Background: Arthritis is very common but is not well understood. Actually, “arthritis” is not a single disease; it is an informal way of referring to joint pain or joint disease. There are more than 100 different types of arthritis and related conditions. People of all ages, sexes and races can and do have arthritis, and it is the leading cause of disability in America. More than 50 million adults and 300,000 children have some type of (...) class='Hi'>arthritis. It is most common among women and occurs more frequently as people get older. Common arthritis joint symptoms include swelling, pain, stiffness and decreased range of motion. Symptoms may come and go. They can be mild, moderate or severe. They may stay about the same for years, but may progress or get worse over time. Severe arthritis can result in chronic pain, inability to do daily activities and make it difficult to walk or climb stairs. Arthritis can cause permanent joint changes. These changes may be visible, such as knobby finger joints, but often the damage can only be seen on X-ray. Some types of arthritis also affect the heart, eyes, lungs, kidneys and skin as well as the joints. Objectives: The main goal of this expert system is to get the appropriate diagnosis of disease and the correct treatment and give the appropriate method of treatment through several tips that concern the disease and how to treat it and we will see it through the application on the expert system. Methods: in this paper the design of the proposed Expert System which was produced to help Orthopedist in diagnosing Arthritis disease through its symptoms such as: pain on pressure in a joint , Inflammation indicated by joint swelling, Stiffness especially in the morning , Loss of flexibility of joint, Limited, joint movement, Deformity of the joints , Weight loss and fatigue , Non-specific fever and Crepitus. The proposed expert system presents an overview about Arthritis disease is given, the cause of diseases is outlined and the treatment of disease whenever possible is given out. SL5 Object Expert System language was used for designing and implementing the proposed expert system. Results: The proposed Arthritis disease diagnosis expert system was evaluated by Orthopedics students and they were satisfied with its performance. Conclusions: The Proposed expert system is very useful for Orthopedist, patients with arthritis and newly graduated Orthopedics students. (shrink)

Rheumatoid arthritis (RA) may not be a multifactorial disease; it can be hypothesized that RA is developed through a series of events following a triggering event, which is the emergence of a chemokine for neutrophils in the synovium. IL‐17A, secreted by infiltrated neutrophils, stimulates synoviocytes to produce CCL20, which attracts various CCR6‐expressing cells, including Th17 cells. Monocytes (macrophages) appear after neutrophil infiltration according to the natural course of inflammation and secrete IL‐1β and TNFα. Then, IL‐17A, IL‐1β, and TNFα stimulate (...) synoviocytes to produce CCL20, amplifying the inflammation. Varieties of chemokines secreted by infiltrating cells accumulate in the synovium and induce synoviocyte proliferation by binding to the corresponding G protein‐coupled receptors, thus expanding the synovial tissue. CCL20 in this tissue attracts circulating monocytes that express both CCR6 and receptor activator of NF‐κB (RANK), which differentiate into osteoclasts in the presence of RANKL. In this way, pannus is formed, and bone destruction begins. (shrink)

This chapter focuses on the view that diseases comprise natural kinds and how this view is in conflict with the essentialist picture of natural kinds as championed by Kripke and Putnam. This essentialist depiction of natural kinds contends that in order for a class of entities to be a natural kind, it is required that all and only members of the class instantiate very specific properties that explain the presence of any other properties typically associated with being a member of (...) the kind; these privileged properties constitute the “essence” of the kind. The problem is that the essentialist picture provides only two options, none of which is desirable: satisfy the essentialist desiderata by locating some etiological feature both necessary and sufficient for kind membership, or reject the thought that similarity between disease instances can be understood in terms of natural kinds. (shrink)

Tyler Burge's (1979) famous thought experiment concerning 'arthritis' is commonly assumed to show that all ascriptions of content to beliefs and other attitudes are dependent for their truth upon facts about the agent's social and linguistic environment. It is also commonly claimed that Burge's argument shows that Putnam's (1975) result regarding natural kind terms applies to all general terms whatever, and hence shows that all such terms have wide meanings.1 But I wish to show here, first, that neither Burge's (...) initial thought experiment nor a second type of example that Burge describes supports either of these conclusions. Second, I will identify the proper conclusion to draw from Burge's discussion and show that this conclusion does not really pose a serious problem for individualism about the mental. And finally, I will argue that Burge's discussion does not in fact provide a conclusive reason for believing its proper conclusion. (shrink)

