This paper presents a bioinspired lower extremity exoskeleton robot. The proposed exoskeleton robot can be adjusted in structure to meet the wearer’s height of 150–185 cm and has a good gait stability. In the gait control part, a method of identifying different locomotion modes is proposed; five common locomotion modes are considered in this paper, including sitting down, standing up, level-ground walking, ascending stairs, and descending stairs. The identification is depended on angle information of the hip, knee, and (...) ankle joints. A deep locomotion mode identification model based on long-short term memory architecture is proposed in this paper for exploiting the angle data. We conducted two experiments to verify the effectiveness of the proposed method. Experimental results show that the DLMIM is capable of learning inherent characteristics of joint angles and achieves more accurate identification than the other models. The last experiment demonstrates that the DLMIM can recognize transitions between different locomotion modes in time and the real-time performance varies with each individual. (shrink)

The present study investigated how multisensory integration in peripersonal space is modulated by limb posture and limb congruency . This was done separately for the upper limbs and the lower limbs . The crossmodal congruency task was used to measure peripersonal space integration for the hands and the feet. It was found that the peripersonal space representation for the hands but not for the feet is dynamically updated based on both limb posture and limb congruency. Together these findings show (...) how dynamic cues from vision, proprioception, and touch are integrated in peripersonal limb space and highlight fundamental differences in the way in which peripersonal space is represented for the upper and lower extremity. (shrink)

The impact of stroke on motor functioning is analyzed at different levels. ‘Impairment’ denotes the loss of basic characteristics of voluntary movement. ‘Activity limitation’ denotes the loss of normal capacity for independent execution of daily activities. Recovery from impairment is accomplished by ‘restitution’ and recovery from activity limitation is accomplished by the combined effect of ‘restitution’ and ‘compensation.’ We aimed to unravel the long-term effects of variation in lesion topography on motor impairment of the hemiparetic lower limb (HLL), and (...) gait capacity as a measure of related activity limitation. Gait was assessed by the 3 m walk test (3MWT) in 67 first-event chronic stroke patients, at their homes. Enduring impairment of the HLL was assessed by the Fugl–Meyer Lower Extremity (FMA-LE) test. The impact of variation in lesion topography on HLL impairment and on walking was analyzed separately for left and right hemispheric damage (LHD, RHD) by voxel-based lesion-symptom mapping (VLSM). In the LHD group, HLL impairment tended to be affected by damage to the posterior limb of the internal capsule (PLIC). Walking capacity tended to be affected by a larger array of structures: PLIC and corona radiata, external capsule and caudate nucleus. In the RHD group, both HLL impairment and walking capacity were sensitive to damage in a much larger number of brain voxels. HLL impairment was affected by damage to the corona radiata, superior longitudinal fasciculus and insula. Walking was affected by damage to the same areas, plus the internal and external capsules, putamen, thalamus and parts of the perisylvian cortex. In both groups, voxel clusters have been found where damage affected FMA-LE and also 3MWT, along with voxels where damage affected only one of the measures (mainly 3MWT). In stroke, enduring ‘activity limitation’ is affected by damage to a much larger array of brain structures and voxels within specific structures, compared to enduring ‘impairment.’ Differences between the effects of left and right hemisphere damage are likely to reflect variation in motor-network organization and post-stroke re-organization related to hemispheric dominance. Further studies with larger sample size are required for the validation of these results. (shrink)

In this paper I reconsider a standard counterexample to the chance-raising theory of singular causation. Extant versions of this theory are so different that it is difficult to formulate the core thesis that they all share, despite the guiding idea that causes raise the chance of their effects. At one extreme, ‘Humean’ theories – which can be traced to Reichenbach – say that a particular event of type C is the cause of a particular event of type E only if (...) P(E|C & K) > P(E|~C & K) where K is a set of background conditions and where the probabilities are interpreted as relative frequencies. At the other extreme, explicitly non-Humean theories take chance to be a physical, particular, local feature of the world. (shrink)

It is often thought that bets on the truth of known propositions become irrational if the losing costs are high enough. This is typically taken to count against the view that knowledge involves assigning credence 1. I argue that the irrationality of such extreme bets can be explained by considering the interactions between the agent and the bookmaker. More specifically, the agent’s epistemic perspective is altered by the fact that the bookmaker proposes that unusual type of bet. Among other things, (...) being willing to offer a bet with unnecessarily harmful losing costs is likely to undermine the baseline level of trustworthiness required for it to be rational to engage in betting exchanges. This sort of explanation does not require granting either that we assign credence lower than 1 to known propositions or that knowledge is sensitive to practical stakes. Moreover, I show that, in our ordinary lives, we frequently perform actions that we know would be disastrous if certain conditions did not obtain. This behaviour can be seen as a form of implicit extreme betting and, nevertheless, it is often rational. (shrink)

This article examines the ethical validity of using viability as the cutoff point for abortion in the Netherlands, in view of potential changes to the Dutch perinatal care guideline. According to the Dutch Penal Code, abortion is permitted until viability: the point at which a fetus can survive outside the womb with technological assistance. Since the law was enacted in 1984, viability has been set at 24 weeks gestational age. Currently, in the Netherlands, the treatment limit for extreme prematurity is (...) also set at 24 weeks. The potential revision of the guideline could lower this threshold. Such a change could have implications for abortion in the Netherlands. We critically evaluate the use of viability within the Dutch context and offer recommendations for modifying the legal framework concerning abortion. We conclude that relying on any interpretation of viability is morally problematic for abortion regulation, as it is too indeterminate a concept to establish a threshold in a morally relevant way. (shrink)

