The increasing application of artificial intelligence (AI) to healthcare raises both hope and ethical concerns. Some advanced machine learning methods provide accurate clinical predictions at the expense of a significant lack of explainability. Alex John London has defended that accuracy is a more important value than explainability in AI medicine. In this article, we locate the trade-off between accurate performance and explainable algorithms in the context of distributive justice. We acknowledge that accuracy is cardinal from outcome-oriented justice because it (...) helps to maximize patients’ benefits and optimizes limited resources. However, we claim that the opaqueness of the algorithmic black box and its absence of explainability threatens core commitments of procedural fairness such as accountability, avoidance of bias, and transparency. To illustrate this, we discuss liver transplantation as a case of critical medical resources in which the lack of explainability in AI-based allocation algorithms is procedurally unfair. Finally, we provide a number of ethical recommendations for when considering the use of unexplainable algorithms in the distribution of health-related resources. (shrink)

Background: The internationalization of clinical studies requires a shared understanding of the fundamental ethical values guiding clinical studies. It is important that these values are not only embraced at the legal level but also adopted by clinicians themselves during clinical studies. Objective: Our goal is to provide an insight on how clinicians in Germany and Poland perceive and identify the different ethical issues regarding informed consent in clinical studies. Methods: To gain an understanding of how clinicians (...) view clinical studies in the countries they work in, we carried out semi-structured problem-centered interviews per telephone in Poland (n = 6) and Germany (n = 6). Our interviewees concentrated on three main topics: an appraisal of the normative framework, challenges in the information process and the protection of all participants in clinical studies. Results: Clinicians generally supported the normative framework, even though they considered it quite complex. In the two study countries, a widely noted dilemma in the information process was whether to overburden participants with extensive information or risking leaving out important facts. Clinicians were ready to exclude larger population groups from participating in clinical studies when the information process could not be carried out with standard procedures or when their inclusion was ethically sensitive. Conclusion: Clinicians need to gain a better understanding of the consequences of excluding larger population groups form participating in clinical studies. They should seek assistance in improving the information process for the inclusion of underrepresented groups in clinical studies. (shrink)

Brummett and Salter propose a useful and timely taxonomy of clinical ethics expertise (2019). As the field becomes further “professionalized” this taxonomy is important, and the core of it is right. It needs some refinement around the edges, however. In their conclusion, Brummett and Salter rightly point out that there is a significant difference between the ethicist whose recommendations are procedure- and process-heavy, consensus-driven, and dialogical and the authoritarian ethicist whose recommendations flow from “private moral views” (Brummett and Salter, (...) 2019). This admission doesn’t go far enough. Brummett and Salter’s taxonomy fails to capture the notion that offering recommendations whose normative force is moral is different in kind from recommendations whose normative force is non-moral, such as those recommendations that are free of moral content or justified by convention. The difference is in kind, not scale. I argue further that clinical ethics expertise, if possible, consists at least in offering recommendations whose normative force is moral. These two claims imply that the taxonomy fails to cut clinical ethics expertise at the joints: the ethicist who offers justified non-moral normative recommendations is a different kind of ethicist from the one who offers justified moral normative recommendations, yet both are categorized as clinical ethics experts. I finish by offering a refinement of the taxonomy that more precisely categorizes clinical ethicists. (shrink)

Background Analysis of aphasic narratives can be a challenge for clinicians. Previous studies have mainly employed measures that categorized speech samples at the word level. They included quantification of the use and misuse of different word classes, presence and absence of narrative contents and errors, paraphasias, and perseverations, as well as morphological structures and errors within a narrative. In other words, a great amount of research has been conducted in the aphasiology literature focusing on micro-linguistic structures of oral narratives. Aspects (...) of macro- linguistic structures, such as the analysis of content information by a speaker, consistency of using cohesive devices to present information within a narrative, and order of presenting information necessary to form a coherent discourse, have not been extensively investigated. The current investigation proposes a clinical analytic system to target three aspects of macro-linguistic structures in narratives among speakers with aphasia. Specifically, (1) the presence of search events (i.e., the mentioning of key events that allow the listener to understand; Capilouto, Wright, &Wagovich, 2006) within a narrative, (2) the sequence of the mentioned events, and (3) the informativeness (i.e., the fulfillment of lexical items that allow the user to understand what the event is detailing) of the event contents, were focused in the proposed framework. Method Ten controls transcripts from were selected from the AphasiaBank (MacWhinney, Fromm, Forbes, & Holland, 2011). Three narrative tasks, including sequential picture description of ‘Refused Umbrella’, procedural narrative of making a ‘Peanut Butter and Jelly Sandwich’, and telling of ‘Cinderella’ story, were used to establish normative data for the basis of analysis. Specifically, the Search Events (e) and Informative Words (i) used by at least 70% of the speakers were listed for each genre. The sequential order of mentioning the Search Events, i.e., common order of events in 90% of the speakers, (s.total) was determined. Twelve speakers with aphasia (nine fluent and three non-fluent) were recruited and administered the Western Aphasia Battery and Object and Action Naming Battery. Their performance in the above three discourse tasks were orthographically transcribed and analyzed using the following measures: e.total, e.matched with norm, e.missed, e.irrlevant, e.extra, s.total, i.pb&j, i.umbr, i.cind, and i.total. Three samples were randomly chosen to be re-analyzed for inter- and intra-rater reliability. Results Results of an independent t-test suggested significant differences between the fluent and non-fluent subjects in sequential order of Search Events for all genres (s.total) and i.total, suggesting sensitivity of this framework to differentiate between the two fluency groups. Results of Pearson product-moment correlations revealed significant relation between Informative Words and WAB spontaneous speech scores, AQ, as well as OAB scores, for both aphasic groups. The mean value of coefficients for intra-rater reliability (0.992), with significant correlations on e.match, e.miss, and e.extra, was higher than that of inter-rater reliability (0.897). Discussion Based on our preliminary results, this objective framework allowed clinical evaluation of impairment in macro-linguistic structures present in aphasic discourse. Further extension should involve more subjects encompassing a wider range of severity with different types of aphasia. (shrink)

Evidence-based medicine relies on the execution of clinical practice guidelines and protocols. A great deal of of effort has been invested in the development of various tools which automate the representation and execution of the recommendations contained within such guidelines and protocols by creating Computer Interpretable Guideline Models (CIGMs). Context-based task ontologies (CTOs), based on standard terminology systems like UMLS, form one of the core components of such a model. We have created DAML+OIL-based CTOs for the tasks mentioned in (...) the WHO guideline for hypertension management, drawing comparisons also with other related guidelines. The advantages of CTOs include: contextualization of ontologies, providing ontologies tailored to specific aspects of the phenomena of interest, dividing the complexity involved in creating ontologies into different levels, providing a methodology by means of which the task recommendations contained within guidelines can be integrated into the clinical practices of a health care set-up. (shrink)

Background If trials of therapeutic interventions are to serve society's interests, they must be of high methodological quality and must satisfy moral commitments to human subjects. The authors set out to develop a clinical - trials compendium in which standards for the ethical treatment of human subjects are integrated with standards for research methods. Methods The authors rank-ordered the world's nations and chose the 31 with >700 active trials as of 24 July 2008. Governmental and other authoritative entities of (...) the 31 countries were searched, and 1004 English-language documents containing ethical and/or methodological standards for clinical trials were identified. The authors extracted standards from 144 of those: 50 designated as ‘core’, 39 addressing trials of invasive procedures and a 5% sample of the remainder. As the integrating framework for the standards we developed a coherent taxonomy encompassing all elements of a trial's stages. Findings Review of the 144 documents yielded nearly 15 000 discrete standards. After duplicates were removed, 5903 substantive standards remained, distributed in the taxonomy as follows: initiation, 1401 standards, 8 divisions; design, 1869 standards, 16 divisions; conduct, 1473 standards, 8 divisions; analysing and reporting results, 997 standards, four divisions; and post-trial standards, 168 standards, 5 divisions. Conclusions The overwhelming number of source documents and standards uncovered in this study was not anticipated beforehand and confirms the extraordinary complexity of the clinical trials enterprise. This taxonomy of multinational ethical and methodological standards may help trialists and overseers improve the quality of clinical trials, particularly given the globalisation of clinical research. (shrink)

This thesis discusses how societies should allocate clinical care resources. The first aim of the thesis is to defend the idea that clinical care resource allocation is a matter for deliberative democratic procedures. I argue that deliberative democracy is justified because of its ability to implement equal respect and autonomy. Furthermore, I address several in-principle objections to the project of applying deliberative democracy to clinical care resource allocation. Most notably, I respond to the narrow view of (...) the scope of deliberative democracy and the critiques of explicit rationing. -/- The second aim of the thesis is to determine what is required by deliberative democracy in clinical care resource allocation. I identify the general requirements that resource allocation agencies should meet, namely public reason, public involvement, transparency, accuracy and revisability. I then examine what is required by deliberative democracy with regard to two particularly salient specific topics, namely the substantive values that should govern resource allocation and the involvement of scientific experts in decision-making. -/- I demonstrate that public reason imposes severe constraints on the substantive values that should be employed. Most of these constraints are rooted in the idea that, under a regime of scarcity, public reason requires that resources be allocated so as to minimise the strongest complaint anyone may have. Out of the variety of values that are commonly proposed as relevant, only priority to the worst-off, ability to benefit, specialness of clinical care and cost are consistent with public reason. Turning to expert involvement, I argue that deliberative democracy can overcome several formidable threats, such as the opacity of expert opinions to laypersons and the tendency to hide uncertainty and disagreement from the public. I also discuss how my proposals on substantive values and expert involvement could be implemented, in order to add to the plausibility of my theory. (shrink)