Objectives: To elicit the perceptions and preferences of patients with rheumatoid arthritis regarding information and participation in treatment decision-making. To analyse the patients’ narratives on the background of the ethical discourse on various approaches to treatment decision-making. Design: In-depth interviews with themes identified using principles of grounded theory. Participants: 22 patients with long-standing rheumatoid arthritis. Main outcome measures: Qualitative data on patients’ perceptions and preferences regarding information and participation in decision-making about treatment. Results: Decision-making about treatment has been (...) described by the patients as a process consisting of different stages with shifting loci of control and responsibility. Patients initially received one treatment recommendation and were not aware of alternative treatment options. Those participants in this study who wanted information about negative effects of a treatment cited “interest in one’s own health” and the potential “use of information” as reasons for their preference. The physicians’ expert knowledge and clinical experience regarding the effects of medication were cited as arguments by patients for a treatment recommendation. Conclusions: The patients’ accounts of decision-making about treatment differ from models of physician–patient relationship that have been put forward in ethical discourse. These differences may be relevant with respect to the starting point of an ethical analysis of treatment decision-making. Patients’ accounts with respect to a lack of information on treatment alternatives point to ethically relevant challenges regarding treatment decision-making in clinical practice. (shrink)

Rheumatoid arthritis is a progressive systemic autoimmune disease characterized by inflammation of the joints and surrounding tissues, which seriously affects the life of patients. The Sharp/van der Heijde method has been widely used in clinical evaluation for the RA disease. However, this manual method is time-consuming and laborious. Even if two radiologists evaluate a specific location, their subjective evaluation may lead to low inter-rater reliability. Here, we developed an efficient model powered by deep convolutional neural networks to solve these (...) problems and automated the overall scoring on hand X-rays. The depthwise separable convolution technique is used based on ResNet-50 due to the high resolution of hand X-rays. An inverted residual block is introduced to devise a ResNet-Dwise50 model to enhance the efficiency of the model. The model was trained and tested using bilateral posteroanterior images of 3818 patients. The experiment results show the ResNet-Dwise50 model achieved an MAE of 14.90 and RMSE of 22.01 while ensuring high efficiency. There was no statistical difference between the average scores given by two experienced radiologists and predicted scores from our model. (shrink)

Cortisone, initially known as ‘compound E’ was the medical sensation of the late 1940s and early 1950s. As early as April 1949, only a week after Philip Hench and colleagues first described the potential of ‘compound E’ at a Mayo Clinic seminar, the New York Times reported the drug’s promise as a ‘modern miracle’ in the treatment of rheumatoid arthritis. Given its high profile, it is unsurprising that historians of medicine have been attracted to study the innovation of cortisone. (...) It arrived at the end of a decade of ‘therapeutic revolutions’, kicked off by penicillin transforming the treatment of bacterial infections and ending with hopes of a revolution in the treatment of non-infectious, chronic inflammatory diseases. Despite these studies of cortisone’s introduction, few historians have taken the story forward and considered how cortisone was adopted and adapted into clinical practice. This article tells the longer of how the drug and its derivatives were taken from research laboratories and integrated into clinical practice; what has in recent decades become known as translational medicine. In exploring cortisone’s first decade in Britain, we focus specifically on its role in the treatment of RA. Our approach is always to consider cortisone’s use in the context of other treatments available to clinicians, and at local and national institutional settings. We do not discuss the many other therapeutic uses of cortisone, which ranged for topical applications for skin diseases to the management of cancers, especially childhood leukaemia, nor do we discuss its close analogue ACTH—AdenoCorticoTropic Hormone. We think there are lessons in our study for TM policies today. (shrink)