Prosthetic devices that replace a lost limb have become increasingly performant in recent years. Recent advances in both software and hardware allow for the decoding of electroencephalogram signals to improve the control of active prostheses with brain-computer interfaces. Most BCI research is focused on the upper body. Although BCI research for the lower extremities has increased in recent years, there are still gaps in our knowledge of the neural patterns associated with lower limb movement. Therefore, the main objective (...) of this study is to show the feasibility of decoding lower limb movements from EEG data recordings. The second aim is to investigate whether well-known neuroplastic adaptations in individuals with an amputation have an influence on decoding performance. To address this, we collected data from multiple individuals with lower limb amputation and a matched able-bodied control group. Using these data, we trained and evaluated common BCI methods that have already been proven effective for upper limb BCI. With an average test decoding accuracy of 84% for both groups, our results show that it is possible to discriminate different lower extremity movements using EEG data with good accuracy. There are no significant differences in the decoding performance of these movements between healthy subjects and subjects with lower extremity amputation. These results show the feasibility of using BCI for lower limb prosthesis control and indicate that decoding performance is not influenced by neuroplasticity-induced differences between the two groups. (shrink)

Prosthetic devices that replace a lost limb have become increasingly performant in recent years. Recent advances in both software and hardware allow for the decoding of electroencephalogram signals to improve the control of active prostheses with brain-computer interfaces. Most BCI research is focused on the upper body. Although BCI research for the lower extremities has increased in recent years, there are still gaps in our knowledge of the neural patterns associated with lower limb movement. Therefore, the main objective (...) of this study is to show the feasibility of decoding lower limb movements from EEG data recordings. The second aim is to investigate whether well-known neuroplastic adaptations in individuals with an amputation have an influence on decoding performance. To address this, we collected data from multiple individuals with lower limb amputation and a matched able-bodied control group. Using these data, we trained and evaluated common BCI methods that have already been proven effective for upper limb BCI. With an average test decoding accuracy of 84% for both groups, our results show that it is possible to discriminate different lower extremity movements using EEG data with good accuracy. There are no significant differences in the decoding performance of these movements between healthy subjects and subjects with lower extremity amputation. These results show the feasibility of using BCI for lower limb prosthesis control and indicate that decoding performance is not influenced by neuroplasticity-induced differences between the two groups. (shrink)

Hemiparetic stroke in adulthood often results in the grouped movement pattern of the upper extremity flexion synergy thought to arise from an increased reliance on cortico-reticulospinal pathways due to a loss of lateral corticospinal projections. It is well-established that the flexion synergy induces reaching constraints in individuals with adult-onset hemiplegia. The expression of the flexion synergy in individuals with brain injuries onset earlier in the lifespan is currently unknown. An early unilateral brain injury occurring prior to six months post (...) full-term may preserve corticospinal projections which can be used for independent joint control and thus minimizing the expression of the flexion synergy. This study uses kinematics of a ballistic reaching task to evaluate the expression of the flexion synergy in individuals with pediatric-onset hemiplegia (PH) ages six to seventeen years. Fifteen individuals with brain injuries before birth (n = 8) and around full-term (n = 7) and nine age-matched controls with no known neurological impairment completed a set of reaches in an admittance controlled robotic device. Descending drive, and the possible expression of the upper extremity flexion snergy, was modulated by increasing shoulder abduction loading. Individuals with early PH achieved lower peak velocities when reaching with the paretic arm compared to controls however no differences in reaching distance were found between groups. Relative maintenance in reaching seen in individuals with early brain injuries highlights minimal expression of the flexion synergy. We interpret this conservation of independent control of the paretic shoulder and elbow as the use of more direct corticospinal projections instead of indirect cortico-reticulospinal pathways used in individuals with adult-onset hemiplegia. (shrink)

Extreme learning machine is a recent scheme for single hidden layer feed forward networks. It has attracted much interest in the machine intelligence and pattern recognition fields with numerous real-world applications. The ELM structure has several advantages, such as its adaptability to various problems with a rapid learning rate and low computational cost. However, it has shortcomings in the following aspects. First, it suffers from the irrelevant variables in the input data set. Second, choosing the optimal number of neurons in (...) the hidden layer is not well defined. In case the hidden nodes are greater than the training data, the ELM may encounter the singularity problem, and its solution may become unstable. To overcome these limitations, several methods have been proposed within the regularization framework. In this article, we considered a greedy method for sparse approximation of the output weight vector of the ELM network. More specifically, the orthogonal matching pursuit algorithm is embedded to the ELM. This new technique is named OMP-ELM. OMP-ELM has several advantages over regularized ELM methods, such as lower complexity and immunity to the singularity problem. Experimental works on nine commonly used regression problems indicate that the investigated OMP-ELM method confirms these advantages. Moreover, OMP-ELM is compared with the ELM method, the regularized ELM scheme, and artificial neural networks. (shrink)