An important part of the Unified Medical Language System (UMLS) is its Semantic Network, consisting of 134 Semantic Types connected to each other by edges formed by one or more of 54 distinct Relation Types. This Network is however for many purposes overcomplex, and various groups have thus made attempts at simplification. Here we take this work further by simplifying the relations which involve the three Semantic Types – Diagnostic Procedure, Laboratory Procedure and Therapeutic or Preventive Procedure. We define operators (...) which can be used to generate terms instantiating types from this selected set when applied to terms designating certain other Semantic Types, including almost all the terms specifying clinical tasks. Usage of such operators thus provides a useful and economical way of specifying clinical tasks. The operators allow us to define a mapping between those types within the UMLS which do not represent clinical tasks and those which do. This mapping then provides a basis for an ontology of clinical tasks that can be used in the formulation of computer-interpretable clinical guideline models. (shrink)

t Intentional sampling methods are non-randomized procedures that select a group of individuals for a sample with the purpose of meeting specific prescribed criteria. In this paper we extend previous works related to intentional sampling, and address the problem of sequential allocation for clinical trials with few patients. Roughly speaking, patients are enrolled sequentially, according to the order in which they start the treatment at the clinic or hospital. The allocation problem consists in assigning each new patient to (...) one, and only one, of the alternative treatment arms. The main requisite is that the profiles in the alternative arms remain similar with respect to some relevant patients’ attributes (age, gender, disease, symptom severity and others). We perform numerical experiments based on a real case study and discuss how to conveniently set up perturbation parameters, in order to yield a suitable balance between optimality – the similarity among the relative frequencies of patients in the several categories for both arms, and decoupling – the absence of a tendency to allocate each pair of patients consistently to the same arm. (shrink)

The new protocol for information distribution amongst scientists within the CERN, once slightly refined and publicly announced as the Worldwide Web in the August of 1991, has led to impressive achievements beyond the starting plan.

The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 dataset is one of the largest international databases of prospectively collected clinical data on people hospitalized with COVID-19. This dataset was compiled during the COVID-19 pandemic by a network of hospitals that collect data using the ISARIC-World Health Organization Clinical Characterization Protocol and data tools. The database includes data from more than 705,000 patients, collected in more than 60 countries and 1,500 centres worldwide. Patient data are available (...) from acute hospital admissions with COVID-19 and outpatient follow-ups. The data include signs and symptoms, pre-existing comorbidities, vital signs, chronic and acute treatments, complications, dates of hospitalization and discharge, mortality, viral strains, vaccination status, and other data. Here, we present the dataset characteristics, explain its architecture and how to gain access, and provide tools to facilitate its use. (shrink)

Introduction In 2013, Dr. J. Muizelaar and Dr. R. Schrot, two neurosurgeons at the University of California Davis Medical Center (UCDMC), were found guilty of research misconduct due to failure to comply with institutional policies as well as Food and Drug Administration (FDA) regulations governing human subjects research. At issue here, however, is the difference between research and innovative therapy in the clinical setting of patient care where clinical judgment is reasonably to be privileged. Methods The UCDMC investigative (...) document is reviewed along with standard literature on clinical ethics and clinical data about glioblastoma multiforme (GBM) cancer. Results In this paper I argue that, by tendentiously focusing on policies, regulations, and procedures governing human subjects research, the UCDMC investigation failed to account for the centrality of clinical judgment and clinical ethics pertinent to judicious review of this matter, especially given the unique clinical context of terminally ill patients having exhausted standard care treatment options for glioblastoma multiforme (GBM) cancer. Conclusions The UCDMC investigation raises serious problems for clinicians who are engaged in innovative therapy in the clinical setting, requiring a regulatory framework separate from the normal Institutional Review Board (IRB) process. (shrink)

Concern about the ethics of clinical drug trials research on patients and healthy volunteers has been the subject of significant ethical analysis and policy development—protocols are reviewed by Research Ethics Committees and subjects are protected by informed consent procedures. More recently attention has begun to be focused on DNA banking for clinical and pharmacogenetics research. It is, however, surprising how little attention has been paid to the commercial nature of such research, or the unique issues that present (...) when subjects are asked to consent to the storage of biological samples. Our contention is that in the context of pharmacogenetic add-on studies to clinical drug trials, the doctrine of informed consent fails to cover the broader range of social and ethical issues. Applying a sociological perspective, we foreground issues of patient/subject participation or ‘work’, the ambiguity of research subject altruism, and the divided loyalties facing many physicians conducting clinical research. By demonstrating the complexity of patient and physician involvement in clinical drug trials, we argue for more comprehensive ethical review and oversight that moves beyond reliance on informed consent to incorporate understandings of the social, political and cultural elements that underpin the diversity of ethical issues arising in the research context. (shrink)

The goal of referent tracking is to create an ever-growing pool of data relating to the entities existing in concrete spatiotemporal reality. In the context of Electronic Healthcare Records (EHRs) the relevant concrete entities are not only particular patients but also their parts, diseases, therapies, lesions, and so forth, insofar as these are salient to diagnosis and treatment. Within a referent tracking system, all such entities are referred to directly and explicitly, something which cannot be achieved when familiar concept-based systems (...) are used in what is called “clinical coding”. In this paper we describe the components of a referent tracking system in an informal way and we outline the procedures that would have to be followed by healthcare personnel in using such a system. We argue that the referent tracking paradigm can be introduced with only minor – though nevertheless ontologically important – technical changes to existing EHR infrastructures, but that it will require a radically different mindset on the part of those involved in clinical coding and terminology development from that which has prevailed hitherto. (shrink)

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion has (...) a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice. (shrink)

Objectives: It is clinically essential to know the location of accessory mental foramen in the mental nerve anesthesia. The aim of this study was to determine the frequency of accessory mental foramen and examining its morphometric properties. Methods: A total of 35 adult mandibles of unknown age, gender, and ethnicity were examined. The presence of accessory mental foramen of the mandible was investigated bilaterally. In cases with the accessory mental foramen, its localization, number, and distance relative to the mental foramen (...) were evaluated. Results: Eleven (15.71%) accessory mental foramens were detected in the 35 mandibles (70 sides) examined. Six (54.55%) of the accessory mental foramens were on the left side, and 5 (45.45%) were on the right side. Conclusion: Knowing the frequency and localization of the accessory mental foramen will make the mental nerve block more effective and facilitate surgical procedures. It should be kept in mind that the presence of accessory mental foramen should be considered in cases where mental nerve block applications are insufficient. (shrink)

Objectives: The most principal nutrition source of a bone is nutrient arteries. They are important at every stage of bone development. A nutrient artery enters a bone through the nutrient foramen, the largest hole on the outer surface of the bone. The foramen is important both morphologically and clinically. -/- Methods: A total of 414 adult human dry bones were investigated in this study to identify topographic and morphological features of nutrient foramina in the scapula, clavicle, humerus, radius and ulna. (...) Nutrient foramina were examined with a hand lens. Their dimensions and directions were determined with a 21-gauge needle, and thus major foramina were detected. Positions of nutrient foramina were noted according to surfaces of the bones, and to segments separated as proximal, middle and distal by calculating foraminal index. -/- Results: A single nutrient foramen was found in 71% of our samples. We observed that 94.2% of foramina in the clavicle, 89.3% of foramina in the humerus, 51.3% of foramina in the radius, and 67.7% of foramina in the ulna were located in the middle 1/3 segment of the bones. -/- Conclusion: Our findings were in line with the data in the literature. On account of pathologies associated with the nutrient foramen, our findings may be helpful for surgeons to design applications performed in the region. In addition, we think that our data by contributing to the literature may be a resource for clinicians due to the importance of the nutrient foramen for surgical procedures. (shrink)

Suppose that a patient is receiving treatment options from her doctor. In one case, the doctor says, “the surgery has a 90% survival rate.” Now, suppose the doctor instead said, “the procedure has a 10% mortality rate.” Predictably, the patient is more likely to consent on the first description and more likely to dissent on the second. This is an example of a framing effect. A framing effect occurs when “the description of [logically-equivalent] options in terms of gains (positive frame) (...) rather than losses (negative frame) elicits systematically different choices.” Framing effects are ubiquitous, but they are particularly troublesome in medicine. Many worry that there is tension between valuing informed consent and using framing effects in clinical settings. In this paper, I answer this question: if an individual is subject to a framing effect when she gives her consent, does this undermine the validity of her consent? I argue that framing effects do not undermine consent in general. (shrink)

Deep brain stimulation (DBS), a surgical procedure involving the implantation of electrodes in the brain, has rekindled the medical community’s interest in psychosurgery. Whereas many researchers argue DBS is substantially different from psychosurgery, we argue psychiatric DBS—though a much more precise and refined treatment than its predecessors—is nevertheless a form of psychosurgery, which raises both old and new ethical and legal concerns that have not been given proper attention. Learning from the ethical and regulatory failures of older forms of psychosurgery (...) can help shed light on how to address the regulatory gaps that exist currently in DBS research. To show why it is important to address the current regulatory gaps within psychiatric DBS, we draw on the motivations underlying the regulation of earlier forms of psychosurgery in the US. We begin by providing a brief history of psychosurgery and electrical brain stimulation in the US. Against this backdrop, we introduce psychiatric DBS, exploring current research and ongoing clinical trials. We then draw out the ethical and regulatory similarities between earlier forms of psychosurgery and psychiatric DBS. As we will show, the factors that motivated strict regulation of earlier psychosurgical procedures mirror concerns with psychiatric DBS today. We offer three recommendations for psychiatric DBS regulation, which echo earlier motivations for regulating psychosurgery, along with new considerations that reflect the novel technologies used in DBS. (shrink)

