Balancing Bioethics by Sensing the Aesthetic

This paper is critical of ‘bioethics’ as it is widely understood and taught, noting in particular an emphasis given to philosophical justification, reason and rationality. It is proposed that ‘balancing’ bioethics be achieved by giving greater weight to practice and the aesthetic: defined in terms of sensory perception, emotion and feeling. Each of those three elements is elaborated as a non-cognitive capacity and, when taken together, comprise aesthetic sensitivity and responsiveness. This is to recognise the aesthetic as a productive element in bioethics as practice. Contributions from the philosophy of art and aesthetics are drawn into the discussion to bring depth to an understanding of ‘the aesthetic’. This approach is buttressed by philosophers—including Foucault and 18th century German philosophers (in particular Kant)—who recognised a link between ethics and aesthetics. The paper aims to give substance to a claim that bioethics necessarily comprises a cognitive component, relating to reason, and a non-cognitive component that draws on aesthetic sensibility and relates to practice. A number of advantages of bioethics, understood to explicitly acknowledge the aesthetic, are proffered. Having defined bioethics in conventional terms, there is discussion of the extent to which other approaches to bioethics (including casuistry, virtue ethics, and narrative ethics) recognise aesthetic sensitivity in their practice. It is apparent that they do so to varying extents although not always explicitly. By examining this aspect of applied ethics, the paper aims to draw attention to aesthetic sensitivity and responsiveness as integral to ethical and effective health care

Globalisation, Economics and Professionalism

This paper presents an analysis of the effect of globalisation and attendant economic factors on the global practice of medicine, medical education, medical ethics and medical professionalism.The authors discuss the implications of these trends, citing case scenarios in the healthcare insurance, medical tourism, pharmaceutical industries, the educational systems as well as in clinical practice, to illustrate the impact of globalisation and economics on professionalism. Globalisation, on the one hand, offers benefits for the global practice of medicine and for medical education. On the other, globalisation can have negative effects, particularly when the main driver is to maximize profitability across national boundaries rather than concern for human well-being. Appraising the effect of globalisation on professionalism involves assessing its effects at the intrapersonal, interpersonal, and institutional levels, and its effects on society at large

Expression analysis of genes associated with human osteosarcoma tumors shows correlation of RUNX2 overexpression with poor response to chemotherapy

Background: Human osteosarcoma is the most common pediatric bone tumor. There is limited understanding of the molecular mechanisms underlying osteosarcoma oncogenesis, and a lack of good diagnostic as well as prognostic clinical markers for this disease. Recent discoveries have highlighted a potential role of a number of genes including: RECQL4, DOCK5, SPP1, RUNX2, RB1, CDKN1A, P53, IBSP, LSAMP, MYC, TNFRSF1B, BMP2, HISTH2BE, FOS, CCNB1, and CDC5L. Methods: Our objective was to assess relative expression levels of these 16 genes as potential biomarkers of osteosarcoma oncogenesis and chemotherapy response in human tumors. We performed quantitative expression analysis in a panel of 22 human osteosarcoma tumors with differential response to chemotherapy, and 5 normal human osteoblasts.Results: RECQL4, SPP1, RUNX2, and IBSP were significantly overexpressed, and DOCK5, CDKN1A, RB1, P53, and LSAMP showed significant loss of expression relative to normal osteoblasts. In addition to being overexpressed in osteosarcoma tumor samples relative to normal osteoblasts, RUNX2 was the only gene of the 16 to show significant overexpression in tumors that had a poor response to chemotherapy relative to good responders. Conclusion: These data underscore the loss of tumor suppressive pathways and activation of specific oncogenic mechanisms associated with osteosarcoma oncogenesis, while drawing attention to the role of RUNX2 expression as a potential biomarker of chemotherapy failure in osteosarcoma. © 2010 Sadikovic et al; licensee BioMed Central Ltd