The osmotic activity produced by internal, non‐permeable, anionic nucleic acids and metabolites causes a persistent and life‐threatening cell swelling, or cellular edema, produced by the Gibbs‐Donnan effect. This evolutionary‐critical osmotic challenge must have been resolved by LUCA or its ancestors, but we lack a cell‐physiology look into the biophysical constraints to the solutions. Like mycoplasma, early cells conceivably preserved their volume with Cl−, Na+, and K+‐channels, Na+/H+‐exchangers, and a light‐dependent bacteriorhodopsin‐like H+‐pump. Here, I simulated protocells having these ionic‐permeabilities and inhabiting (...) an oceanic pond before the Great‐Oxygenation‐Event. Protocells showed better volume control and stable resting potentials at lower external pH and higher temperatures, favoring a certain type of extremophile life. Prevention of Na+‐influx at night, with low bacteriorhodopsin activity, required deep shutdown of highly voltage‐sensitive Na+‐channels and extremely selective K+‐channels, two conserved features essential for modern neuronal encoding. The Gibbs‐Donnan effect universality implies that extraterrestrial cells, if they exist, may reveal similar volume‐controlling mechanisms. (shrink)

In recent years, shared decision-making has become entrenched in the medical literature and the law as the ideal method for involving patients in decisions related to their health care. Shared decision-making represents a compromise between the opposed extremes of paternalistic interactions that limit patients’ control of their health care, and “informed choice” interactions that require physicians to provide technical expertise only, leaving patients to make all treatment decisions on their own. An implicit goal of shared decision-making is to improve medical (...) care by promoting joint participation of patients and physicians in clinical consultations. The model of shared decision-making may, however, inadequately address the health care needs of lower literate patients, a significant portion of the general population.As shared decision-making is widely held as a clinical ideal, we highlight the difficulties that physicians might have in implementing shared decision-making with lower literate patients. (shrink)

In recent years, shared decision-making has become entrenched in the medical literature and the law as the ideal method for involving patients in decisions related to their health care. Shared decision-making represents a compromise between the opposed extremes of paternalistic interactions that limit patients’ control of their health care, and “informed choice” interactions that require physicians to provide technical expertise only, leaving patients to make all treatment decisions on their own. An implicit goal of shared decision-making is to improve medical (...) care by promoting joint participation of patients and physicians in clinical consultations. The model of shared decision-making may, however, inadequately address the health care needs of lower literate patients, a significant portion of the general population.As shared decision-making is widely held as a clinical ideal, we highlight the difficulties that physicians might have in implementing shared decision-making with lower literate patients. (shrink)

I first met Van Potter nearly 40 years ago when I was 17 and entering the University of Wisconsin as a new freshman. During the summer of 1963, Van was a participant in a series of evening seminars designed to familiarize premed students to the community at the University of Wisconsin Medical School. I was immediately struck by Van's unique ability to cut straight to the core of virtually any issue having to do with biomedicine. As with many of his (...) students, I quickly found myself in a father-son relationship of both our making. Van has been a source of inspiration and guidance to me ever since. (shrink)

The present discussion of dialectic thought is an extension of Van's original discussion of “realism” as the dialectic synthesis of conservatism (theism) and liberalism (empiricism) as approaches to thought.

Bioethics and Global Bioethics are currently among the most visible programs in ethics in the global academic community. It was my good fortune to have met Dr. Van Rensselaer Potter in 1963, long before he coined the term “Bioethics” and emerged as America's first Bioethicist, maintaining “The Wisconsin Tradition” established by John Muir and Aldo Leopold. Van believed that all ethics are properly based on a pan-cultural scientific knowledge base. How it is that ethics are related to knowledge, and to (...) values and morals, is the subject of this discussion. (shrink)

Dr. Van Rensselaer Potter was always quick to point out that a viable ethics must be based upon a viable scientific knowledge base. The implications are clear, that a global ethics must be based upon a global philosophy. The present discussion provides the conceptual basis for a Global Philosophy, specifically a global theology with criteria of belief for a mature Global Bioethics.

Some individuals facing dementia contemplate hastening their own death: weighing the possibility of living longer with dementia against the alternative of dying sooner but avoiding the later stages of cognitive and functional impairment. This weighing resonates with an ethical and legal consensus in the United States that individuals can voluntarily choose to forgo life‐sustaining interventions and also that medical professionals can support these choices even when they will result in an earlier death. For these reasons, whether and how a terminally (...) ill individual can choose to control the timing of their death is a topic that cannot be avoided when considering the dementia trajectory. With a focus on the U.S. context, this landscape review considers the status of provisions that would legally permit people facing dementia to hasten death with appropriate support from medical professionals. This review can be used to plan and guide clinical and legal practitioner discussion and policy development concerning evolving questions not fully covered by existing medical decision‐making provisions. (shrink)