With the recent report of a live birth after use of Mitochondrial replacement therapy, sometimes called ‘Three-parent IVF’, the clinical application of the technique is fast becoming a reality. While the United Kingdom allows the procedure under regulatory scrutiny, it remains effectively outlawed in many other countries. We argue that such prohibitions may violate individuals’ procreative rights, grounded in individuals’ interest in genetic affinity. The interest in genetic affinity was recently endorsed by Singapore’s highest court, reflecting an emphasis on (...) the importance of biological ties found across the globe. We apply that reasoning to make the case for a right to ‘Three-parent IVF’. (shrink)

Sortition, i.e. random appointment for public duty, has been employed by societies throughout the years as a firewall designated to prevent illegitimate interference between parties in a legal case and agents of the legal system. In judicial systems of modern western countries, random procedures are mainly employed to select the jury, the court and/or the judge in charge of judging a legal case. Therefore, these random procedures play an important role in the course of a case, and should (...) comply with some principles, such as transparency and complete auditability. Nevertheless, these principles are neglected by random procedures in some judicial systems, which are performed in secrecy and are not auditable by the involved parties. The assignment of cases in the Brazilian Supreme Court is an example of such a procedure, for it is performed using procedures unknown to the parties involved in the judicial cases. This article presents a review of how sortition has been historically employed by societies and discusses how Mathematical Statistics may be applied to random procedures of the judicial system, as it has been applied for almost a century on clinical trials, for example. A statistical model for assessing randomness in case assignment is proposed and applied to the Brazilian Supreme Court. As final remarks, guidelines for the development of good randomization procedures are outlined. (shrink)

There are few moral principles less controversial than “don’t touch people’s private parts without consent.” Though the principle doesn’t make explicit that there are exceptions, there clearly are some. Parents must wipe their infants. If an unconscious patient is admitted to the emergency room with a profusely bleeding laceration on their genitals, a doctor must give them stitches. The researchers who proposed the study in question, which would look for a connection between burn patients’ microbiomes and their clinical outcomes, (...) presumably believed they had identified an additional exception to the aforementioned principle. I argue that they did not. Rather, because of their tremendous inherent risks, we ought only to perform intimate procedures on those who can’t consent when the procedure is for their own good. -/- Intimate violations have been overlooked in both philosophy and medicine. Because of this, we have lacked an adequate conceptual framework for identifying certain kinds of harms research can inflict. When we understand these special risks, we see that the IRB was right to deny a waiver of consent. (shrink)

A medical intervention is a medical procedure or application intended to relieve or prevent illness or injury. Examples of medical interventions include vaccination and drug administration. After a medical intervention, adverse events (AEs) may occur which lie outside the intended consequences of the intervention. The representation and analysis of AEs are critical to the improvement of public health. Description: The Ontology of Adverse Events (OAE), previously named Adverse Event Ontology (AEO), is a community-driven ontology developed to standardize and integrate data (...) relating to AEs arising subsequent to medical interventions, as well as to support computer-assisted reasoning. OAE has over 3,000 terms with unique identifiers, including terms imported from existing ontologies and more than 1,800 OAE-specific terms. In OAE, the term ‘adverse event’ denotes a pathological bodily process in a patient that occurs after a medical intervention. Causal adverse events are defined by OAE as those events that are causal consequences of a medical intervention. OAE represents various adverse events based on patient anatomic regions and clinical outcomes, including symptoms, signs, and abnormal processes. OAE has been used in the analysis of several different sorts of vaccine and drug adverse event data. (shrink)

