Discourse and Identity Benwell, Bethan; Stokoe, Elizabeth
03/2006, Volume:
v.Series Number 23
eBook
'Identity' is a central organizing feature of our social world. Across the social sciences and humanities, it is increasingly treated as something that is actively and publicly accomplished in ...discourse. This book defines identity in its broadest sense, in terms of how people display who they are to each other. Each chapter examines a different discursive environment in which people do 'identity work': everyday conversation, institutional settings, narrative and stories, commodified contexts, spatial locations, and virtual environments. The authors describe and demonstrate a range of discourse and interaction analytic methods as they are put to use in the study of identity, including 'performative' analyses, conversation analysis, membership categorization analysis, critical discourse analysis, narrative analysis, positioning theory, discursive psychology and politeness theory. The book aims to give readers a clear sense of the coherence (or otherwise) of these different approaches, the practical steps taken in analysis, and their situation within broader critical debates. Through the use of detailed and original 'identity' case studies in a variety of spoken and written texts in order, the book offers a practical and accessible insight into what the discursive accomplishment of identity actually looks like, and how to go about analyzing it.
Features:
*Accessible introduction to the study of discourse and identity across a variety of contexts.
*Interdisciplinary in scope, the book is relevant to a wide range of courses such as English language and linguistics, psychology, media, cultural studies, gender studies and sociology.
*Each chapter includes a critical overview of work in the area, original case studies, practical instruction for analyses, points for further discussion and suggested reading.
In this article, we depart from our recent work on ‘small stories’, which we propose as an antidote to canonical narrative studies, and we advance our argumentation by sketching out a five-step ...analytical operation for tapping into small stories as sites of identity work. These steps grow out of the model of positioning (as put forward by Bamberg 1997, and elaborated in Bamberg 2004a; cf. also Georgakopoulou 2000) that succeeds in navigating between the two extreme ends of fine-grained micro analysis and macro accounts. We will work with positioning in the close analysis of a small story event (as part of a moderated group discussion involving ten-year-old boys in an American school) in which we will show how the teller's announcement of the story, the subsequent withdrawal, and the pre-telling negotiation with the interlocutors are as integral parts of our analysis as the actual telling. We will also demonstrate how viewing story content as a function of interactional engagement opens up new insights into identity constructions of sameness in the face of adversative conditions and constant change.
The standard of care for anaplastic gliomas is surgery followed by radiotherapy. The NOA-04 phase III trial compared efficacy and safety of radiotherapy followed by chemotherapy at progression with ...the reverse sequence in patients with newly diagnosed anaplastic gliomas.
Patients (N = 318) were randomly assigned 2:1:1 (A:B1:B2) to receive conventional radiotherapy (arm A); procarbazine, lomustine (CCNU), and vincristine (PCV; arm B1); or temozolomide (arm B2) at diagnosis. At occurrence of unacceptable toxicity or disease progression, patients in arm A were treated with PCV or temozolomide (1:1 random assignment), whereas patients in arms B1 or B2 received radiotherapy. The primary end point was time to treatment failure (TTF), defined as progression after radiotherapy and one chemotherapy in either sequence.
Patient characteristics in the intention-to-treat population (n = 274) were balanced between arms. All histologic diagnoses were centrally confirmed. Median TTF (hazard ratio HR = 1.2; 95% CI, 0.8 to 1.8), progression-free survival (PFS; HR = 1.0; 95% CI, 0.7 to 1.3, and overall survival (HR = 1.2; 95% CI, 0.8 to 1.9) were similar for arms A and B1/B2. Extent of resection was an important prognosticator. Anaplastic oligodendrogliomas and oligoastrocytomas share the same, better prognosis than anaplastic astrocytomas. Hypermethylation of the O(6)-methylguanine DNA-methyltransferase (MGMT) promoter (HR = 0.59; 95% CI, 0.36 to 1.0), mutations of the isocitrate dehydrogenase (IDH1) gene (HR = 0.48; 95% CI, 0.29 to 0.77), and oligodendroglial histology (HR = 0.33; 95% CI, 0.2 to 0.55) reduced the risk of progression. Hypermethylation of the MGMT promoter was associated with prolonged PFS in the chemotherapy and radiotherapy arm.
Initial radiotherapy or chemotherapy achieved comparable results in patients with anaplastic gliomas. IDH1 mutations are a novel positive prognostic factor in anaplastic gliomas, with a favorable impact stronger than that of 1p/19q codeletion or MGMT promoter methylation.