Lower extremity non-contact soft tissue injuries are prevalent in elite futsal. The purpose of this study was to develop robust screening models based on pre-season measures obtained from questionnaires and field-based tests to prospectively predict LE-ST injuries after having applied a range of supervised Machine Learning techniques. One hundred and thirty-nine elite futsal players underwent a pre-season screening evaluation that included individual characteristics; measures related to sleep quality, athlete burnout, psychological characteristics related to sport performance and self-reported perception (...) of chronic ankle instability. A number of neuromuscular performance measures obtained through three field-based tests [isometric hip strength, dynamic postural control and lower extremity joints range of motion ] were also recorded. Injury incidence was monitored over one competitive season. There were 25 LE-ST injuries. Only those groups of measures from two of the field-based tests, as independent data sets, were able to build robust models [area under the receiver operating characteristic curve score ≥0.7] to identify elite futsal players at risk of sustaining a LE-ST injury. Unlike the measures obtained from the five questionnaires selected, the neuromuscular performance measures did build robust prediction models. The inclusion in the same data set of the measures recorded from all the questionnaires and field-based tests did not result in models with significantly higher performance scores. The model generated by the UnderBagging technique with a cost-sensitive SMO as the base classifier and using only four ROM measures reported the best prediction performance scores. The models developed might help coaches, physical trainers and medical practitioners in the decision-making process for injury prevention in futsal. (shrink)

The aim of this paper is to describe and assess the energetic-metabolic activity of selected muscles of upper and lower extremities during Rotational Training (RT). The influence of RT on temperature changes in the biceps and triceps brachii muscles as well as the quadriceps and biceps femoris muscles of healthy university students were verified, in addition to temperature differences between the left and right side before and after RT. The study was conducted on 18 subjects. RT was conducted in (...) accordance with accepted forms of training methodology of collective fitness. An important part of RT was the performance of circular and rotational movements. Thermograms taken before and immediately after RT focused on 4 regions of selected agonists and synergists in the upper and lower body. The camera used was the infrared hand-held CEDIP Titanium 560M IR (USA), located at a distance of 10 m from the subject. After RT, median Tsk (skin temperature) decreased in almost all of the examined ROIs, except for the left and right Qf (the quadriceps femoris, rectus femoris, and sartorius muscles) as well as the left Tb (triceps brachii) in female subjects. In male subjects, left and right Tsk of Qf increased both for the left and right Tb. Left-Right ΔTsk (temperature difference) was statistically significant (p <0.05) for Of, Bf, Bb, Tb in female as well as male subjects. It was concluded that thermography is a non-invasive, safe, and low-cost method for the recording of physiological response of the skin to RT. (shrink)

When the first r lower extreme order statistics of a sample of large size n, 1 < r < s < n, are observed, asymptotic predictive intervals of the future extreme order statistic with a rank s are constructed. The only assumption that we adopt is that the first failure time is attracted to the Weibull distribution. In addition, we suggest an efficient point estimator of its shape parameter and then a confidence interval is constructed for it. Moreover, new (...) interesting asymptotic properties of the distributions that belong to the minimum domain of attraction of the Weibull distribution are revealed. Furthermore, extensive simulation studies are conducted to demonstrate the efficiency of the proposed methods. Two real datasets are analyzed to illustrate and corroborate the obtained results. The main results concern large samples. (shrink)

When the first r lower extreme order statistics of a sample of large size n, 1 < r < s < n, are observed, asymptotic predictive intervals of the future extreme order statistic with a rank s are constructed. The only assumption that we adopt is that the first failure time is attracted to the Weibull distribution. In addition, we suggest an efficient point estimator of its shape parameter and then a confidence interval is constructed for it. Moreover, new (...) interesting asymptotic properties of the distributions that belong to the minimum domain of attraction of the Weibull distribution are revealed. Furthermore, extensive simulation studies are conducted to demonstrate the efficiency of the proposed methods. Two real datasets are analyzed to illustrate and corroborate the obtained results. The main results concern large samples. (shrink)

Falls are a leading cause of serious injury and restricted participation among persons with stroke (PwS). Reactive balance control is essential for fall prevention, however, only a few studies have explored the effects of lesion characteristics (location and extent) on balance control in PwS. We aimed to assess the impact of lesion characteristics on reactive and anticipatory balance capacity, gait, and hemiparetic lower limb function, in PwS. Forty-six subacute PwS were exposed to forward, backward, right and left unannounced horizontal (...) surface translations in 6 increasing intensities, while standing. Fall threshold (i.e., perturbation intensity that results in a fall into the harness system) was measured. In addition, the Berg Balance Scale (BBS), 6 Minute Walk Test (6MWT) and Lower Extremity Fugl-Meyer (LEFM) were measured. Lesion effects were analyzed separately for left- and right-hemisphere damaged (LHD, RHD) patients, using voxel-based lesion-symptom mapping (VLSM). Our results show that voxel clusters where damage exerted a significant impact on balance, gait and lower-limb function were found in the corticospinal tract, in its passage in the corona radiata and in the posterior limb of the internal capsule. Additional significant impact was found to lesions affecting the putamen and the external capsule. Balance, gait, and hemiparetic lower limb function showed much overlap of the corresponding ‘significant’ voxel clusters. Test scores of RHD and LHD patients were affected largely by damage to homologous regions, with the LHD group showing a wider distribution of ‘significant’ voxels. The study corroborates and extends previous findings by demonstrating that balance control, gait, and lower limb function are all affected mainly by damage to essentially the same brain structures, namely - the corticospinal tract and adjacent structures in the capsular-putaminal region. (shrink)

