Suffering and the Dimensionality of Medical Knowledge: A Critique of Evidence Based Medicine

Evidence Based Medicine (EBM) is a recent philosophy that is highly influential in medicine. EBM is centred on the notion that medical practice should be supported by rigorous clinical research. This thesis explores a “dimensional” framework of knowledge and argues EBM results in the exclusion of certain non-scientific knowledge forms. Since these knowledge forms are essential to the realisation of medicine’s goals, EBM is holding medicine back. I frame the primary goal of medicine as to attend to suffering. There is a tendency to view the goal of medicine as the treatment of disease, but this fails to account for much of what occurs in practice. Suffering incorporates disease and also other humanistic aspects of medicine that may not be investigable in a scientific manner. Medical knowledge determines medical practice, so medicine must have knowledge of what suffering is to effectively attend to suffering. I propose a dimensional theory of knowledge that includes explicit, tacit, general and particular forms of knowledge. Explicated general knowledge includes the knowledge of science. Tacit knowledge is more readily enacted than articulated. Particular knowledge is knowledge that is applicable to specific circumstances and individuals. The existence of tacit and particular knowledge moderates the possibility and need for scientific justification and also means knowledge exists within the knower and not exclusively in abstracted forms. EBM’s philosophical framework excludes tacit and particular knowledge in its selective recognition of explicit-generalised “evidence”. This means that EBM’s conception of knowledge is incomplete and is philosophically inadequate. Though EBM makes useful contributions to clinical research appraisal, its normative assertions of “what counts as knowing” in medicine obscures human suffering and so might harm practice. This thesis presents the foundations for an alternative philosophy to EBM that would see “EBM” reframed as “clinical epidemiology” as a remedy for EBM’s normative restriction of medical knowledge

\u3ci\u3ePostmodernism, “Reality” and Public Administration: A Discourse\u3c/i\u3e

Chapter, Deconstructing Administrative Behavior: The “Real” as Representation, authored by Gary Marshall, UNO faculty member.https://digitalcommons.unomaha.edu/facultybooks/1237/thumbnail.jp

An Equine Herpesvirus-1 Gene 71 Deletant Is Attenuated and Elicits a Protective Immune Response in Mice

AbstractThe pathogenesis of pulmonary infection and the immune response following intranasal inoculation of mice with two equine herpesvirus type 1 (EHV-1) deletion mutants have been assessed. The mutants, ED71 and ED75, have deletions in genes 71 (EUS4) and 75 (10K), respectively. Deletions were replaced by theEscherichia coli lacZgene driven by the simian virus 40 (SV40) early promoter. It has previously been shown that the protein products of genes 71 and 75 are dispensablein vitrobut that removal of gene 71 results in a defect in virus maturation and capsid envelopment which impairs the ability of mutant virus to spread via release and readsorption. This study demonstrated that the 192-kDa gene 71 product is required for full expression of virulence in mice, whereas the putative 10-kDa product of gene 75 has minimal effect. Both mutants exhibited the same tissue and cytotropism as wild-type EHV-1 and induced both humoral and cell-mediated immune responses indistinguishable from those induced by the parental strain. Irrespective of the reduced pathogenicity of the gene 71 mutant, infected mice were protected against a challenge with wild-type EHV-1. These findings highlight the potential of ED71 as a vaccine candidate

Integrated stratigraphy of the Kimmeridge Clay Formation (Upper Jurassic) based on exposures and boreholes in south Dorset, UK

For the purposes of a high-resolution multi-disciplinary study of the Upper Jurassic Kimmeridge Clay Formation, two boreholes were drilled at Swanworth Quarry and one at Metherhills, south Dorset, UK. Together, the cores represent the first complete section through the entire formation close to the type section. We present graphic logs that record the stratigraphy of the cores, and outline the complementary geophysical and analytical data sets (gamma ray, magnetic susceptibility, total organic carbon, carbonate, [delta]13Corg). Of particular note are the new borehole data from the lowermost part of the formation which does not crop out in the type area. Detailed logs are available for download from the Kimmeridge Drilling Project web-site at http://kimmeridge.earth.ox.ac.uk/. Of further interest is a mid-eudoxus Zone positive shift in the [delta]13Corg record, a feature that is also registered in Tethyan carbonate successions, suggesting that it is a regional event and may therefore be useful for correlation. The lithostratigraphy of the cores has been precisely correlated with the nearby cliff section, which has also been examined and re-described. Magnetic-susceptibility and spectral gamma-ray measurements were made at a regular spacing through the succession, and facilitate core-to-exposure correlation. The strata of the exposure and core have been subdivided into four main mudrock lithological types: (a) medium-dark–dark-grey marl; (b) medium-dark–dark grey–greenish black shale; (c) dark-grey–olive-black laminated shale; (d) greyish-black–brownish-black mudstone. The sections also contain subordinate amounts of siltstone, limestone and dolostone. Comparison of the type section with the cores reveals slight lithological variation and notable thickness differences between the coeval strata. The proximity of the boreholes and different parts of the type section to the Purbeck–Isle of Wight Disturbance is proposed as a likely control on the thickness changes