Cortisone, initially known as ‘compound E’ was the medical sensation of the late 1940s and early 1950s. As early as April 1949, only a week after Philip Hench and colleagues first described the potential of ‘compound E’ at a Mayo Clinic seminar, the New York Times reported the drug’s promise as a ‘modern miracle’ in the treatment of rheumatoid arthritis. Given its high profile, it is unsurprising that historians of medicine have been attracted to study the innovation of cortisone. (...) It arrived at the end of a decade of ‘therapeutic revolutions’, kicked off by penicillin transforming the treatment of bacterial infections and ending with hopes of a revolution in the treatment of non-infectious, chronic inflammatory diseases. Despite these studies of cortisone’s introduction, few historians have taken the story forward and considered how cortisone was adopted and adapted into clinical practice. This article tells the longer of how the drug and its derivatives were taken from research laboratories and integrated into clinical practice; what has in recent decades become known as translational medicine. In exploring cortisone’s first decade in Britain, we focus specifically on its role in the treatment of RA. Our approach is always to consider cortisone’s use in the context of other treatments available to clinicians, and at local and national institutional settings. We do not discuss the many other therapeutic uses of cortisone, which ranged for topical applications for skin diseases to the management of cancers, especially childhood leukaemia, nor do we discuss its close analogue ACTH—AdenoCorticoTropic Hormone. We think there are lessons in our study for TM policies today. (shrink)

Cortisone, initially known as ‘compound E’ was the medical sensation of the late 1940s and early 1950s. As early as April 1949, only a week after Philip Hench and colleagues first described the potential of ‘compound E’ at a Mayo Clinic seminar, the New York Times reported the drug’s promise as a ‘modern miracle’ in the treatment of rheumatoid arthritis. Given its high profile, it is unsurprising that historians of medicine have been attracted to study the innovation of cortisone. (...) It arrived at the end of a decade of ‘therapeutic revolutions’, kicked off by penicillin transforming the treatment of bacterial infections and ending with hopes of a revolution in the treatment of non-infectious, chronic inflammatory diseases. Despite these studies of cortisone’s introduction, few historians have taken the story forward and considered how cortisone was adopted and adapted into clinical practice. This article tells the longer of how the drug and its derivatives were taken from research laboratories and integrated into clinical practice; what has in recent decades become known as translational medicine. In exploring cortisone’s first decade in Britain, we focus specifically on its role in the treatment of RA. Our approach is always to consider cortisone’s use in the context of other treatments available to clinicians, and at local and national institutional settings. We do not discuss the many other therapeutic uses of cortisone, which ranged for topical applications for skin diseases to the management of cancers, especially childhood leukaemia, nor do we discuss its close analogue ACTH—AdenoCorticoTropic Hormone. We think there are lessons in our study for TM policies today. (shrink)

Background Genuine uncertainty on superiority of one intervention over the other is called equipoise. Physician-investigators in randomized controlled trials need equipoise at least in studies with more than minimal risks. Ideally, this equipoise is also present in patient-participants. In pediatrics, data on equipoise are lacking. We hypothesize that 1) lack of equipoise at enrolment among parents may reduce recruitment; 2) lack of equipoise during participation may reduce retention in patients assigned to a less favoured treatment-strategy. Methods We compared preferences of (...) parents/patients at enrolment, documented by a questionnaire, with preferences developed during follow-up by an interview-study to investigate equipoise of child-participants and parents in the BeSt-for-Kids-study. This trial in new-onset Juvenile Idiopathic Arthritis-patients consists of three strategies. One strategy comprises initial treatment with a biological disease-modifying-antirheumatic-drug, currently not standard-of-care. Semi-structured interviews were conducted with 23 parents and 7 patients, median 11 months after enrolment. Results Initially most parents and children were not in equipoise. Parents/patients who refused participation, regularly declined due to specific preferences. Many participating families preferred the biological-first-strategy. They participated to have a chance for this initial treatment, and would even consider stopping trial-participation when not randomized for it. Their conviction of superiority of the biological-first strategy was based on knowledge from internet and close relations. According to four parents, the physician-investigator preferred the biological-first-strategy, but the majority stated that she had no preferred strategy. In phase 2, preferences tended to change to the treatment actually received. Conclusions Lack of equipoise during enrolment did not reduce study recruitment, mainly due to the fact that preferred treatment was only available within the study. Still, when developing a trial it is important to evaluate whether the physicians’ research question is in line with preferences of the patient-group. By exploring so-called ‘informed patient-group’-equipoise, successful recruitment may be enhanced and bias avoided. In our study, lack of equipoise during trial-participation did not reduce retention in those assigned to a less favoured option. We observed a change for preference towards treatment actually received, possibly explained by comparable outcomes in all three arms. (shrink)