REPRODUÇÃO ANIMAL: TRANSFERÊNCIA DE EMBRIÕES EM ANIMAIS, E A INDÚSTRIA DE EMBRIÕES NO BRASIL -/- ANIMAL BREEDING: EMBRYO TRANSFER IN ANIMALS, AND THE EMBRYO INDUSTRY IN BRAZIL Apoio: Emanuel Isaque Cordeiro da Silva Departamento de Zootecnia da UFRPE E-mail: [email protected] WhatsApp: (82)98143-8399 -/- 1. INTRODUÇÃO A técnica da inseminação artificial tornou possível aumentar o impacto na descendência de touros geneticamente superiores em termos de produção láctea das filhas. Com a transferência de embriões é possível aumentar o impacto da fêmea sobre (...) a população das filhas. A transferência de embriões data de 1890, ano em que Heape obteve o nascimento de coelhos transferindo ovócitos fecundados de uma fêmea para outra. A partir de 1930, é repetida uma série de experiências para desenvolver a técnica e aplicá-la em ovinos, caprinos (1934) e bovinos (1951) como espécies mais idôneas para a reprodução. A Inglaterra e os Estados Unidos estabeleceram as bases para o comércio de embriões durante os anos sessenta e setenta. De forma resumida, a transferência de embriões implica na estimulação da produção de ovócitos mediante a aplicação de hormônios: cerca de 6-8 dias após a cobrição dessas fêmeas ou da sua inseminação artificial, os óvulos fertilizados são extraídos dos órgãos genitais da fêmea doadora por perfusão ou lavagem com soluções biológicas controladas e testadas, originando-se uma deposição dos gametas fecundados nas fêmeas receptoras que serão encarregadas de levar adiante a gestação e o parto sem influência sobre as produções do novo indivíduo. 2. MANEJO DAS FÊMEAS DOADORAS É relativamente fácil obter um embrião, uma vez que pode origina-se a partir do cio natural das vacas cíclicas. No entanto, a fim de otimizar a técnica, o normal é «superovular» a fêmea doadora e obter um número superior de gametas fecundadas após cada lavagem ou perfusão das genitais. A maioria das fêmeas doadoras são tratadas com gonadotrofinas (PMSG) ou com hormônios estimuladores da foliculogênese (FSH). Estes hormônios invertem a atresia normal de folículos permitindo uma maturação, que em condições normais não se realizaria. O mecanismo exato do funcionamento destas hormonas não é totalmente claro. A superovulação multiplica por um fator de 10 o número de ovócitos recuperados no caso das vacas, ovelhas e cabras, mas apenas por um fator 2 ou 3 no caso das porcas. Existe um acordo geral sobre a utilização das gonadotrofinas; a PMSG deve ser aplicada durante a transição da fase luteica para a folicular, ou seja, no 16º dia do ciclo. As doses de gonadotrofinas variam entre 1500 e 3000 UI em bovinos, aumentando a resposta e a variabilidade individual com o aumento da dose. A resposta ao tratamento varia de acordo em função de diversos fatores. Neste contexto, merecem especial atenção a espécie, a raça, a época e a conformação corporal do animal, bem como o lote de fabricação da preparação hormonal (quadro 7.1). Estudos demonstram que, nos bovinos, as raças de corte respondem melhor ao tratamento do que as raças leiteiras. Tabela 1: Doses de gonadotrofinas em UI -/- Espécie Dia do ciclo Crescimento folicular_ ___ PMSG FSH Ovulação _____ PMSG FSH Bovinos 8 – 10 1500 – 3000 20 – 50 1500 – 2000 75 – 200 Caprinos 16 – 17 1000 – 1500 12 – 20 1000 – 1500 50 – 75 Ovinos 12 – 14 1000 – 2000 12 – 20 1000 – 1500 50 – 75 Suínos 15 – 17 750 – 1500 10 – 20 500 – 1000 25 – 50 Coelhos — 25 – 75 2 – 3 25 – 75 2 – 3 Fonte: HAFEZ, 2004. O FSH também é utilizado para superovulação em várias espécies. Nos ovinos, injetam-se 2 mg desta hormona 12 horas antes da retirada das esponjas, aplicando-se mais três injeções, com um intervalo de 12 horas, até 24 horas após a retirada das esponjas, o que corresponde a um total de 8 mg de FSH injetados por tratamento e animal. Às vezes, e dependendo do país, existem dificuldades para a obtenção desse hormônio em condições de pureza adequada para que o tratamento proporcione o resultado esperado. Nas vacas dadoras devem ter passado mais de 50 dias após o último parto: também ser animais cíclicos, encontrar-se num nível nutricional elevado e em aumento, sem deficiências especificas alimentares. Existe uma indicação de suplementação das fêmeas doadoras com minerais essenciais antes do tratamento. 3. OBTENÇÃO DE EMBRIÕES Uma vez as fêmeas doadoras inseminadas, entre o sexto e o oitavo dia, procede-se a coleta dos embriões. Para isso, atualmente se utilizam cateteres de obtenção transcervical (tipo Foley, Rusch. etc.) munidos de uma bola insuflável na sua extremidade que permite criar um compartimento estanque na parte distal do córneo uterino e proceder ao arrasto dos embriões ali localizados. Para obter esta «lavagem» utiliza-se uma solução aquosa tamponada: o meio mais frequentemente utilizado é o tampão fosfato salino (PBS: pH = 7; PO = 280 - 290 mOsm/kg) suplementado com antibióticos e proteínas. Depois de recuperado o meio de lavagem, os embriões devem ser isolados do volume total, avaliados segundo critérios do Manual da Sociedade Internacional de Transferência de Embriões de acordo com seu estado de desenvolvimento. Código numérico para determinar o grau de desenvolvimento embrionário: N° 1: ovócito não fertilizado ou embrião de uma célula (1 dia). N° 2: Identifica embriões com 2 a 16 células (2-4 dias). N° 3: Identifica mórulas adiantadas (5-6 dias). N° 4: Identifica mórulas compactas de 6 dias de idade. N° 5: blastocisto adiantado (7 dias). N° 6: blastocisto (7-8 dias). N° 7: blastocisto expandido (8-9 dias). N° 8: blastocisto eclodido (9 dias) a partir do nono ou décimo dia o blastocisto já está fora da zona pelúcida. Além da classificação por estado de desenvolvimento, a referida Sociedade Internacional estabeleceu uma categorização dos embriões com base na qualidade dos mesmos. Assim os denomina: 1: excelente; 2: bom; 3: regular; 4: degenerado. Segundo as investigações de diversos autores especialistas no tema não devem ser transferidos embriões que não tenham sido classificados como excelentes ou bons. A obtenção dos embriões pode ser realizada em uma clínica, em unidades móveis especializadas, ou na própria fazenda. Em todo o caso, a doadora não deve apresentar quaisquer sintomas clínicos de doença, sendo esta responsabilidade direta do veterinário. O rebanho de onde provém a doadora deve estar livre de medidas cautelares sanitárias. Os técnicos devem estar adequadamente limpos e preparados para esta atuação, em um lugar tranquilo e que permita a colocação de equipamentos e material em condições limpas e seguras. 4. TÉCNICAS DE TRANSFERÊNCIA DE EMBRIÕES Recomenda-se que os embriões sejam transferidos o mais rápido possível depois da recuperação. A fêmea receptora deve apresentar um ambiente uterino o mais semelhante possível ao da fêmea doadora. Isto quer dizer que a receptora também será mantida num sistema de sincronização para que coincida o mais possível o estágio de desenvolvimento embrionário com seu correspondente estado uterino. A margem de assincronia para evitar efeitos indesejáveis é de ± 24 horas. Os métodos hormonais de sincronização são análogos aos das doadoras. As técnicas para a deposição dos embriões no seu novo habitat podem ser igualmente cirúrgicas e não cirúrgicas, mas devido aos problemas do uso de anestésicos em técnicas cirúrgicas, as transferências foram direcionadas para modelos não-cirúrgicos ou transcervicais. Este método é baseado na utilização do colo uterino de forma análoga como é realizada na inseminação artificial. Devido às relações entre o embrião e o ovário, as porcentagens de fertilidade são aumentadas ao serem depositadas no corno ipsilateral no ovário que se encontra ativo. A utilização desta técnica implica na obtenção de mais fêmeas gestantes. O uso de novilhas como fêmeas receptoras aumenta também a taxa de gestações a partir de uma maior facilidade de manejo, uniformidade na resposta hormonal e um custo mais baixo. O fator humano ou habilidade do técnico que realiza esta técnica também constitui um fator que influencia decisivamente no êxito da transferência, encontrando-se variações de 20 a 60% devidas a este fator. 5. CONTROLES SANITÁRIOS Com a utilização da inseminação artificial, verificou-se que, embora as tecnologias reprodutivas colaborativas fossem mais avançadas em termos de técnicas destinadas a aumentar a produtividade individual, da mesma forma, podem constituir um perigo de contaminação e de dispersão de doenças estrangeiras para o grupo ou rebanho para onde são transferidos os novos genes. Neste contexto, a transferência embrionária (TE) deve realizar-se tendo em conta os riscos que pode implicar uma manipulação inadequada. Uma vez mais, a Sociedade Internacional (IETS) na Reunião Regional da OIE (Oficina Internacional de Epizootias) estabeleceu as normas em 1985 para que a TE pudesse ser utilizada como meio para controle de doenças na pecuária. Para que a utilização da TE se realize sem risco para a saúde, é necessário ter em conta um certo número de regras e condições específicas que evitem os riscos de contaminação. O embrião está separado do meio externo por três barreiras de proteção: o corpo da mãe, o útero por si só e a terceira, e mais importante, pela zona pelúcida, a qual nos animais domésticos tem demonstrado ser totalmente impermeável a qualquer elemento patogênico, desde que fique intacta. Portanto, o risco de contaminação dos embriões pode vir por duas vias diferentes: a) Fatores extrínsecos - por invasão dos agentes patogênicos na cavidade uterina principalmente. Isto está relacionado com o estado sanitário médio do país, região ou rebanho de origem. b) Fatores intrínsecos - Segundo Thibier podemos considerar diferentes fontes potenciais de contaminação, que segundo o risco sanitário se classificam nas seguintes ordens: 1° Zigoto. 2° Penetração. 3° Absorção. 4° Armazenamento. 5° Exame. 6° Transferência. Os esforços para que os embriões se tornem livres de contaminação devem ser semelhantes aos que são efetuados com os animais vivos e com as doses seminais. O momento mais perigoso encontra-se entre a coleta das células fecundadas e a sua deposição, após seu exame, no trato reprodutivo da receptora. As condições em que o referido processo deve ser realizado encontram-se detalhadas no manual da Sociedade Internacional de Transferência de Embriões (IETS). 6. REGRAS DA IETS A transferência de embriões é a via mais segura para a troca de genes. No entanto, os técnicos devem esforçar-se por manter todas as regras e normas sanitárias para que a coleta e a manipulação dos embriões se realizem sob condições de absoluta garantia higiênica e sanitária. A transferência embrionária implica, pela primeira vez na história da medicina veterinária, que a vigilância sanitária não se aplica estritamente ao animal, uma vez que, na sua fase "in vitro", está inteiramente sob o controle do técnico. Por conseguinte, não haverá futuro para este tipo de biotecnologia se, paralelamente, não houver um elevado nível de garantia de que não «servirá» para não disseminar ou difundir doenças. As conclusões da Sociedade Internacional de Transferência de Embriões (IETS) na sua reunião anual de 14 de Janeiro de 1992 estabelecem, tendo em conta a revisão efetuada em 1991 pela Subdireção de Investigação e pelo Comitê de Importação e Exportação, uma classificação das doenças. Esta classificação corresponde às seguintes categorias: Categoria 1 - Doenças ou agentes de doenças para as quais foram recolhidas provas suficientes para afirmar que o risco de transmissão é negligenciável, desde que os embriões sejam corretamente manipulados entre a coleta e a transferência: a) Leucose bovina enzoótica. b) Febre aftosa (bovinos). c) Língua azul (bovinos). d) Brucelose bovina. e) Rintraqueíte infecciosa bovina. f) Doença de Aujeszky. Categoria 2 - Doenças para as quais foram recolhidas provas substanciais que indicam que o risco de transmissão é insignificante, desde que os embriões sejam corretamente manipulados entre a coleta e a transferência, mas para as quais é necessário verificar os dados existentes através de novas transferências: a) Peste suína clássica. Categoria 3 - Doenças ou agentes de doenças para as quais os resultados preliminares indicam que o risco de transmissão é insignificante, desde que os embriões sejam corretamente manipulados, entre a coleta e a transferência, mas para os quais essas verificações preliminares devem ser corroboradas por dados experimentais complementares "in vitro" e "in vivo": a) Peste bovina. b) Diarreia viral bovina. c) Língua azul (ovinos). d) Febre aftosa (suínos, ovelhas e cabras). e) Campylobacter fetus (ovinos). f) Doença vesicular do porco. g) Peste suína africana. h) Prurido lombar (ovinos). i) Haemophilus somnus. Categoria 4 - Doenças ou agentes de doenças que foram ou são objeto de trabalhos preliminares: a) Vírus Akabane (bovino). b) Estomatite vesicular (bovinos e suínos). c) Chlamydia psittaci (bovinos e suínos). d) Ureaplasma/micoplasmose (bovinos e caprinos). e) Maedi-visna (ovino). f) Adenomatosa pulmonar (ovino). g) Prurido lombar (caprinos). h) Língua azul (caprinos). i) Artrite e encefalite caprina. j) Parvovírus (suíno). k) Enterovírus (bovinos e suínos). I) Leptospirose (suíno). m) Herpesvírus 4 dos bovinos. n) Mycobacterium paratuberculose (bovinos). o) brucelose ovina. p) Doença de Border (ovinos). q) Vírus parainfluenza 3 (bovinos). r) Agente da encefalopatia espongiforme bovina. É interessante salientar que apenas seis doenças estão incluídas na categoria 1 (a mais segura). Isso não significa que as outras doenças tenham um risco maior, apenas indica que o risco de transmissão das doenças da categoria 1 é irrelevante, estatisticamente falando. É importante assinalar que as doenças mais importantes dos bovinos se situam na categoria 1. Isto significa que a incidência do embrião patogênico nos bovinos parece ser perfeitamente controlável, desde que sejam adotadas metodologias adequadas. Isto serve também como linha de defesa adicional para que o técnico centre sua atenção e cuidados entre a fase de obtenção e a de transferência. 7. SITUAÇÃO ATUAL DA TRANSFERÊNCIA DE EMBRIÕES ANIMAIS NO BRASIL O Brasil é um dos grandes responsáveis mundiais pela implantação da tecnologia na reprodução animal, sendo assim, o país conseguiu inserir-se no mercado internacional como um dos maiores produtores de embriões in vivo e in vitro. Nas últimas duas décadas, especialmente entre os anos de 1997 e 2017 o país passou por importantes transformações nesse segmento, dentre essas transformações vale destacar a posição relativa do Brasil no contexto mundial. O Brasil passou de referência regional, nos anos 1990, para se tornar o maior produtor mundial de embriões entre os anos 2012 e 2013, sendo líder no uso e na produção de embriões in vitro. Os primeiros registros da TE produzidos in vivo no Brasil datam da década de 1980, e uma década depois o país já tornara-se referência e detinha um mercado consolidado de produção e TE na espécie bovina. Não obstante, no ano de 1997 o país ainda era referência apenas no contexto regional, detendo 68,3% dos embriões transferidos na América Latina, esse percentual corresponde a 24.085 embriões de um total de 35.254 produzidos na América Latina. Esse percentual regional representa apenas 6,6% de toda a produção mundial de embriões in vivo, que produziu, em 1997, 360.656 embriões in vivo. Nos últimos anos, o mercado de embriões, principalmente o bovino, teve retração moderada de -2,5% ao ano entre 2003 e 2018, porém essa retração contrasta com o ligeiro crescimento observado a partir dos anos 2000 conforme figura 1: Figura 1: Produção de embriões bovinos no Brasil no período 1996-2018, total e por tecnologia adotada (in vivo[IVD] ou in vitro [IVP]). Em 2018, o mercado de embriões bovinos manteve-se inalterado se compararmos com os três anos anteriores, houve reduções nós segmentos de corte, leite e no total comparado ao ano de 2017. Em 2014, a produção de embriões para melhoramento do gado leiteiro teve seu ápice, porém de lá para cá esse mercado manteve-se estagnado como demonstra a tabela 2. Tabela 2: Produção de embriões bovinos no Brasil em 2018, estratificada por segmento e por tecnologia adotada (in vivo ou in vitro). 7.1 Crise, economia e mercado de embriões A indústria de embriões reflete, em maior ou menor grau, o momento da economia brasileira. Apesar do segmento agropecuário ser um setor em constante crescimento no país, ao qual, sem dúvidas, em meio a inúmeras crises mantém-se em constante crescimento. Porém vale ressaltar que esse mercado é emergente e está refletido em paralelo com os bens produzidos pelo país, como demonstra a figura 2. Figura 2: Produção de embriões bovinos e variação no produto interno bruto (PIB) no Brasil, no período 1996-2018. Cada vez mais o setor agropecuário do Brasil investe em novas tecnologias que maximizem o mercado e que melhore a produção dos animais seja no segmento corte ou leite. Segundo a OCDE, 1997, essa indústria da produção de embriões é um conjunto de novas técnicas e processos, frutos do desenvolvimento técnico-científico, que chega ao mercado e - o mais importante - o transforma. Logo, todas essas técnicas e biotecnologias visam, além da alta produção e do lucro, o melhoramento e a suplementação alimentícia da população mundial que está em crescente avanço. A evolução da tecnologia embrionária no país, seja para o melhoramento dos equinos para os esportes como as vaquejadas, hipismo, corridas, etc., onde são investidos tempo, dedicação e dinheiro para formar um novo animal que apresente força, conformação, conversão alimentar e que custa milhões, em muitos casos, não só dos equinos, mas também dos caprinos, ovinos, suínos e até mesmo os bovinos onde o mercado da TE é mais presente e aquecida, venceu os estigmas do “modismo” e o chamado “elitismo”, porém deve enfrentar novos desafios, em especial num contexto de forte concentração do mercado de genética e de concorrência globalizada. Mesmo com todos esses avanços e retrocessos, essa relativização dos números demonstra que um percentual bastante reduzido das fêmeas bovinas que estão em idade reprodutiva é utilizado para a técnica da transferência de embriões, e que o mercado brasileiro ainda tem um grande potencial de crescimento no setor de produção in vivo e in vitro. 8. RESUMO E PRIMEIRAS CONCLUSÕES Ao longo deste trabalho pretendi realizar uma revisão sumária sobre um tema de grande importância presente, e sobretudo futura; referir-me à transferência embrionária. Atualmente, esta técnica atingiu um grau notável de penetração, a nível prático, no gado leiteiro. No entanto, num futuro mais ou menos longínquo, não temos dúvidas quanto a esta técnica, pelas vantagens indubitáveis que apresenta a nível de avanço genético, que será aplicada em outras espécies úteis ao homem. Na minha exposição, tentei dar especial ênfase a dois aspectos: as técnicas de transferência, incluindo as normas IETS e os controles sanitários a serem efetuados. Por fim, a indústria brasileira de embriões mostrou-se em retrocessos e avanços, porém o mercado ainda têm grandes desafios a serem enfrentados ao longo dos anos, mas que serão sanados mediante as técnicas desenvolvidas pelos inúmeros centros de pesquisa embrionárias e seus especialistas. -/- Realização -/- Emanuel Isaque Cordeiro da Silva – Departamento de Zootecnia da UFRPE. Recife, 2020. REFERÊNCIAS BIBLIOGRÁFICAS -/- BALL, Peter JH; PETERS, Andy R. Reproduction in cattle. Nova Jersey: John Wiley & Sons, 2008. BARUSELLI, Pietro Sampaio et al. Sêmen sexado: inseminação artificial e transferência de embriões. Revista Brasileira de Reprodução Animal, v. 31, n. 3, p. 374-381, 2007. BRACKELL, B. G.; JR SEIDEL, G. E.; SEIDEL, S. Avances en zootecnia nuevas técnicas de reproducción animal. Zaragoza: Acribia, 1988. COLE, H. H.; CUPPS, P. T. Reproduction in domestic animals. 1ª ed. Londres: Academic Press, 1977. CURTIS, John L. et al. Cattle embryo transfer procedure. An instruction manual for the rancher, dairyman, artificial insemination technician, animal scientist, and veterinarian. Londres: Academic Press, Inc., 1991. DA SILVA, Emanuel Isaque Cordeiro. Fisiologia da Reprodução Animal: Ovulação, Controle e Sincronização do Cio. Disponível em:. Acesso em: Março de 2020. DA SILVA, Emanuel Isaque Cordeiro. Fisiologia da Reprodução Animal: Fecundação e Gestação. Disponível em:. Acesso em: Março de 2020. DE LA FUENTE, J. Manipulación de embriones en ganado vacuno. Bovis, n. 58, p. 51-61, 1994. GIBBONS, A.; CUETO, M. Manual de transferencia de embriones ovinos y caprinos. Bariloche: Inta, 2013. GONÇALVES, Paulo Bayard Dias; DE FIGUEIREDO, José Ricardo; DE FIGUEIRÊDO FREITAS, Vicente José. Biotécnicas aplicadas à reprodução animal. São Paulo: Editora Roca, 2008. GONÇALVES, Rômany Louise Ribeiro; VIANA, João Henrique Moreira. Situação atual da produção de embriões bovinos no Brasil e no mundo. In: Embrapa Recursos Genéticos e Biotecnologia-Artigo em anais de congresso (ALICE). Revista Brasileira de Reprodução Animal, v. 43, n. 2, p. 156-159, abr./jun. 2019., 2019. HAFEZ, E. S. E.; HAFEZ, B. Reprodução animal. São Paulo: Manole, 2004. HOPPER, Richard M. (Ed.). Bovine reproduction. Nova Jersey: John Wiley & Sons, 2014. PÉREZ PÉREZ, F.; PÉREZ GUTIÉRREZ, F. Reproducción animal, inseminación animal y transplante de embriones. Barcelona: Cientifico-medica, 1985. MANSOUR, R. T.; ABOULGHAR, M. A. Optimizing the embryo transfer technique. Human reproduction, v. 17, n. 5, p. 1149-1153, 2002. MARTINS, Carlos Frederico. O impacto da transferência de embriões e da fecundação in vitro na produção de bovinos no Brasil. Embrapa Cerrados-Artigo de divulgação na mídia (INFOTECA-E), 2010. REFERÊNCIAS BIBLIOGRÁFICAS MCKINNON, A. O.; SQUIRES, E. L. Equine embryo transfer. Veterinary Clinics of North America: Equine Practice, v. 4, n. 2, p. 305-333, 1988. PALMA, G. A.; BREM, G. Transferencia de los embriones. GA Palma & G. Brem. Transferencia de embriones y biotecnología de la reproducción en la especie bovina. Ed. Hemisferio Sur. Buenos Aires, Argentina, p. 143-161, 1993. SCHOOLCRAFT, William B.; SURREY, Eric S.; GARDNER, David K. Embryo transfer: techniques and variables affecting success. Fertility and sterility, v. 76, n. 5, p. 863-870, 2001. SEIDEL, George E. Superovulation and embryo transfer in cattle. Science, v. 211, n. 4480, p. 351-358, 1981. STRINGFELLOW, D. A.; SEIDEL, S. M. Manual of IETS. Savoy IL: IETS, p. 103-130, 1998. STRINGFELLOW, D. A. Manual da sociedade internacional de transferência de embriões. Brasília: Sociedade Brasileira de Transferência de Embriões (SBTE), 1999. THIBIER, M.; NIBART, M. Disease control and embryo importations. Theriogenology, v. 27, n. 1, p. 37-47, 1987. VIANA, J. H. M. Produção e transferência de embriões bovinos em 2018. In: Jornal o embrião. Edição 64, ano 33. Brasília: SBTE, 2019. -/- . (shrink)