Enhancement of interlayer exchange in an ultrathin two-dimensional magnet

Following the recent isolation of monolayer CrI3 (ref. 1), many more two-dimensional van der Waals magnetic materials have been isolated2,3,4,5,6,7,8,9,10,11,12. Their incorporation in van der Waals heterostructures offers a new platform for spintronics5,6,7,8,9, proximity magnetism13 and quantum spin liquids14. A primary question in this field is how exfoliating crystals to the few-layer limit influences their magnetism. Studies of CrI3 have shown a different magnetic ground state for ultrathin exfoliated films1,5,6 compared with the bulk, but the origin is not yet understood. Here, we use electron tunnelling through few-layer crystals of the layered antiferromagnetic insulator CrCl3 to probe its magnetic order and find a tenfold enhancement of the interlayer exchange compared with bulk crystals. Moreover, temperature- and polarization-dependent Raman spectroscopy reveals that the crystallographic phase transition of bulk crystals does not occur in exfoliated films. This results in a different low-temperature stacking order and, we hypothesize, increased interlayer exchange. Our study provides insight into the connection between stacking order and interlayer interactions in two-dimensional magnets, which may be relevant for correlating stacking faults and mechanical deformations with the magnetic ground states of other more exotic layered magnets such as RuCl3 (ref. 14)

Enhancing Doctors and Healthcare Professionals Patient-care Role through Actor-training: Workshop Participants’ Responses

Workshops for 'Applying Techniques from Actor-training to Performativity of Doctors and Healthcare Practitioners' were held in 2013 and 2014 within Yong Loo Lin School of Medicine, National University of Singapore. We conclude from participants’ responses that the workshops were well received and that there were revelations in understanding and potential changes in approach to “acting in the role” of a doctor, nurse and other healthcare worker. Participants understood that acting is not about hiding but about playing one’s role more effectively. Actors are superbly trained in the nuances of observation, body awareness, and in relating effectively to others. This goes beyond mere role-playing and communication training to encompass an embodied understanding that may enable trainees to be more creative and genuine within themselves, and more effective with patients and other staff

Protocol for the RELATE trial:A feasibility and pilot randomised controlled trial of a low-intensity group intervention for young people in care with elevated posttraumatic stress symptoms

Introduction: Young people in out-of-home care have often experienced trauma, such as direct maltreatment or witnessing violence. There is good evidence that rates of mental health difficulties are high in this group, including posttraumatic stress disorder (PTSD), a trauma-specific mental health outcome. There remains less evidence to guide how to effectively address elevated PTSD symptoms (PTSS) in these young people, particularly in ways that are feasible and scalable for stretched social-care and mental health services. Methods and analysis: This protocol describes a feasibility study comprising a pilot two-arm randomised controlled trial (RCT). Participants (N = 50) will be randomised to either (a) a group-based trauma-focused programme (Teaching Recovery Techniques), delivered by mental health practitioners both online and in-person, or (b) care-as-usual. Primarily, the trial aims to explore the key feasibility and protocol acceptability questions, including rates of recruitment and retention, as well as the acceptability of the intervention (particularly the online delivery format) to participants and services. In addition, outcomes including PTSS (primary clinical outcome), depression and functioning will be assessed at baseline (pre-randomisation), post-intervention and at a 3-month follow-up. Ethics and dissemination: Ethical approval has been received from the Health Research Authority (Wales REC1 Ref 20/WA/0100) and University, with further approval from the host trust and social care site. The results will inform the design of a definitive RCT. Dissemination will include peer-reviewed journal articles reporting the qualitative and quantitative results, as well as presentations at conferences and lay summaries. Trial registration: ClinicalTrials.gov, NCT04467320. Registered on 13 July 2020

Grace Under Pressure: a drama-based approach to tackling mistreatment of medical students