ObjectiveLeveraging an integrative multimodal MRI paradigm to elaborate on the hippocampus-derived structural and functional changes in children and adolescents with juvenile idiopathic arthritis and to explore potential correlations within the “joint-inflammation-brain” axis during the period of central neural system development.MethodsTwenty-one patients with JIA all completed the multimodal MRI scanning, laboratory tests, and neuropsychological assessments; meanwhile, 23 matched controls were recruited. We then harnessed the spherical harmonics with a point distribution model and the ROI-to-voxel functional connectivity to measure the hippocampal (...) shape and hippocampo-cortical FC patterns. Correlation analysis was performed to explore the potential links in neuroimaging features with disease-related indices.ResultsCompared to controls, JIA patients only presented an atrophic tendency in the posterior part of the bilateral hippocampus. The hippocampo-cortical FC revealed the between-group divergences mainly located at the pain matrix, striatum, and temporal lobe. Remarkably, the enhanced FC between the right hippocampus and postcentral cortex is positively correlated with the disability index, while the weakened FC of right anterior hippocampus with right insula and that of left posterior hippocampus with left superior temporal gyrus was inversely related to the erythrocyte sedimentation rate and anxiety status, separately.ConclusionAs with macroscopic damages, the altered functional-connectome patterns of the hippocampus in JIA patients might be more sensitive to detect the early neuropathological changes. Moreover, the functional disturbances were demonstrated associated with the physical disability, inflammation, and emotional status. These findings may enlighten us on the underlying neuropathological mechanism of CNS comorbidities in JIA. (shrink)

BackgroundAwareness of aging brings to light one’s own perceived behavioral, physical, and cognitive changes associated with getting older. Personality and physical illness are each related to two components of awareness of aging: attitudes toward own aging, and awareness of age-related changes. Here, we move beyond main effects to examine how personality and arthritis interact with respect to awareness of aging.Materials and Methods296 participants completed online self-report questionnaires of personality, arthritis, ATOA, and AARC gains and losses.ResultsWe ran three hierarchical (...) multiple regression models to test how personality traits and arthritis interacted to predict ATOA, AARC gains, and AARC losses, respectively. Higher extraversion was related to positive ATOA, and higher openness was related to positive ATOA and more AARC gains. Higher neuroticism was related to negative ATOA, more AARC losses, and less AARC gains. We found a main effect for arthritis, where those with arthritis reported more AARC losses. Lastly, we found a significant interaction between arthritis and agreeableness when predicting AARC gains. Among those with low agreeableness, people with arthritis reported significantly more AARC gains compared to those without arthritis.ConclusionPersonality and arthritis are each important for awareness of aging. Overall, our study suggests that for those with arthritis, it is especially important to consider behavioral and cognitive factors related to agreeableness, as they may be important means of promoting positive views on aging. (shrink)

The above-mentioned article has been published online on 7 November 2019 as part of topical collection ‘_Before Translational Medicine: Laboratory Clinic Relations_’.

The above-mentioned article has been published online on 7 November 2019 as part of topical collection ‘Before Translational Medicine: Laboratory Clinic Relations’.

The problem of disease definition is related to theproblem of proving that a certain agent is thenecessary cause of a certain disease. Natural kindterms like ‘rheumatoid arthritis’ and ‘AIDS’ refer toessences which are discoverable rather thanpredeterminate. No statement about such diseases isa priori necessarily true. Because theories onnecessary causes involve natural kind semantics,Koch's postulates cannot be used to falsify or verifysuch theories. Instead of proving that agent A is thenecessary cause of disease D, we include A in atheoretical definition (...) of D, take this to representthe real meaning of ‘D’, and discard thepretheoretical definition. This is illustrated byKoch's own attempt to prove he had discovered thenecessary cause of tuberculosis. Methodologicalarguments about disease causation require a clear viewof our use of diagnostic terms. Medical lexicographersshould do more to provide such a view. (shrink)

In the past decade, the availability of genetically modified animals has enabled the discovery of interesting roles for phosphatidylinositol 3‐kinase‐γ (PI3Kγ) and ‐δ (PI3Kδ) in different cell types orchestrating innate and adaptive immune responses. Therefore, these PI3K isoforms appear to be attractive drug targets for the treatment of diseases caused by unrestrained immune reactions. Currently, pharmacological targeting of PI3Kγ and/or PI3Kδ represents one of the most promising challenges for companies interested in the development of novel safe treatments for inflammatory diseases. (...) In this review we provide a general outline of PI3Kγ‐ and PI3Kδ‐specific functions in distinct subsets of inflammatory cells. We also discuss the therapeutic impact of novel compounds targeting PI3Kγ, PI3Kδ or both, in mouse models of autoimmune disorders (systemic lupus erythematosus (SLE) and rheumatoid arthritis), respiratory diseases (allergic asthma and chronic obstructive pulmonary disease) and cardiovascular dysfunctions (atherosclerosis and myocardial infarction). (shrink)