This article reflects on the skills required in trades services to people dedicated to coordinate services in complex clinical situations because of their multidimensionality and chronicity. All human activity requires for its proper effectuation, the coordination of interdependencies between actors. Coordination of interdependencies is done in ordinary mode, in everyday activities, but also in dedicated mode, that is to say, through a practice that has a primary mandate to manage them in a conscious, voluntary and accountable for intervention situations (...) whose complexity is high. This passage from the ordinary form in the form of dedicated coordination undertakes a transformation of skills and professional knowledge mobilized in the professional gesture. Further skills and knowledge relating to the disciplinary control of clinical objects, the case manager or professional figure who best embodies this form of coordination, should mobilize expertise and procedural knowledge (assessment, planning, communication, negotiation, activation networks, etc..) required to control the interfaces between technical systems and professional and organizational actors, posing as the interdependence of actants primary purpose in work. For this he must do it in a time of temporality combining organizational project in clinical time. Le présent article réfléchit aux compétences requises dans les métiers de services aux personnes dédiés à coordonner les services dans les situations cliniques complexes en raison de leur multi-dimensionnalité et leur chronicité. Toute activité humaine exige, pour sa bonne effectuation, la coordination des interdépendances entre les acteurs concernés. La coordination des interdépendances se réalise en mode ordinaire, dans les activités de tous les jours, mais aussi en mode dédié, c’est-à-dire à travers une pratique qui a pour mandat principal de les gérer de manière consciente, volontaire et imputable pour les situations d’intervention dont la complexité est grande. Ce passage de la forme ordinaire à la forme dédiée de coordination engage une transformation des compétences et savoirs professionnels mobilisés dans le geste professionnel. En outre des compétences et savoirs relatifs à la maîtrise des objets cliniques disciplinaires, le gestionnaire de cas, soit la figure professionnelle qui incarne le mieux cette modalité de coordination, doit mobiliser des compétences et savoirs procéduraux (évaluation, planification, communication, négociation, activation de réseaux, etc.) requis à la maîtrise des interfaces entre systèmes techniques et acteurs professionnels et organisationnels, en posant l’interdépendance des actants comme objet premier de son action professionnelle. Pour cela, il doit effectuer cette dernière dans une temporalité conjuguant le temps du projet organisationnel au temps clinique. (shrink)