This article critically examines the recent turn to narratives as tools for identity construction and identity analysis. While self and sense of self will be used largely as synonyms, the attempt is ...made to draw up a distinction between self (sense of self) on one hand and identity on the other. Rather than starting with a definition of features and functions of self and identity, I propose to start from the identification of three practical challenges that self and identity formation processes are facing. These three challenges will be explicated in terms of dilemmatic spaces within which identity activities—and at their center: narrating—are “navigated.” They consist of: (i) a successful diachronic navigation between constancy and change, (ii) the establishment of a synchronic connection between sameness and difference (between self and other), and (iii) the management of agency between the double-arrow of a person-to-world versus a world-to-person direction of fit. While biographical approaches (big story research) have contributed in valuable ways to identity research by exploring the links between narrative and life, they have traditionally confined themselves to the analysis of lives as texts. A narrative practice approach (small story research) is suggested to solve a number of problems and shortcomings of traditional approaches.
Summary Background High-dose methotrexate is the standard of care for patients with newly diagnosed primary CNS lymphoma. The role of whole brain radiotherapy is controversial because delayed ...neurotoxicity limits its acceptance as a standard of care. We aimed to investigate whether first-line chemotherapy based on high-dose methotrexate was non-inferior to the same chemotherapy regimen followed by whole brain radiotherapy for overall survival. Methods Immunocompetent patients with newly diagnosed primary CNS lymphoma were enrolled from 75 centres and treated between May, 2000, and May, 2009. Patients were allocated by computer-generated block randomisation to receive first-line chemotherapy based on high-dose methotrexate with or without subsequent whole brain radiotherapy, with stratification by age (<60 vs ≥60 years) and institution (Berlin vs Tübingen vs all other sites). The biostatistics centre assigned patients to treatment groups and informed local centres by fax; physicians and patients were not masked to treatment group after assignment. Patients enrolled between May, 2000, and August, 2006, received high-dose methotrexate (4 g/m2 ) on day 1 of six 14-day cycles; thereafter, patients received high-dose methotrexate plus ifosfamide (1·5 g/m2 ) on days 3–5 of six 14-day cycles. In those assigned to receive first-line chemotherapy followed by radiotherapy, whole brain radiotherapy was given to a total dose of 45 Gy, in 30 fractions of 1·5 Gy given daily on weekdays. Patients allocated to first-line chemotherapy without whole brain radiotherapy who had not achieved complete response were given high-dose cytarabine. The primary endpoint was overall survival, and analysis was per protocol. Our hypothesis was that the omission of whole brain radiotherapy does not compromise overall survival, with a non-inferiority margin of 0·9. This trial is registered with ClinicalTrials.gov , number NCT00153530. Findings 551 patients (median age 63 years, IQR 55–69) were enrolled and randomised, of whom 318 were treated per protocol. In the per-protocol population, median overall survival was 32·4 months (95% CI 25·8–39·0) in patients receiving whole brain radiotherapy (n=154), and 37·1 months (27·5–46·7) in those not receiving whole brain radiotherapy (n=164), hazard ratio 1·06 (95% CI 0·80–1·40; p=0·71). Thus our primary hypothesis was not proven. Median progression-free survival was 18·3 months (95% CI 11·6–25·0) in patients receiving whole brain radiotherapy, and 11·9 months (7·3–16·5; p=0·14) in those not receiving whole brain radiotherapy. Treatment-related neurotoxicity in patients with sustained complete response was more common in patients receiving whole brain radiotherapy (22/45, 49% by clinical assessment; 35/49, 71% by neuroradiology) than in those who did not (9/34, 26%; 16/35, 46%). Interpretation No significant difference in overall survival was recorded when whole brain radiotherapy was omitted from first-line chemotherapy in patients with newly diagnosed primary CNS lymphoma, but our primary hypothesis was not proven. The progression-free survival benefit afforded by whole brain radiotherapy has to be weighed against the increased risk of neurotoxicity in long-term survivors. Funding German Cancer Aid.
OBJECTIVE:This is the final report of a phase III randomized study to evaluate whole-brain radiotherapy (WBRT) in primary therapy of primary CNS lymphoma (PCNSL) after a median follow-up of 81.2 ...months.
METHODS:Patients with newly diagnosed PCNSL were randomized to high-dose methotrexate (HDMTX)–based chemotherapy alone or followed by WBRT. We hypothesized that the omission of WBRT would not compromise overall survival (OS; primary endpoint), using a noninferiority design with a margin of 0.9.
RESULTS:In the per-protocol population (n = 320), WBRT nonsignificantly prolonged progression-free survival (PFS) (median 18.2 vs 11.9 months, hazard ratio HR 0.83 95% confidence interval (CI) 0.65–1.06, p = 0.14) and significantly PFS from last HDMTX (25.5 vs 12.0 months, HR 0.65 95% CI 0.5–0.83, p = 0.001), but without OS prolongation (35.6 vs 37.1 months, HR 1.03 95% CI 0.79–1.35, p = 0.82). In the intent-to-treat population (n = 410), there was a prolongation by WBRT of both PFS (15.4 vs 9.9 months, HR 0.79 95% CI 0.64–0.98, p = 0.034) and PFS from last HDMTX (19.4 vs 11.9 months, HR 0.72 95% CI 0.58–0.89, p = 0.003), but not of OS (32.4 vs 36.1 months, HR 0.98 95% CI 0.79–1.26, p = 0.98).