A positive and respectful learning environment is fundamental to the development of professional identities in healthcare. Yet medical students report poor behaviour from healthcare professionals that contradict professionalism teaching. An interdisciplinary group designed and implemented a drama-based workshop series, based on applied theatre techniques, to help students develop positive professional qualities and interpersonal skills to deal with challenges in the healthcare setting. We piloted the workshops at the University of Sydney in 2015. Attendees completed evaluation questionnaires and participated in a focus group or interview. Of 30 workshop attendances, there were 29 completed questionnaires and three participants attended a focus group or interview. Workshop activities were rated as ‘very good’ or ‘good’ by 21/22; (95.5%). Thematic analysis of qualitative data highlighted the rationale for participation (to deal with bullying, prevent becoming a bully, learn social skills), workshop benefits (express emotions, learn about status dynamics and deconstructing personalities, empathy, fun), challenges (meeting participants’ expectations, participants’ need for further practice), and implications for medical education (need to develop awareness of others’ perspectives). Our research has shown that there is momentum to challenge mistreatment in medical education. While a multipronged approach is needed to generate systemic change, this pilot offers a positive and creative innovation. It helps students improve their interpersonal skills and sense of self to deal with challenges in the healthcare setting, including mistreatment

Verbatim Theater: Prompting Reflection and Discussion about Healthcare Culture as a Means of Promoting Culture Change

Problem: The mistreatment of medical and nursing students and junior health professionals has been reported internationally in research and the media. Mistreatment can be embedded and normalized in hierarchical healthcare workplaces, limiting the effectiveness of policies and reporting tools to generate change; as a result, some of those who experience mistreatment later perpetuate it. We used a novel, creative approach, verbatim theater, to highlight the complexity of healthcare workplaces, encourage critical reflection, and support long-term culture change. Intervention: Verbatim theater is a theater-for-change documentary genre in which a playscript is devised using only the words spoken by informants. In 2017, 30 healthcare students and health professionals were recruited and interviewed about their experience of work and training by the multidisciplinary Sydney Arts and Health Collective using semi-structured interviews. Interview transcripts became the primary material from which the script for the verbatim theater play ‘Grace Under Pressure’ was developed. The performing arts have previously been used to develop the communication skills of health professional students; this esthetic expression of the real-life effects of healthcare workplace culture on trainees and students was implemented to stimulate consciousness of, and dialogue about, workplace mistreatment in healthcare work and training. Context: The play premiered at a major Sydney theater in October 2017, attended by the lay public and student and practicing health professionals. In November 2017, three focus groups were held with a sample of audience members comprising healthcare professionals and students. These focus groups explored the impact of the play on reflection and discussion of healthcare culture and/or promoting culture change in the health workplace. We analyzed the focus group data using theoretical thematic analysis, informed by Turner’s theory of the relation between ‘social’ and ‘esthetic’ drama to understand the impact of the play on its audience. Impact: Focus group members recognized aspects of their personal experience of professionalism, training, and workplace culture in the play, Grace Under Pressure. They reported that the play’s use of real-life stories and authentic language facilitated their critical reflection. Participants constructed some learning as ‘revelation,’ in which the play enabled them to gain significant new insight into the culture of health care and opened up discussions with colleagues. As a result, participants suggested possible remedies for unhealthy aspects of the culture, including systemic issues of bullying and harassment. A small number of participants critiqued aspects of the play they believed did not adequately reflect their experience, with some believing that the play over-emphasized workplace mistreatment. Lessons Learned: Verbatim theater is a potent method for making personal experiences of healthcare workplace and training culture more visible to lay and health professional audiences. In line with Turner’s theory, the play’s use of real-life stories and authentic language enabled recognition of systemic challenges in healthcare workplaces by training and practicing health professionals in the audience. Verbatim theater provides a means to promote awareness and discussion of difficult social issues and potential means of addressing them

Probing magnetism in 2D van der Waals crystalline insulators via electron tunneling