Background: The regulation of muscle force is a vital aspect of sensorimotor control, requiring intricate neural processes. While neural activity associated with upper extremity force control has been documented, extrapolation to lower extremity force control is limited. Knowledge of how the brain regulates force control for knee extension and flexion may provide insights as to how pathology or intervention impacts central control of movement.Objectives: To develop and implement a neuroimaging-compatible force control paradigm for knee extension and flexion.Methods: (...) A magnetic resonance imaging safe load cell was used in a customized apparatus to quantify force during neuroimaging. Visual biofeedback and a target sinusoidal wave that fluctuated between 0 and 5 N was provided via an MRI-safe virtual reality display. Fifteen right leg dominant female participants completed a knee extension and flexion force matching paradigm during neuroimaging. The force-matching error was calculated based on the difference between the visual target and actual performance. Brain activation patterns were calculated and associated with force-matching error and the difference between quadriceps and hamstring force-matching tasks were evaluated with a mixed-effects model.Results: Knee extension and flexion force-matching tasks increased BOLD signal among cerebellar, sensorimotor, and visual-processing regions. Increased knee extension force-matching error was associated with greater right frontal cortex and left parietal cortex activity and reduced left lingual gyrus activity. Increased knee flexion force-matching error was associated with reduced left frontal and right parietal region activity. Knee flexion force control increased bilateral premotor, secondary somatosensory, and right anterior temporal activity relative to knee extension. The force-matching error was not statistically different between tasks.Conclusion: Lower extremity force control results in unique activation strategies depending on if engaging knee extension or flexion, with knee flexion requiring increased neural activity for the same level of force and no difference in relative error. These fMRI compatible force control paradigms allow precise behavioral quantification of motor performance concurrent with brain activity for lower extremity sensorimotor function and may serve as a method for future research to investigate how pathologies affect lower extremity neuromuscular function. (shrink)

Common symptoms of multiple sclerosis include motor impairments of the lower extremities, particularly gait disturbances. Loss of balance and muscle weakness, representing some peripheral effects, have been shown to influence these symptoms, however, the individual role of cortical and subcortical structures in the central nervous system is still to be understood. Assessing [18F]fluorodeoxyglucose uptake in the CNS can assess brain activity and is directly associated with regional neuronal activity. One potential modality to increase cortical excitability and improve motor function (...) in patients with MS is transcranial direct current stimulation. However, tDCS group outcomes may not mirror individual subject responses, which impedes our knowledge of the pathophysiology and management of diseases like MS. Three PwMS randomly received both 3 mA tDCS and SHAM targeting the motor cortex that controls the more-affected leg for 20 min on separate days before walking on a treadmill. The radiotracer, FDG, was injected at minute two of the 20 min walk and the subjects underwent a Positron emission tomography scan immediately after the task. Differences in relative regional metabolism of areas under the tDCS anode and the basal ganglia were calculated and investigated. The results indicated diverse and individualized responses in regions under the anode and consistent increases in some basal ganglia areas. Thus, anodal tDCS targeting the M1 that controls the more-affected leg of PwMS might be capable of affecting remote subcortical regions and modulating the activity of the circuitry connected to these regions. (shrink)

A 78-year-old Chinese woman joined a clinical trial sponsored by a Pharmaceutical companies. Unfortunately a serious Serious Adverse Event occurred. The sponsor paid for the cost of the medical care arising from the SAE, but refused the family’s request for compensation. The family then sued the company and the hospital in Beijing. Although the SAE was related to a complication of lower extremity angiography and not the drug itself, it was a direct consequence of participating in the trial. (...) According Good Clinical Practice, a set of regulations promulgated under Chinese law, “the sponsor should provide Insurance to those human subjects who participate in clinical trials, cover the cost of Treatment and the corresponding economic compensation for the occurrence of the harm or death associated with the trial”. The court ordered the trial sponsor to provide a translation of the company’s insurance policy, so that the court could understand the amount of compensation available to the Patient under the policy, but the sponsor never surrendered either the documentation or a translation. Consensus was never reached about the amount of compensation due to the patient through negotiation with the hospital, the company and the family. The Litigation ended after nine hearings and five long years. This chapter provides an ethical analysis of the case relative to at least three areas of Risks of Exploitation when a major, international Pharmaceutical companies sponsors clinical research in a country with an immature legal system and where Research participants have limited resources. (shrink)

Objective: Stand-to-sit task is an important daily function, but there is a lack of research evidence on whether knee osteoarthritis affects the postural balance during the task. This study aimed to compare individuals with knee OA and asymptomatic controls in postural balance and identify kinematic and lower extremity muscle activity characteristics in individuals with knee OA during the stand-to-sit task.Methods: In total, 30 individuals with knee OA and 30 age-matched asymptomatic controls performed the 30-s Chair Stand Test at (...) self-selected speeds. Motion analysis data and surface electromyography were collected while participants performed the 30sCST. To quantify postural balance, the displacement of the center of mass and the peak instantaneous velocity of the CoM were calculated. The kinematic data included forward lean angles of the trunk and pelvic, range of motion of the hip, knee, and ankle joints in the sagittal plane. The averaged activation levels of gluteus maximus, vastus lateralis, vastus medialis, rectus femoris, biceps femoris, tibialis anterior, and medial head of gastrocnemius muscles were indicated by the normalized root mean square amplitudes.Results: Compared with the asymptomatic control group, the knee OA group prolonged the duration of the stand-to-sit task, demonstrated significantly larger CoM displacement and peak instantaneous CoM velocity in the anterior-posterior direction, reduced ankle dorsiflexion RoM, greater anterior pelvic tilt RoM, and lower quadriceps femoris and muscles activation level coupled with higher BF muscle activation level during the stand-to-sit task.Conclusion: This study indicates that individuals with knee OA adopt greater pelvic forward lean RoM and higher BF muscle activation level during the stand-to-sit task. However, these individuals exist greater CoM excursion in the anterior-posterior direction and take more time to complete the task. This daily functional activity should be added to the rehabilitation goals for individuals with knee OA. The knee OA group performs reduced ankle dorsiflexion RoM, quadriceps femoris, and TA activation deficit. In the future, the rehabilitation programs targeting these impairments could be beneficial for restoring the functional transfer in individuals with knee OA. (shrink)