This article reflects on the skills required in trades services to people dedicated to coordinate services in complex clinical situations because of their multidimensionality and chronicity. All human activity requires for its proper effectuation, the coordination of interdependencies between actors. Coordination of interdependencies is done in ordinary mode, in everyday activities, but also in dedicated mode, that is to say, through a practice that has a primary mandate to manage them in a conscious, voluntary and accountable for intervention situations (...) whose complexity is high. This passage from the ordinary form in the form of dedicated coordination undertakes a transformation of skills and professional knowledge mobilized in the professional gesture. Further skills and knowledge relating to the disciplinary control of clinical objects, the case manager or professional figure who best embodies this form of coordination, should mobilize expertise and procedural knowledge (assessment, planning, communication, negotiation, activation networks, etc..) required to control the interfaces between technical systems and professional and organizational actors, posing as the interdependence of actants primary purpose in work. For this he must do it in a time of temporality combining organizational project in clinical time. e présent article réfléchit aux compétences requises dans les métiers de services aux personnes dédiés à coordonner les services dans les situations cliniques complexes en raison de leur multi-dimensionnalité et leur chronicité. Toute activité humaine exige, pour sa bonne effectuation, la coordination des interdépendances entre les acteurs concernés. La coordination des interdépendances se réalise en mode ordinaire, dans les activités de tous les jours, mais aussi en mode dédié, c’est-à-dire à travers une pratique qui a pour mandat principal de les gérer de manière consciente, volontaire et imputable pour les situations d’intervention dont la complexité est grande. Ce passage de la forme ordinaire à la forme dédiée de coordination engage une transformation des compétences et savoirs professionnels mobilisés dans le geste professionnel. En outre des compétences et savoirs relatifs à la maîtrise des objets cliniques disciplinaires, le gestionnaire de cas, soit la figure professionnelle qui incarne le mieux cette modalité de coordination, doit mobiliser des compétences et savoirs procéduraux (évaluation, planification, communication, négociation, activation de réseaux, etc.) requis à la maîtrise des interfaces entre systèmes techniques et acteurs professionnels et organisationnels, en posant l’interdépendance des actants comme objet premier de son action professionnelle. Pour cela, il doit effectuer cette dernière dans une temporalité conjuguant le temps du projet organisationnel au temps clinique. (shrink)

Randomization is an integral part of well-designed statistical trials, and is also a required procedure in legal systems. Implementation of honest, unbiased, understandable, secure, traceable, auditable and collusion resistant randomization procedures is a mater of great legal, social and political importance. Given the juridical and social importance of randomization, it is important to develop procedures in full compliance with the following desiderata: (a) Statistical soundness and computational efficiency; (b) Procedural, cryptographical and computational security; (c) Complete auditability and traceability; (...) (d) Any attempt by participating parties or coalitions to spuriously influence the procedure should be either unsuccessful or be detected; (e) Open-source programming; (f) Multiple hardware platform and operating system implementation; (g) User friendliness and transparency; (h) Flexibility and adaptability for the needs and requirements of multiple application areas (like, for example, clinical trials, selection of jury or judges in legal proceedings, and draft lotteries). This paper presents a simple and easy to implement randomization protocol that assures, in a formal mathematical setting, full compliance to the aforementioned desiderata for randomization procedures. (shrink)

Polymyalgia Rheumatica (PMR) presents with a broad spectrum of clinical manifestations and almost exclusively occurs in the population aged over 50 years. After rheumatoid arthritis, PMR is the second most common autoimmune rheumatic disorder. Visual loss is the most feared complication in temporal arteritis, and extracranial arteries. No specific laboratory parameter exists for diagnosis of PMR. Imaging techniques such as ultrasonography, MRI or F-fluorodeoxyglucose PET may be helpful in the diagnosis and evaluation of the extent of vascular involvement in (...) these diseases. This paper presets an expert system for classification criteria for PMR, recent advances of diagnostic and therapeutic procedures. This expert System was written using SL5 Object Expert System Language. (shrink)

Assisted reproduction using donor gametes is a procedure that allows those who are unable to produce their own gametes to achieve gestational parenthood. Where conception is achieved using donor sperm, the child lacks a genetic link to the intended father. Where it is achieved using a donor egg, the child lacks a genetic link to the intended mother. To address this lack of genetic kinship, some fertility clinics engage in the practice of matching the ethnicity of the gamete donor to (...) that of the recipient parent. The intended result is for the child to have the phenotypic characteristics of the recipient parents. This paper examines the philosophical and ethical problems raised by the policy of ethnic matching in gamete donation. I consider arguments for the provision of ethnic matching based on maximising physical resemblance and fostering ethnic identity development. I then consider an argument against ethnic matching based on the charge of racialism. I conclude that while the practice of ethnic matching in gamete donation could promote positive ethnic identity development in donor-conceived children from historically subjugated ethnic minorities, it also risks endorsing the problematic societal attitudes and assumptions regarding ethnicity that enabled such subjugation in the first place. (shrink)

The proliferation of work by autistic writers continues apace, defying a long and multidisciplinary tradition of constructing autistic people as lacking the capacity for narration. To study neurodivergent literature, then, is to witness the refusal of these exclusionary narrative conventions, and to register the ideological presuppositions that underpin pathologization. In this article, I engage with recent insights from Neurodiversity Studies (especially the work of Justine Egner, Erin Manning, Julia Miele Rodas, Nick Walker, and Remi Yergeau) to explore the connections between (...) narrative neuronormativity and other discourses of oppression, especially those that have generated racialized, gendered, and colonial narratives of desubjectification. Focusing on the neuroqueer movement – an emergent practice of disidentification that refuses the interpellations of neuronormativity, ableism, heteronormativity, and cisnormativity – I discuss the concept of allism, arguing that this satirical critique of pathologization harbors a deconstructive force that denaturalizes the dialectic of recognition. Neuroqueer work on allism reveals this dialectic to be the hegemonic form of relationality that marks neurodivergence as asocial and intersubjectively non-reciprocal in order to secure a non- autistic identity. The dialectic of recognition thus instrumentalizes neurodivergence to confer normalcy and neutrality upon subjects that meet its criteria. Pursuing the discursive context and theoretical implications of this critique, I provide a short genealogy of narrative neuronormativity, connecting the operation of the dialectic in the early novel to the clinical texts of child psychology. To demonstrate the neuroqueer subversion of this tradition, I then read An Unkindness of Ghosts, by Rivers Solomon, a text that stages a disidentification with storytelling. Aster, the novel’s protagonist, is neurodivergent as well as Black, enslaved, and gender non-conforming. As she struggles against an authoritarian regime, Aster also declines to comply with the rules that would allow her to narrate her own story. Aster’s neuroqueer refusal reveals a similarity between the construction of Blackness as an ontological foil for whiteness, and the construction of autism as a standard of disordered sociality that neuronorms can be measured against. In both cases, the colonizing term articulates its supremacy via a comparison with that which it denigrates, while disavowing this dependence at all costs, dependency being inimical to free subjectivity in the liberal humanism that has shaped these procedures. My reading of Unkindness suggests that the extant techniques of literary narratorship are political instruments that, unless repurposed, will continue to disseminate these dispossessive dialectics. (shrink)

