Relational Autonomy, Maternalism, and the Nocebo Effect

In their target article, Menkes et al. suggest that the nocebo effect, in which an individual experiences an adverse effect of medical treatment due to negative expectations, occasions a dilemma between autonomy and nonmaleficence. They work to resolve the dilemma by arguing that in some cases, nonmaleficence outweighs autonomy. In this commentary article, we suggest that the concept of autonomy presumed to underlie informed consent practices is at the root of this predicament – not a pro tanto conflict between autonomy and nonmaleficence. We propose that if the concept of relational autonomy (understood in terms of autonomy competencies) is utilized instead, this conflict dissolves. To concretize this conceptual point, we describe how the types of informed consent practices described as untenable by the authors (in which disclosure is calibrated to the individual patient) are actually widely practiced in Japan. Elucidation of these practices requires a wider lens on informed consent practices that includes support staff such as nurses and medical social workers as well as family members. These practices, best understood as maternalistic, are ethically justifiable from a relational autonomy perspective. As we argue, there are good reasons to approach the nocebo effect from this perspective; doing so both dissolves the autonomy/best interests dilemma and grounds concrete suggestions for reducing the nocebo effect

Improving uptake of seasonal influenza vaccination by healthcare workers: Implementation differences between higher and lower uptake NHS trusts in England

Background Uptake of influenza vaccination by healthcare workers (HCWs) may be related to how influenza campaigns are implemented. This study explores differences in annual influenza campaign implementation between NHS trusts (healthcare organisations) with higher and lower vaccine uptake. Methods A cross-sectional survey with influenza campaign staff in 2016/2017 in 87 NHS trusts in England. The survey measured vaccination policy and uptake target, staff involvement, accessibility, use of peer vaccinators, communication strategies, strategies to address HCW concerns, use of incentives, and management support. The analysis considered implementation differences between higher (n Z 50) and lower (n Z 37) uptake trusts. Results and Conclusions Higher uptake trusts were more likely to set higher uptake targets, involve a broader range of staff groups in the campaign, and make the vaccine easy to access by core or hard-toreach HCWs. Higher uptake trusts were also more likely to use a greater range of communication strategies, provide real-time feedback on uptake, provide a greater range of incentives to be vaccinated, and have vaccine uptake considered important by managers. Successful influenza vaccination programmes are multifaceted and involve implementation factors at a strategic, organisational, logistical, and personnel level. Lower uptake trusts could improve uptake by identifying and implementing examples of best practice from higher uptake trusts

The effect of frontal airbags on belted driver injury patterns in Europe and the U.S. - where do future priorities lie?

Injury patterns by body region were compared for belted drivers who had sustained at least one moderate or greater injury (MAIS 2+ belted drivers) in airbag equipped and non-airbag cars. For airbag equipped cars, both European and US data showed about a 30% decrease in the fraction of these drivers who sustained AIS 2+ head injuries. European data found little difference in the relative frequency of AIS 2+ chest injury and cervical strain, whereas U.S. data showed a decreased frequency of AIS 2+ chest injury for MAIS 2+ belted drivers in airbag equipped cars. Both European and U.S. data show a substantially increased frequency of AIS 2+ upper limb injury for these drivers. AIS 2+ shoulder injuries contributed significantly to the increase. U.K., U.S. and German data show only a very small risk of head injury for all belted drivers in the no-deployment condition. On the other hand, European data suggests that the airbag appears to have little effect on injury outcome below 30 km/h delta v for all belted drivers. Currently, the North American experience of frontal airbag field performance is more extensive than it is in Europe. This is a consequence of their much earlier introduction into the car fleet. U.S. field studies show that airbags are effective in reducing occupant fatality by 31% in purely frontal crashes (NHTSA, 1996). Studies have also looked at effectiveness related specifically to airbag and belt combinations, belt only and airbag only

Mandatory policies for influenza vaccination:Views of managers and healthcare workers in England

Mandatory policies have the potential to increase uptake of influenza ('flu') vaccination among healthcare workers (HCWs), but concerns have been expressed about their acceptability and effectiveness. We explored views on three mandatory policies (declination forms, face masks or reduced patient contact, and mandatory vaccination) among both HCWs and flu vaccination programme managers in the National Health Service (NHS) in England. Method: A mixed method approach was employed. An online cross-sectional survey was conducted with staff responsible for implementing influenza campaigns in NHS trusts (healthcare organisations) in England (n = 72 trusts). The survey measured perceived effectiveness of the three mandatory policies and perceived support for them among HCWs. Qualitative interviews were conducted in four trusts, with influenza campaign managers (n = 24) and with HCWs who had the opportunity to receive the influenza vaccination (n = 32). Interviews explored respondents’ views of the three strategies and were analysed thematically using QSR NVivo 11 All data were collected shortly after the 2016/2017 influenza season. Results: In the survey, views varied on the effectiveness of the three policies and none of the interventions were thought to be strongly supported by HCWs, with particularly low levels of support perceived for mandatory vaccination and for face masks or reduced patient contact. The qualitative interviews revealed substantial concerns around the practicability and enforceability of mandatory policies and the potential discriminatory effect on HCWs who made a principled decision or had medical reasons for exemption. Additional doubts were also expressed regarding the effectiveness of face masks and their potential to worry patients, and the ethics of compelling staff to accept medical intervention. Discussion: Mandatory vaccination and face masks would not be strongly supported if introduced in the UK. If declination forms are adopted, they should be used in a constructive intelligence-gathering manner which avoids stigmatising HCW