Jeremy sustained bilateral complete brachial plexus injuries in an auto collision on an icy road a month before his third birthday. The accident rendered both upper extremities completely flail and insensate: he has no motor or sensory function of his shoulders, elbows, wrists, or digits. Jeremy does, however, have normal function of the lower extremities. Physical therapists have worked with the child for over a year with no noted improvement in arm function. Jeremy falls frequently, causing injury to his (...) face and head, and occasionally, his arms get twisted or caught in his crib and his fingers turn blue. Jeremy's mother, who carries the main responsibility for his daily care, believes that his insensate arms are too heavy and “get in his way,” causing the falls. She and Jeremy's father present to the orthopedic clinic at the children's hospital with the request of having both arms amputated. The primary orthopedic surgeon and the orthopedic team disagree with the parents that bilateral upper-extremity amputation offers any medical benefit, but Jeremy's mother tells the surgeon that, if he will not perform the surgery, her family will find a doctor who will. The surgeon, who feels ethically distressed by the parental insistence on this amputation in such a young child, requests an ethics consultation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Breaking the Readmission CycleBrian HattenI want to share the story of my difficult patient Ms. L. She has twenty-seven current medical issues. Thirty-five active prescriptions. Limited mobility requiring the use of a motorized scooter. Non-medical care gaps. And over twenty hospital admissions since 2020. I met Ms. L approximately five years ago as her hospital attending and have continued to care for her during her frequent hospitalizations. I could (...) recite this 77-year-old female's litany of medical problems. But sufficed to say, her history is complex, with her admitting diagnoses running the gambit from cellulitis to gastrointestinal bleeding to altered mental status. But, her diagnosis and frequent exacerbations of congestive heart failure (CHF) are particularly frustrating for us both and will be my focus today.CHF makes her susceptible to fluid overload leading to feelings of shortness of breath, which progresses to respiratory distress. Like other individuals with CHF, she uses diuretics to prevent herself from becoming fluid overloaded. And, like many individuals who take diuretics, she hates them. She (un)affectionately calls her water pills "the bomb" because the effect is sudden, profound, and explosive when they begin working. The combination of the diuretic effect and her limited mobility causes significant emotional stress for Ms. L, a woman who values presenting herself outwardly as in control, well-dressed, and put together. Her dislike of the medical effect of her diuretics has led to her either taking them less often or outright discontinuing them. So, while discontinuation avoids those frustrating effects, it leads to fluid accumulation, subsequent respiratory distress, and readmission to the hospital.Her medical records mention she has memory issues. It is unclear how much her mild cognitive impairment affects her frequent readmissions. We have had many conversations where I would never suspect something was amiss. But sometimes, she can be forgetful and does not recall our recent discussions. That being said, she knows the names and uses of her medications. She can report to me her home weights when she checks them and knows what her "dry" weight should be. Yet, she does not act when her scales begin reading heavier or when she develops leg swelling. Instead, she presents to the emergency department in extremis. When directly questioned about why she lets her situation deteriorate to such a state that she requires hospitalization, she demurs. She comments that she can often be stubborn, that the diuretic effect of "the bomb" is burdensome, but always reminds me she is honest in admitting she wasn't taking her water pills.During several admissions, I worried for her survival after she had self-discontinued her medications and showed up at the emergency department in respiratory failure. For any patient with recurrent admissions, I discuss their overall goals of care to ensure we are working together toward achievable medical ends. But this conversation was essential to have with Ms. L. The possibility existed that she would present to the hospital too late in her disease process, and we would not be able to correct her respiratory failure. I wanted to ensure that the hospital staff and I respected her wishes regarding her care. Despite raising my concerns, she would [End Page 22] decline to discuss her wishes. Even worse, attempting to have her complete advance care planning documents like advance directives or a Physician Orders for Life-Sustaining Treatment (POLST) form was a futile endeavor. Ms. L was always vague and non-committal. She simply did not want to engage in those types of conversations. When asked why she declined to discuss these issues, Ms. L would reply that she was doing okay, the discussion was unnecessary, and she had family members to make those decisions for her.Caring for her during her hospital stays was a source of professional frustration for me. Her recurrent admissions made me feel like I was failing her. During each hospital stay, we would go over her medications. We repeatedly discussed how she should check her weights daily and monitor for lower extremity edema. We created multiple action plans for when to call her physicians so we could head off another hospital visit. We completed all the... (shrink)