In 2015 the United Kingdom (UK) became the first nation to legalize egg and zygotic nuclear transfer procedures using mitochondrial replacement techniques (MRTs) to prevent the maternal transmission of serious mitochondrial DNA diseases to offspring. These techniques are a form of human germline genetic modification and can happen intentionally if female embryos are selected during the MRT clinical process, either through sperm selection or preimplantation genetic diagnosis (PGD). In the same year, an MRT was performed by a United (...) States (U.S.)-based physician team. This experiment involved a cross-border effort: the MRT procedure per se was carried out in the US, and the embryo transfer in Mexico. The authors examine the ethics of MRTs from the standpoint of genetic relatedness and gender implications, in places that lack adequate laws and regulation regarding assisted reproduction. Then, we briefly examine whether MRTs can be justified as a reproductive option in the US and Mexico, after reassessing their legalization in the UK. We contend that morally inadequate and ineffective regulations regarding egg donation, PGD, and germline genetic modifications jeopardize the ethical acceptability of the implementation of MRTs, suggesting that MRTs are currently difficult to justify in the US and Mexico. In addition to relevant regulation, the initiation and appropriate use of MRTs in a country require a child-centered follow-up policy and more evidence for its safety. (shrink)

Innovative practice involves medical interventions that deviate from standard practice in significant ways. For many patients, innovative practice offers the best chance of successful treatment. Because little is known about most innovative treatments, clinicians who engage in innovative practice might consider including extra procedures, such as scans or blood draws, to gather information about the innovation. Such information-gathering interventions can yield valuable information for modifying the innovation to benefit future patients and for designing scientific studies of the innovation. However, (...) existing guidelines do not say when or whether it is appropriate to add potentially risky information-gathering interventions for these purposes. As a result, clinicians may assume that information-gathering interventions are ethically inappropriate and should not be used in innovative practice. This assumption can lead to seriously negative consequences, such as increasing the likelihood that harmful or ineffective innovations will be adopted and creating new barriers to the development of genuinely beneficial treatments. We argue that health care institutions need to promote the responsible use of information-gathering interventions as an adjunct to innovative practice, and that these interventions are not clinical research and should not be subject to research oversight. (shrink)

This article provides insights into Grade 11 learner understanding of the roots of quadratic equations, how learners used solution strategies to find equations with given roots, how they determine the unknown values and the other root when one root is given and how they determine the unknown values when two roots of the equation are given. The study was underpinned by Skemp’s relational and instrumental understanding, and Kilpatrick, Swafford and Findel’s conceptual and procedural understanding to gain the insights into Grade (...) 11 learners’ understanding of the roots of quadratic equations. A case study design was espoused to answer the main research questions of this study. A written test was administered to 42 learners, and eight learners were purposively sampled to participate in a clinical interview based on their responses to the test. The findings of this study revealed that learners find it difficult to describe the roots, determine the other root when one root is given, to solve quadratic equations written in standard form, to represent the roots to determine the value of unknown variable(s), and to execute the reversal process using the given roots to find the equation. (shrink)

Objective: to evaluate CANLPH score and systemic immune inflammation index (SII) in patients with symptomatic rheumatic mitral stenosis (MS) undergoing percutaneous mitral balloon valvuloplasty (PMBV). -/- Methods: 62 patients who underwent PMBV in our clinic between 2018 and 2021 were included retrospectively. The patients were divided into 2 groups according to echo score. The CANLPH score was calculated from the cut-off values of C-reactive protein to albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR) and platelet to hemoglobin ratio (PHR), determined (...) with the Youden index and SII by the formula platelet x neutrophil/lymphocyte. P <0.05 was considered statistically significant. -/- Results: The mean age of the patients was 44.5±10.4 years (40 female, 64.5%). The mean values of SII and CANLPH scores were higher in the Echo score >8 group (p <0.001, both). The mean mitral gradient before and after PMBV was 12.6±5.7mm Hg and 5.0±2.4 mm Hg, and the mean valve area was 1.12±0.27 cm2 and 1.85±0.29 cm2. A statistically significant and negative correlation was observed between the gradient decrease after the procedure and the CANLPH score and SII (r=-0.426, p=0.001 and r=-0.418, p=0.001, respectively). In receiver operating characteristic (ROC) curve analysis, it was concluded that the ability of CANPLH score to predict the higher Echo scores was noninferior to SII with an area under curve (AUC:0.820 (0.701-0.906) and AUC:0.786 (0.664-0.880), z statistics 0.576 and p=0.564. -/- Conclusion: SII and CANLPH scores are correlated with Echo score. A significant negative relationship was found with both biomarkers and gradient decrease after the PMBV. (shrink)

In using brain stimulation technology to suppress an individual’s fear response to a traumatic memory, we are effectively altering that individual’s identity. In this article, I argue that until we learn more, such technology should be available only to patients with objectively debilitating fear responses who give their informed consent. First, I provide an overview of how the technology works. Second, I analyze the artificial, natural, and clinical changes in memory, and explores the ethical concerns associated with altering an (...) individual’s identity. I conclude by asserting that the benefits of brain stimulation technology outweigh the concerns if the proper administrative procedure is followed. (shrink)

Introduction: Liposomal bupivacaine (LB) is a long-acting analgesic that, due to its liposomal formulation, purportedly extends its analgesic effect up to 72 hours. However, the clinical efficacy of LB appears mixed. This systematic review seeks to evaluate the effectiveness of liposomal bupivacaine in improving postoperative outcomes compared to ropivacaine (ROPI), another commonly used long-acting analgesic. -/- Materials and Methods: Prospective and randomized controlled trials (RCTs) evaluating the efficacy of LB compared to ROPI were selected for review. Primary outcomes included (...) hospital length of stay (LOS) and postoperative opioid consumption measured in oral morphine equivalents (OME). Secondary outcomes included analgesic cost. -/- Results: 14 studies met the review criteria. We found that LB and ROPI are equivalent in managing postoperative pain. 8 of the 14 trials reported equal efficacy between LB and ROPI as determined by OME post-procedure and 10 of the 14 trials reported similar LOS after surgery. These findings remained consistent across multiple surgical procedures and multiple drug administrative modalities. -/- Conclusion: Our systematic review found that LB was not superior to ROPI in reducing postoperative OME use and hospital LOS. The only consistent finding was the significantly increased cost of LB compared to that of ROPI. Therefore, the use of LB over ROPI cannot be justified. (shrink)

Amyand’s hernia refers to the condition in which an inflamed, perforated, or normal appendix is present in the hernia sac. It accounts for 1% of all inguinal hernias and its preoperative diagnosis in patients is difficult. A 67-year-old male patient who underwent right-sided inguinal hernia repair with a mesh approximately 2 years before at another healthcare center was referred to our clinic with complaints of pain in his right inguinal area and swelling, which became evident while coughing or straining, for (...) approximately 2 months. A surgical procedure to repair his recurrent inguinal hernia was planned, and appendiceal tissue was observed in the hernia sac during the procedure. Appendectomy was not performed because the appendix was observed to be normal. Tension-free mesh hernioplasty was performed. The patient was discharged on postoperative day 1, without any complications. Amyand’s hernia is generally intraoperatively diagnosed and is a rare form of hernia with no specific symptoms. In this case report, we showed that despite the patient undergoing a surgical procedure, the appendix was present in the hernia sac because of recurrence, and we aimed at reviewing Amyand’s hernia with the literature. (shrink)

In order to achieve the World Health Organization’s Millennium Development Goal of reducing maternal mortality by three quarters by 2015, a strong global commitment is needed to address this issue in low-income nations where the risk to women is greatest. A comprehensive international effort must include provision of obstetric and general medical care as well as community-based interventions, with an emphasis on the latter in nations where the majority of women deliver babies at home without a trained attendant. Methods: This (...) systematic analysis evaluates interventions published in Medline and CINAHL whose outcome measure is maternal mortality. Analysis includes components of the intervention, nation and maternal death rates. Results: Nine studies documented the effectiveness of various clinical and community-based interventions, including specific drug regimens and procedures, in reducing the risk of maternal death. Six studies reported interventions that did not significantly alter maternal mortality outcomes, and the intervention in one study demonstrated increased risk of maternal death. Conclusion: The dearth of evidence highlights the need for increased focus on translational research that bridges the gap between medical advances and community-based interventions that are feasible in low-income nations. This cannot be accomplished without a stronger commitment to reducing maternal mortality by global health practitioners and researchers. (shrink)

