bridged. It seems obvious that there are only amoral facts to form beliefs and act upon. The shift from the I-sentences to the O-sentences, however, is based on a selective interpretation of some facts. Minimally, those facts must, in principle, relate to the rules of the moral speech-act, viz., necessary conditions of free action. Once expressed by a moral speech-act, those facts are constituted as moral. Thus, the feeling of causa sui, which divorces the O-sentences from the I-sentences, re-connects them since some of the I-sentences express the factual preconditions of this feeling. It seems obvious that human beings must satisfy some of their needs and pursue their interests to enjoy freedom of action. Therefore, the I-sentences that express those needs and interests which are the prerequisites of enjoyment of freedom of action can be seen as expressing the facts which are evaluative in themselves. Some of the facts Nietzsche calls typefacts seem to be promising in this context. The facts relating to biological-physiological and psychological needs are no doubt cut out for the job of the inferential shift between the I-sentences and the O-sentences as such needs must be met so freedom of action must be enjoyed. To clarify the conclusion, the rules of the moral speech-act in the O-sentences serve to express the feeling of causality in the second sense of the term Hume uses. Moral action must be caused freely, and the feeling of moral freedom finds its expression in the modal shift from “Is” to “Ought.” As it is the case, some of the I-sentences express the preconditions of the enjoyment of freedom in the action prescribed by an O-sentence, and as such, they can be used to close the gap opened up by the feeling of moral freedom. Even if free will is not indemonstrable, then, provided that free will is to be possible at all, if morality is to be possible at all, one should be able to demonstrate what makes its factual enjoyment possible. All human beings need food, sleep, shelter, recognition, education, social interaction and context, among many other things, so they can enjoy their moral freedom implied in the moral speech-act [61,62]. The previous sentence above can be taken as an instance of the conjunction of the basic I-sentences that makes use of the O-sentences possible. That is to say, in order for the gap to be possible, in order for the problem of “Is vs. Ought” to be intelligible, the factual preconditions and implications of the problem must be possible and finally in order to close up the gap and solve the problem, one should inquire into what makes its expression possible. Moral freedom expressed on the linguistic level, thus, must be traced back to the preconditions of its enjoyment on the factual level [63,64]. Further study is required to dig deeper into the litany of the basic needs and preconditions that would make freedom of action possible. I believe it would be wise to pursue the naturalist strand of thought in Hume and Nietzsche to pursue the question at stake [65].

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