The patterns of physical growth (stature, BMI, subscapular and arm fat-fold thickness, upper and lower extremity length, chest circumference, arm, and hip breadth, and age at menarche) were studied in 857 of Maya and Mestizo girls and 1314 of Creole girls aged 6-18 years. Data were collected between 1998-2001 in primary, secondary, and high schools of Merida, Capital City of the Yucatan State, Mexico. The ethnicity of girls was defined using their two surnames (from the father and mother (...) side). The results show that Creoles are taller, have more abundant fat tissue, and greater BMI, especially at the age of 11 years, which means that they are better prepared to start pubertal spurt. Maya girls have relatively longer upper extremities to lower ones, greater biacromial breadth, and chest circumference to stature than Creoles, which shows their more stocky body build. The adolescent (pubertal) spurt in height starts earlier in Creoles (9-10 years) and its rate is greater (max. = 7.48 cm/ year) than in Maya and Mestizos girls (10-11 years; max. = 6.25 cm/year). In Mayas and Mestizos, there is only a slight difference between the rate of changes before and during the pubertal spurt. There are no significant differences in age at menarche between girls from both ethnic groups (11.96 in Mayas and Mestizos and 12.04 in Creoles), but there are statistically significant differences between age at menarche of studied girls and their mothers (12.4 for both groups) in each ethnic group. There is evidence that the onset of pubertal spurt in height and its rate may depend on ethnicity. Creoles may lead to a more “westernized” style of life than the Maya and Mestizos girls. (shrink)

"New wave" reductionism aims at advancing a kind of reduction that is stronger than unilateral dependency of the mental on the physical. It revolves around the idea that reduction between theoretical levels is a matter of degree, and can be laid out on a continuum between a "smooth" pole (theoretical identity) and a "bumpy" pole (extremely revisionary). It also entails that both higher and lower levels of the reductive relationship sustain some degree of explanatory autonomy. The new wave predicts (...) that reductions of folk psychology to neuroscience will be located in the middle of this continuum; as neuroscientific evidence about mental states checks in, theoretical folk psychology will therefore be moderately revised. However, the model has conceptual problems which preclude its success in reviving reductionism, and its commitment to a syntactic approach wrecks its attempt to rescue folk psychology. Moreover, the architecture of the continuum operates on a category mistake that sneaks in an eliminativist conclusion. I argue that new wave reductionism therefore tends to be eliminativism in disguise. (shrink)

AimIn case of extremely rare diseases, case reports are often the only experience to draw from for evidence-based management. Carmi syndrome is a rare, mostly lethal combination of junctional epidermolysis bullosa and pyloric atresia. During an ethical board, there were differences in perception of mortality rate. We tested the hypothesis that the cumulative mortality of single case reports is lower than that of multiple case series.CaseA baby girl was born at 33 weeks gestation with Carmi syndrome. The treatment options (...) discussed in an interdisciplinary ethics board were a palliative approach versus surgical gastrojejunostomy. Because about one third of operated children described in case reports survived, we opted for surgical treatment. The patient died a painful death 4 weeks later.MethodsThe PubMed database was systematically searched for reports of Carmi syndrome. Single case reports were compared to case series in terms of outcome.ResultsA total of 102 cases of Carmi syndrome were identified in the literature. Mortality of single case reports was 17 out of 27 patients (63%), while that of case series was higher at 62 out of 74 patients (84%,p = 0.036).ConclusionsSelection and publication bias may lead to inflation of survival rates in single case reports because successful cases are more likely to be published in the literature. These biases may lead to inappropriately aggressive treatment in futile cases. Clinicians should be cautious when discussing prognosis and making decisions based on the cumulative experience of case reports of extremely rare or novel diseases. (shrink)

Surrogate selection can be extremely consequential for patients. Most surrogates are selected by default, so we should care about whether legal provisions for default surrogate selections are ethically justified. Most U.S. states use an inflexible, prioritized list of relationships, that is, a hierarchical list where eligible classes of higher-ranked individuals must be selected before lower-ranked individuals. I argue that while some inflexible, prioritized lists may roughly reflect the order that many patients would select, there is a significant minority that (...) inflexible lists systematically disempower. This is morally unacceptable given the availability of less morally problematic alternatives. One alternative is a flexible, prioritized list, which provides conditions for lower-ranked individuals to be selected ahead of higher-ranked ones. I argue that since all the U.S. states that currently have an inflexible, prioritized list systematically disempower a significant proportion of their residents, they have good reason to adopt a flexible, prioritized list instead. Furthermore, the Universal Law Commission currently recommends that states adopt an inflexible, prioritized list, so they have good reason to change their recommendation. (shrink)

Should we make significant sacrifices to ever-so-slightly lower the chance of extremely bad outcomes, or to ever-so-slightly raise the chance of extremely good outcomes? *Fanaticism* says yes: for every bad outcome, there is a tiny chance of extreme disaster that is even worse, and for every good outcome, there is a tiny chance of an enormous good that is even better. I consider two related recent arguments for Fanaticism: Beckstead and Thomas's argument from *strange dependence on space and time*, (...) and Wilkinson's *Indology* argument. While both arguments are instructive, neither is persuasive. In fact, the general principles that underwrite the arguments (a *separability* principle in the first case, and a *reflection* principle in the second) are *inconsistent* with Fanaticism. In both cases, though, it is possible to rehabilitate arguments for Fanaticism based on restricted versions of those principles. The situation is unstable: plausible general principles tell *against* Fanaticism, but restrictions of those same principles (with strengthened auxiliary assumptions) *support* Fanaticism. All of the consistent views that emerge are very strange. (shrink)