Verification of Unstructured Grid Adaptation Components

Adaptive unstructured grid techniques have made limited impact on production analysis workflows where the control of discretization error is critical to obtaining reliable simulation results. Recent progress has matured a number of independent implementations of flow solvers, error estimation methods, and anisotropic grid adaptation mechanics. Known differences and previously unknown differences in grid adaptation components and their integrated processes are identified here for study. Unstructured grid adaptation tools are verified using analytic functions and the Code Comparison Principle. Three analytic functions with different smoothness properties are adapted to show the impact of smoothness on implementation differences. A scalar advection-diffusion problem with an analytic solution that models a boundary layer is adapted to test individual grid adaptation components. Laminar flow over a delta wing and turbulent flow over an ONERA M6 wing are verified with multiple, independent grid adaptation procedures to show consistent convergence to fine-grid forces and a moment. The scalar problems illustrate known differences in a grid adaptation component implementation and a previously unknown interaction between components. The wing adaptation cases in the current study document a clear improvement to existing grid adaptation procedures. The stage is set for the infusion of verified grid adaptation into production fluid flow simulations

Facilitators and barriers to teaching undergraduate medical students in general practice

CONTEXT Globally, primary health care is facing workforce shortages. Longer and higher-quality placements in primary care increase the likelihood of medical students choosing this specialty. However, the recruitment and retention of community primary care teachers are challenging. Relevant research was predominantly carried out in the 1990s. We seek to understand contemporary facilitators and barriers to general practitioner (GP) engagement with undergraduate education. Communities of practice (CoP) theory offers a novel conceptualisation, which may be pertinent in other community-based teaching settings. METHODS Semi-structured interviews were undertaken with 24 GP teachers at four UK medical schools. We purposively sampled GPs new to teaching, established GP teachers and GPs who had recently stopped teaching. We undertook NVivo-assisted deductive and inductive thematic analysis of transcripts. We used CoP theory to interpret data. RESULTS Communities of practice theory illustrated that teachers negotiate membership of three CoPs: (i) clinical practice; (ii) the medical school, and (iii) teaching. The delivery of clinical care and teaching may be integrated or exist in tension. This can depend upon the positioning of the teaching and teacher as central or peripheral to the clinical CoP. Remuneration, workload, space and the expansion of GP trainee numbers impact on this. Teachers did not identify strongly as members of the medical school or a teaching community. Perceptions of membership were affected by medical school communication and support. The findings demonstrate gaps in medical school recruitment. CONCLUSIONS This research demonstrates the marginalisation of primary care-based teaching and proposes a novel explanation rooted in CoP theory. Concepts including identity and membership may be pertinent to other community-based teaching settings. We recommend that medical schools review and broaden recruitment methods. Teacher retention may be improved by optimising the interface between medical schools and teachers, fostering a teaching community, increasing professional rewards for teaching involvement and altering medical school expectations of learning in primary care

A comparison of hospital readmission rates between two general physicians with different outpatient review practices

BACKGROUND: There has been a relentless increase in emergency medical admissions in the UK over recent years. Many of these patients suffer with chronic conditions requiring continuing medical attention. We wished to determine whether conventional outpatient clinic follow up after discharge has any impact on the rate of readmission to hospital. METHODS: Two consultant general physicians with the same patient case-mix but markedly different outpatient follow-up practice were chosen. Of 1203 patients discharged, one consultant saw twice as many patients in the follow-up clinic than the other (Dr A 9.8% v Dr B 19.6%). The readmission rate in the twelve months following discharge was compared in a retrospective analysis of hospital activity data. Due to the specialisation of the admitting system, patients mainly had cardiovascular or cerebrovascular disease or had taken an overdose. Few had respiratory or infectious diseases. Outpatient follow-up was focussed on patients with cardiac disease. RESULTS: Risk of readmission increased significantly with age and length of stay of the original episode and was less for digestive system and musculo-skeletal disorders. 28.7% of patients discharged by Dr A and 31.5 % of those discharged by Dr B were readmitted at least once. Relative readmission risk was not significantly different between the consultants and there was no difference in the length of stay of readmissions. CONCLUSIONS: Increasing the proportion of patients with this age- and case-mix who are followed up in a hospital general medical outpatient clinic is unlikely to reduce the demand for acute hospital beds

RESULTS OF THE FIRST SIMULTANEOUS X-RAY, OPTICAL, AND RADIO CAMPAIGN ON THE BLAZAR PKS 1622-297

Coordinated X-ray, optical, and radio observations of the blazar PKS 1622-297 were obtained during a three-week campaign in 2006 using the Rossi X-Ray Timing Explorer (RXTE), the University of Michigan Radio Astronomy Observatory, and optical telescopes at Cerro Tololo Inter-American Observatory. The RXTE observations indicate that this object is a comparatively weak X-ray emitter for a Flat-Spectrum Radio Quasar. The observed broadband spectral shape indicates that X-rays were most likely produced by the Inverse Compton processes. Optical observations of this object produced unexpected results in that this object appeared redder when in a bright state and bluer when in a faint state, contrary to the observed behavior of BL Lac objects