Phylogenetics of Flowering Plants Based on Combined Analysis of Plastid atpB and rbcL Gene Sequences

Following (1) the large-scale molecular phylogeny of seed plants based on plastid rbcL gene sequences (published in 1993 by Chase et al., Ann. Missouri Bot. Gard. 80:528-580) and (2) the 18S nuclear phylogeny of flowering plants (published in 1997 by Soltis et al., Ann. Missouri Bot. Gard. 84:1-49), we present a phylogenetic analysis of flowering plants based on a second plastid gene, atpB, analyzed separately and in combination with rbcL sequences for 357 taxa. Despite some discrepancies, the atpB-based phylogenetic trees were highly congruent with those derived from the analysis of rbcL and 18S rDNA, and the combination of atpB and rbcL DNA sequences (comprising ∼3000 base pairs) produced increased bootstrap support for many major sets of taxa. The angiosperms are divided into two major groups: noneudicots with inaperturate or uniaperturate pollen (monocots plus Laurales, Magnoliales, Piperales, Ceratophyllales, and Amborellaceae-Nymphaeaceae-Illiciaceae) and the eudicots with triaperturate pollen (particularly asterids and rosids). Based on rbcL alone and atpB/rbcL combined, the noneudicots (excluding Ceratophyllum) are monophyletic, whereas in the atpB trees they form a grade. Ceratophyllum is sister to the rest of angiosperms with rbcL alone and in the combined atpB/rbcL analysis, whereas with atpB alone, Amborellaceae, Nymphaeaceae, and Illiciaceae/Schisandraceae form a grade at the base of the angiosperms. The phylogenetic information at each codon position and the different types of substitutions (observed transitions and transversions in the trees vs. pairwise comparisons) were examined; taking into account their respective consistency and retention indices, we demonstrate that third-codon positions and transitions are the most useful characters in these phylogenetic reconstructions. This study further demonstrates that phylogenetic analysis of large matrices is feasibl

Baseline Factors Predicting Placebo Response to Treatment in Children and Adolescents With Autism Spectrum Disorders: A Multisite Randomized Clinical Trial

The finding of factors that differentially predict the likelihood of response to placebo over that of an active drug could have a significant impact on study design in this population

Are there Social Spillovers in Consumers’ Security Assessments of Payment Instruments?

Even though security of payments has long been identified as an important aspect of the consumer payment experience, recent literature fails to appropriately assess the extent of social spillovers among payment users. We test for the existence and importance of such spillovers by analyzing whether social influence affects consumers’ perceptions of the security of payment instruments. Based on a 2008–2014 annual panel data survey of consumers, we find strong evidence of social spillovers in payment markets: others’ perceptions of security of payment instruments exert a positive influence on one’s own payment security perceptions. The significant and robust results imply that a consumer’s assessments of security converge to his peers’ average assessment: a 10 percent change in the divergence between one’s own security rating and peers’ average rating will result in a 7 percent change in one’s own rating in the next period. The results are robust to many specifications and do not change when we control for actual fraud or crime data. Our results indicate that spillovers rather than reflection appear to be the cause, although separating the two causes is very difficult (Manski 1993). In particular, the spillovers are stronger for people who experience an exogenous shock to security perception, people who have more social interactions, and younger consumers, who are more likely to be influenced by social media. We also examine the effects of social spillovers on payment behavior (that is, on decisions regarding payment adoption and use). Our results indicate that social spillovers have a rather limited impact on payment behavior, as others’ perceptions seem to affect one’s own payment behavior mainly indirectly through the effect on one’s own perceptions

Quantum Gravity in 2+1 Dimensions: The Case of a Closed Universe

In three spacetime dimensions, general relativity drastically simplifies, becoming a ``topological'' theory with no propagating local degrees of freedom. Nevertheless, many of the difficult conceptual problems of quantizing gravity are still present. In this review, I summarize the rather large body of work that has gone towards quantizing (2+1)-dimensional vacuum gravity in the setting of a spatially closed universe.Comment: 61 pages, draft of review for Living Reviews; comments, criticisms, additions, missing references welcome; v2: minor changes, added reference