Magnetic insulators are a key resource for next-generation spintronic and topological devices. The family of layered metal halides promises varied magnetic states including ultrathin insulating multiferroics, spin liquids, and ferromagnets, but device-oriented characterization methods are needed to unlock their potential. Here, we report tunneling through the layered magnetic insulator CrI3 as a function of temperature and applied magnetic field. We electrically detect the magnetic ground state and inter-layer coupling and observe a field-induced metamagnetic transition. The metamagnetic transition results in magnetoresistances of 95%, 300%, and 550% for bilayer, trilayer, and tetralayer CrI3 barriers, respectively. We further measure inelastic tunneling spectra for our junctions, unveiling a rich spectrum consistent with collective magnetic excitations (magnons) in CrI3.This work was supported by the Center for Integrated Quantum Materials under NSF grant DMR-1231319 as well as the Gordon and Betty Moore Foundation’s EPiQS Initiative through Grant GBMF4541 to PJH. Device fabrication has been partly supported by the Center for Excitonics, an Energy Frontier Research Center funded by the U.S. Department of Energy (DOE), Office of Basic Energy Sciences (BES) under Award Number DESC0001088. DRK acknowledges partial support by the NSF Graduate Research Fellowship Program (GRFP) under Grant No. 1122374. JLL acknowledges financial support from the ETH Zurich Postdoctoral Fellowship program. DS acknowledges the Marie Curie Cofund program at INL. JFR thanks support from PTDC/FIS-NAN/3668/2014. Growth of hexagonal boron nitride crystals at NIMS was supported by the Elemental Strategy Initiative conducted by the MEXT, Japan and JSPS KAKENHI Grant Numbers JP15K21722 and JP25106006. Work done at Ames Laboratory (PCC and SM) was supported by the DOE BES Division of Materials Sciences and Engineering. Ames Laboratory is operated for the DOE by Iowa State University under Contract No. DE-AC02-07CH11358. SM was funded by the Gordon and Betty Moore Foundation’s EPiQS Initiative through Grant GBMF4411

Integrated therapist and online CBT for depression in primary care (INTERACT): study protocol for a multi-centre randomised controlled trial

BACKGROUND: Cognitive behavioural therapy (CBT) is an effective treatment for depression. Self-directed online CBT interventions have made CBT more accessible at a lower cost. However, adherence is often poor and, in the absence of therapist support, effects are modest and short-term. Delivering CBT online using instant messaging is clinically and cost-effective; however, most existing platforms are limited to instant messaging sessions, without the support of between-session "homework" activities. The INTERACT intervention integrates online CBT materials and 'high-intensity' therapist-led CBT, delivered remotely in real-time. The INTERACT trial will evaluate this novel integration in terms of clinical and cost-effectiveness, and acceptability to therapists and clients. METHODS: Pragmatic, two parallel-group multi-centre individually randomised controlled trial, with 434 patients recruited from primary care practices in Bristol, London and York. Participants with depression will be identified via General Practitioner record searches and direct referrals. INCLUSION CRITERIA: aged ≥ 18 years; score ≥ 14 on Beck Depression Inventory (BDI-II); meeting International Classification of Diseases (ICD-10) criteria for depression. EXCLUSION CRITERIA: alcohol or substance dependency in the past year; bipolar disorder; schizophrenia; psychosis; dementia; currently under psychiatric care for depression (including those referred but not yet seen); cannot complete questionnaires unaided or requires an interpreter; currently receiving CBT/other psychotherapy; received high-intensity CBT in the past four years; participating in another intervention trial; unwilling/unable to receive CBT via computer/laptop/smartphone. Eligible participants will be randomised to integrated CBT or usual care. Integrated CBT utilises the standard Beckian intervention for depression and comprises nine live therapist-led sessions, with (up to) a further three if clinically appropriate. The first session is 60-90 min via videocall, with subsequent 50-min sessions delivered online, using instant messaging. Participants allocated integrated CBT can access integrated online CBT resources (worksheets/information sheets/videos) within and between sessions. Outcome assessments at 3-, 6-, 9- and 12-month post-randomisation. The primary outcome is the Beck Depression Inventory (BDI-II) score at 6 months (as a continuous variable). A nested qualitative study and health economic evaluation will be conducted. DISCUSSION: If clinically and cost-effective, this model of integrated CBT could be introduced into existing psychological services, increasing access to, and equity of, CBT provision. TRIAL REGISTRATION: ISRCTN, ISRCTN13112900. Registered on 11/11/2020. Currently recruiting participants. Trial registration data are presented in Table 1