The so-called “conciliatory” norm in epistemology and meta-ethics requires that an agent, upon encountering peer disagreement with her judgment, lower her confidence about that judgment. But whether agents actually abide by this norm is unclear. Although confidence is excessively researched in the empirical sciences, possible effects of disagreement on confidence have been understudied. Here, we target this lacuna, reporting a study that measured confidence about moral beliefs before and after exposure to moral discourse about a controversial issue. Our findings (...) indicate that participants do not abide by the conciliatory norm. Neither do they conform to a rival “steadfast” norm that demands their confidence to remain the same. Instead, moral discourse seems to boost confidence. Interestingly, we also find a confidence boost for factual beliefs, and a correlation between the extremity of moral views and confidence. One possible explanation of our findings is that when engaging in moral discourse participants become more extreme in their opinions, which leads them to become more confident about them, or vice versa: they become more confident and in turn more extreme. Although our work provides initial evidence for the former mechanism, further research is needed for a better understanding of confidence and moral discourse. (shrink)

Cognitive archaeologists attempt to infer the cognitive and cultural features of past hominins and their societies from the material record. This task faces the problem of _minimum necessary competence_: as the most sophisticated thinking of ancient hominins may have been in domains that leave no archaeological signature, it is safest to assume that tool production and use reflects only the lower boundary of cognitive capacities. Cognitive archaeology involves selecting a model from the cognitive sciences and then assessing some aspect (...) of the material record through that lens. We give examples to show that background theoretical commitments in cognitive science that inform those models lead to different minimum necessary competence results. This raises an important question: what principles should guide us in selecting a model from the cognitive sciences? We outline two complementary responses to this question. The first involves using _independent_ lines of evidence to converge on a particular capacity. This can then influence model choice. The second is a broader suggestion. Theoretical diversity is a good thing in science, but is only beneficial over a limited amount of time. According to recent modelling work, one way of limiting diversity is to introduce extreme priors. We argue that having a broad spectrum of views in the philosophy of cognitive science may actually help cognitive archaeologists address the problem of minimum necessary competence. (shrink)

Drawing on risk mitigation theory, this article examines whether the improvement of firms’ social performance reduces debt financing costs (CDFs) in China, the world’s largest emerging market. Employing both the ordinary least square (OLS) and the two-stage instrumental variable regression methods, we find that improved corporate social responsibility (CSR) reduces the CDF when firms’ CSR investment is lower than an optimal level; however, this relationship is reversed after the CSR investment exceeds the optimal level. Firms with extremely low or (...) extremely high CSR are subject to a higher CDF. The results also suggest that the optimal CSR level for small firms is higher than that for large firms. This study is the first to document a U-shaped relationship between CSR and CDF and also the first to investigate this relationship within an emerging market context. (shrink)

: In recent years, research on the family role and entrepreneurship has increased extremely, consolidating itself as a valid and current subject of study. However, a part of the scientific literature seems to lack systematization and the boundaries appear unclear, maybe due to its multidisciplinary nature. This paper presents a systematic analysis of academic research, applying bibliometric indicators and cluster analysis, which define the state of research on the international scene. For this purpose, using three well accepted databases among the (...) research community: Scopus, Web of Science, Business Source, a total of 92 articles were selected and analyzed, published between 1989 and 2019 (until March). The results show that this is a relatively recent field of study, with a multidisciplinary character and in which the most influential authors do not coincide with the most productive scientific journals. A cluster analysis finds out five main areas of literature development: the cluster with the largest percentage of co-occurrences (25%) is the one that relates to the dimensions of entrepreneurship, self-employment and personality; in contrast, the area with a lower percentage of co-occurrences of keywords (12,1%) is refers to family business, succession, economic development and Arabia Saudita. Based on the outcome obtained and the shortcomings above, in the final part of the article, possible points of reflection for future research are exposed, which could be useful to further of this field of study. (shrink)

Helmuth Plessner’s Levels of Organic Life and the Human [Die Stufen des Organischen und der Mensch, 1928] is one of the founding texts of twentieth century philosophical anthropology (understood as philosophical reflection on the fundamental characteristics of the human lifeform). It is argued that Plessner’s work demonstrates the fundamental indispensability of the qualitative humanities vis-à-vis the natural-scientific study of man. Plessner’s non-reductionist, emergentist naturalism allots complementary roles to the causal and functional investigations of the life sciences and the phenomenological and (...) hermeneutic interpretation of the phenomenon of life in its successive levels and stages. Within this context, human agency can be understood as a higher-order property of organic life, which act by the selective activation of lower-level psychophysical powers. Plessner’s three ‘anthropological laws’ are used to situate the notion of practical self-understanding in between two extremes: deterministic views that deny human freedom and responsibility and views that ascribe an unrealistic amount of autonomy to human beings. (shrink)