The issue of safety culture is one of the most important in a modern medical facility because any problems during the provision of services may lead to irreversible consequences. Not only the patient may suffer, but the doctor who assisted. Unfortunately, very little attention to this issue is paid in Ukraine. Based on this, we can say that the topic is relevant and requires studying. -/- The purpose of writing this article is the analysis of the ways of forming professional (...) safety culture in clinical medicine. The methods by which we carried out scientific research are observation, analysis, evaluation, comparison, generalization. -/- The work examined interpretation of the term "safety culture", types of innovation in which it belongs and the main methods of its creation in the medical field. -/- Safety culture in the medical field involves the right of all health care workers to use measures to prevent actions that can harm a patient or a colleague. Different approaches were considered in the interpretation of the term "safety culture" and we proposed our own: safety culture is a system of values, objectives, knowledge and skills, rules and procedures, convictions shared by representatives of a certain medical profession and supported by patients, creating a favourable working climate, atmosphere of trust and becoming an efficient tool for achieving the goals of the organization. -/- The main components of the safety culture were defined: responsibilities of managers, communication, performance, resources of safety, trust, the degree of job satisfaction, etc. Based on several studies, it was found that no country has a perfect medical system. Every system should be improved. -/- We proposed measures to fix the situation with the safety culture in health care facilities. The correct management of safety can eliminate or fix many medical errors. That is why the need for a clear program of implementation, execution and control of SC in the medical establishment is necessary. -/- Scientific novelty of this work lies in the interpretation of the term "safety culture" at medical institutions and in determining major steps towards its creation. Practical value of the work is the opportunity to implement these steps in medical institutions for improvement of the safety culture and, therefore, to reduce the risk of bad accidents during treatment. -/- Further research can address safety culture management in medical institutions on the examples from the experience of countries with effective systems of health care. (shrink)

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the National Institute of Mental Health’s Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, and the general psychopathology factor, as well as a revival of interest in phenomenological psychopathology. The question naturally emerges as to what the relationship between these new approaches is – are they mutually exclusive, competing approaches, or can they be integrated in some way (...) and used to enrich each other? In this opinion piece, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology, such as selfhood, embodiment, affectivity, etc., can be overlaid on clinical stages in order to enrich and deepen the phenotypes captured in clinical staging (‘high resolution’ clinical phenotypes). This approach may be useful both ideographically and nomothetically, in that it could complement diagnosis, enrich clinical formulation, and inform treatment of individual patients, as well as help guide aetiological, prediction, and treatment research. The overlaying of phenomenological domains on clinical stages may require that these domains are reformulated in dimensional rather than categorial terms. This integrative project requires assessment tools, some of which are already available, that are sensitive and thorough enough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging may be enriched by introducing greater depth to phenotypes; phenomenological psychopathology may be enriched by introducing stages of severity and disorder progression to phenomenological analysis. (shrink)

Collective deliberation is fuelled by disagreements and its epistemic value depends, inter alia, on how the participants respond to each other in disagreements. I use this accountability thesis to argue that deliberation may be valued not just instrumentally but also for its procedural features. The instrumental epistemic value of deliberation depends on whether it leads to more or less accurate beliefs among the participants. The procedural epistemic value of deliberation hinges on the relationships of mutual accountability that characterize appropriately conducted (...) deliberation. I will argue that it only comes into view from the second-person standpoint. I shall explain what the second-person standpoint in the epistemic context entails and how it compares to Stephen Darwall’s interpretation of the second-person standpoint in ethics. (shrink)

This is a non-technical version of "The Decision Problem for Effective Procedures." The “somewhat vague, intuitive” notion from computability theory of an effective procedure (method) or algorithm can be fairly precisely defined, even if it does not have a purely mathematical definition—and even if (as many have asserted) for that reason, the Church–Turing thesis (that the effectively calculable functions on natural numbers are exactly the general recursive functions), cannot be proved. However, it is logically provable from the notion of (...) an effective procedure--without reliance on any (partially) mathematical thesis or conjecture concerning effective procedures, such as the Church–Turing thesis--that the class of effective procedures is undecidable, i.e., that no effective procedure is possible for ascertaining whether a given procedure is effective. The proof does not appeal to a precise definition of ‘effective procedure’. Instead, it relies solely and entirely on a basic grasp of the intuitive notion of such a procedure. Though this undecidability result itself is not surprising, it is also not without significance. It has the consequence, for example, that the solution to a decision problem, if it is to be complete, must be accompanied by a separate argument that the proposed ascertainment procedure is, in fact, a decision procedure, i.e., effective—for example, that it invariably terminates with the correct verdict. (shrink)

The desideratum of semantic interoperability has been intensively discussed in medical informatics circles in recent years. Originally, experts assumed that this issue could be sufficiently addressed by insisting simply on the application of shared clinical terminologies or clinical information models. However, the use of the term ‘ontology’ has been steadily increasing more recently. We discuss criteria for distinguishing clinical ontologies from clinical terminologies and information models. Then, we briefly present the role clinical ontologies play in (...) two multicentric research projects. Finally, we discuss the interactions between these different kinds of knowledge representation artifacts and the stakeholders involved in developing interoperational real-world clinical applications. We provide ontology engineering examples from two EU-funded projects. (shrink)

Outcomes research in healthcare has been a topic much addressed in recent years. Efforts in this direction have been supplemented by work in the areas of guidelines for clinical practice and computer-interpretable workflow and careflow models.In what follows we present the outlines of a framework for understanding the relations between organizations, guidelines, individual patients and patient-related functions. The derived framework provides a means to extract the knowledge contained in the guideline text at different granularities, in ways that can help (...) us to assign tasks within the healthcare organization and to assess clinical performance in realizing the guideline. It does this in a way that preserves the flexibility of the organization in the adoption of the guidelines. (shrink)

Does morality have a procedure? Unlike law, morality is arguably neither posited nor institutional. Thus, while morality undeniably prescribes various procedures, that morality itself has a procedure is less obvious. Indeed, the coexistence of procedural moral norms alongside substantive moral norms might seem paradoxical, given that they often yield contradictory prescriptions. After all, one may wonder, is morality not substantive all the way down? Nevertheless, the paper argues that morality has a “procedural branch” containing numerous norms that are themselves (...) procedural. These norms comprise what we hold are the three hallmarks of a procedural norm: second-orderness, providing reasons on how to engage with other norms, and outcome-neutrality. In this respect, morality is more like law than what one might have expected. (shrink)

The move from open outcry to electronic trading added another responsibility to futures exchanges—that of matching orders between buyers and sellers. Matching systems can affect the level and speed of price discovery, the distribution of revenue, as well as the level of price efficiency of a given market. Whether the matching system is procedurally fair is another important consideration. I argue that while FIFO (First In First Out) is a fair procedure in principle and is perceived as the default matching (...) system, it is not a fair procedure in practice. Likewise, while pro rata is a fair procedure in principle, it is not so in practice. Nevertheless, both FIFO and pro rata are relics of an open outcry system. Instead, I propose an alternative approach to matching systems that builds on the strengths of electronic trading—the ability to randomize in real time. I introduce random selection for service (RSS) as a matching system that is procedurally fair both in principle and in practice. (shrink)

Democratic theorists often distinguish between two views of democratic procedures. ‘Outcomes theorists’ emphasize the instrumental nature of these procedures and argue that they are only valuable because they tend to produce good outcomes. In contrast, ‘proceduralists’ emphasize the intrinsic value of democratic procedures, for instance, on the grounds that they are fair. In this paper. I argue that we should reject pure versions of these two theories in favor of an understanding of the democratic ideal that recognizes (...) a commitment to both intrinsically valuable democratic procedures and democratic outcomes. In instances in which there is a conflict between these two commitments, I suggest they must be balanced. This balancing approach offers a justification of judicial review on the grounds that it potentially limits outcomes that undermine democracy. But judicial review is not justifiable in any instance in which a bad democratic outcome results from democratic procedures. When the loss that would result from overturning a democratic procedure is greater than the gain to democracy that would result from ensuring against an undemocratic outcome; judicial review is not justifiable. Loss or gain to democracy is defined by the negative or positive impact of each action on the core democratic values of equality and autonomy, aspects of the democratic ideal. Even when judicial review is justified, the fact that it overturns intrinsically valuable procedures suggests that such review is never ideal from the standpoint of democracy. (shrink)

The Belmont Report was written by a US Commission charged by the US Congress to advise on research supported by the US government. Its focus was understandably domestic. In the 40 years since its publication, clinical research has become increasingly international. Many clinical trials have sites in multiple countries, and many of the host countries are relatively impoverished. Such research raises some distinctive ethical issues. This paper outlines some of the key ethical challenges that have been raised by (...) clinical research conducted in low- and middle-income countries (LMICs) and sponsored by high-income country (HIC) institutions. It then considers whether the Belmont Report has the resources to address these problems and argues that it does not. The article closes by noting some parallels between this international research and domestic US research, which suggest that the US might benefit from the discussions abroad. (shrink)

There is widespread agreement among both supporters and opponents that affirmative action either must not violate any principle of equal opportunity or procedural justice, or if it does, it may do so only given current extenuating circumstances. Many believe that affirmative action is morally problematic, only justified to the extent that it brings us closer to the time when we will no longer need it. In other words, those that support affirmative action believe it is acceptable in nonideal theory, but (...) not ideal theory. This paper argues that affirmative action is entirely compatible with equal opportunity and procedural justice and would be even in an ideal world. I defend a new analysis of Rawlsian procedural justice according to which it is permissible to interfere in the outcomes of procedures, and thus I show that affirmative action is not morally problematic in the way that many have supposed. (shrink)

Many extant theories of placebo focus on their causal structure wherein placebo effects are those that originate from select features of the therapy (e.g., client expectations or “incidental” features like size and shape). Although such accounts can distinguish placebos from standard medical treatments, they cannot distinguish placebos from everyday occurrences, for example, when positive feedback improves our performance on a task. Providing a social-epistemological account of a treatment context can rule out such occurrences, and furthermore reveal a new way to (...) distinguish clinical placebos from standard medical treatments. (shrink)