CONCLUSION:Although the statistical proof of noninferiority regarding OS was not given, our results suggest no worsening of OS without WBRT in primary therapy of PCNSL.
CLASSIFICATION OF EVIDENCE:This study provides Class II evidence that in PCNSL HDMTX-based chemotherapy followed by WBRT does not significantly increase survival compared to chemotherapy alone. The study lacked the precision to exclude an important survival benefit or harm from WBRT.
Purpose
In the randomized G-PCNSL-SG-1 trial, the addition of whole brain radiotherapy (45 Gy) to high-dose methotrexate (HD-MTX)-based chemotherapy (early WBRT arm) did not prolong overall survival ...(OS) as compared to HD-MTX-based chemotherapy alone (no early WBRT arm) in primary CNS lymphoma (PCNSL) patients. To determine whether WBRT might lead to quality of life (QoL)-relevant late neurotoxicity, this trial prospectively monitored QoL.
Methods
QoL measurements were performed using the EORTC-QLQ-C30 and BN20 questionnaires and combined with repeated Mini Mental State Examinations (MMSE). Exploratory data analysis included the 318 patients in the per-protocol population.
Results
In year 2 after randomization, cognitive functioning and global health status were reduced in the early WBRT arm as compared to the no early WBRT arm (
p
= 0.004 and
p
= 0.022, respectively). Also, fatigue (
p
= 0.037), appetite loss (
p
= 0.006) and hair loss (
p
= 0.002) were more intense in the early WBRT arm. MMSE testing revealed lower values (
p
= 0.002) in the early WBRT arm. A mixed model analysis of longitudinal data additionally showed differences favoring the no early WBRT arm in 15 of 26 dimensions of QoL.
Conclusions
The analysis of subjective QoL questionnaires and objective MMSE testing revealed that QoL and cognition were conserved in the arm without early WBRT. Thus, even though it was an exploratory analysis, the results of G-PCNSL-SG1 challenge the place of WBRT in the primary therapy of PCNSL.
To avoid an unnecessary extend of surgery in primary central nervous system lymphoma (PCNSL), the diagnosis should be suspected after MRI. Pre-treatment MRI examinations of 100 immunologically ...competent patients with biopsy-proven PCNSL were evaluated. All patients had T2- and T1-weighted images with contrast enhancement. Diffusion-weighted MRI (DW-MRI) was available in 15, proton-MR-spectroscopy (1H-MRS) in four patients. The number of lesions ranged from one (n=65 patients) to eight (n=1) with a mean of 1.7. The most frequent locations were the cerebral hemispheres (n=66), the basal ganglia (n=27) and the corpus callosum (n=24). In the 65 patients with a solitary lesion, hemispheric lesions were most frequent (n=23) followed by corpus callosum (n=18). Contrast enhancement was found in all but one patient. 1H-MRS revealed a uniformly pathologic pattern of metabolite concentrations in all patients. Characteristic imaging features of PCNSL are contrast-enhancing lesions with a diameter of at least 15 mm in contact with the subarachnoid space. DW-MRI and proton spectroscopy may aid in differential diagnosis.
The observation that human meningioma cells strongly express somatostatin receptor (SSTR 2) was the rationale to analyze retrospectively in how far DOTATOC PET/CT is helpful to improve target volume ...delineation for intensity modulated radiotherapy (IMRT).
In 26 consecutive patients with preferentially skull base meningioma, diagnostic magnetic resonance imaging (MRI) and planning-computed tomography (CT) was complemented with data from (68)Ga-DOTA-D Phe(1)-Tyr(3)-Octreotide (DOTATOC)-PET/CT. Image fusion of PET/CT, diagnostic computed tomography, MRI and radiotherapy planning CT as well as target volume delineation was performed with OTP-Masterplan((R)). Initial gross tumor volume (GTV) definition was based on MRI data only and was secondarily complemented with DOTATOC-PET information. Irradiation was performed as EUD based IMRT, using the Hyperion Software package.
The integration of the DOTATOC data led to additional information concerning tumor extension in 17 of 26 patients (65%). There were major changes of the clinical target volume (CTV) which modify the PTV in 14 patients, minor changes were realized in 3 patients. Overall the GTV-MRI/CT was larger than the GTV-PET in 10 patients (38%), smaller in 13 patients (50%) and almost the same in 3 patients (12%). Most of the adaptations were performed in close vicinity to bony skull base structures or after complex surgery. Median GTV based on MRI was 18.1 cc, based on PET 25.3 cc and subsequently the CTV was 37.4 cc. Radiation planning and treatment of the DOTATOC-adapted volumes was feasible.
DOTATOC-PET/CT information may strongly complement patho-anatomical data from MRI and CT in cases with complex meningioma and is thus helpful for improved target volume delineation especially for skull base manifestations and recurrent disease after surgery.
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