The provider–patient relationship is typically regarded as an expert-to-novice relationship, and with good reason. Providers have extensive education and experience that have developed in them the competence to treat conditions better and with fewer harms than anyone else. However, some researchers argue that many patients with long-term conditions (LTCs), such as arthritis and chronic pain, have become “experts” at managing their LTC. Unfortunately, there is no generally agreed-upon conception of “patient expertise” or what it implies for the provider–patient relationship. (...) I review three prominent accounts of patient expertise and argue that all face serious objections. I contend, however, that a plausible account of patient expertise is available and that it provides a framework both for further empirical studies and for enhancing the provider–patient relationship. (shrink)

This paper charts the concepts of grip and the bodily auxiliary in Maurice Merleau-Ponty to consider how they find expression in disability narratives. Arguing against the notion of “maximal grip” that some commentators have used to explicate intentionality in Merleau-Ponty, I argue that grip in his texts functions instead as a compensatory effort to stave off uncertainty, lack of mastery, and ambiguity. Nearly without exception in Phenomenology of Perception, the mobilization of “grip” is a signal of impending loss, and is (...) offered as a strategy for managing failure rather than as an example of sure-footed mastery. I read Merleau-Ponty alongside Mary Felstiner's Out of Joint: A Public and Private Story of Arthritis to explore these other, attenuated dimensions of grip. Finally, the paper turns to Harriet McBryde Johnson's memoir Too Late to Die Young as an example of a way of thinking disabled embodiment otherwise. (shrink)

This article presents an archaeological inquiry into the early histories of Quality of Life measures, and takes this as an occasion to rethink the concept of the ‘medical model of disability’. Focusing on three instruments that set the ground for the emergence of QoL measures, namely, the Karnofsky Performance Scale, and the classification of functional capacity as a diagnostic criterion for heart diseases and as a supplementary aid to therapeutic criteria in rheumatoid arthritis – I discuss how medicine, throughout (...) the emergence of QoL, began to expand its gaze beyond the confines of the body to what that body does in daily life. Building upon Armstrong et al.’s notion of ‘distal symptoms’ and Wahlberg’s idea of ‘knowledge of living’, I propose the notion of disabilitization to encapsulate this expansion of the clinical gaze, through which medicine has come to articulate diseases and their treatments in new ways, and in so doing, has inadvertently created disability as a new kind of knowledge category in itself – a category that is defined not through its reduction to mere pathology, but through its dispersal into everyday life. I present this concept not as a periodization, but as a provocative discontinuity with the totalizing history assumed within the medical model of disability, and in so doing, ask what, in fact, holds ‘the medical model’ together, and whether there might be other ways of understanding medicine’s complex relationship to disability than what the concept of the medical model allows us to envisage. (shrink)

This paper charts the concepts of grip and the bodily auxiliary in Maurice Merleau-Ponty to consider how they find expression in disability narratives. Arguing against the notion of “maximal grip” that some commentators have used to explicate intentionality in Merleau-Ponty, I argue that grip in his texts functions instead as a compensatory effort to stave off uncertainty, lack of mastery, and ambiguity. Nearly without exception in Merleau-Ponty’s Phenomenology of Perception, the mobilisation of “grip” is a signal of impending loss and (...) is offered as a strategy for managing failure rather than as an example of sure-footed mastery. I read Merleau-Ponty alongside Mary Felstiner’s Out of Joint: A Public and Private Story of Arthritis to explore these other, attenuated dimensions of grip as an example of a way of thinking disabled embodiment otherwise. (shrink)

Philosophy and science employ abstract hypothetical scenarios- thought experiments - to illustrate, defend, and dispute theoretical claims. Since thought experiments furnish no new empirical observations, the method prompts two epistemological questions: whether anything may be learnt from the merely hypothetical, and, if so, how. Various sceptical arguments against the use of thought experiments in philosophy are discussed and criticized. The thesis that thought experiments in science provide a priori knowledge through non-sensory grasping of abstract entities is discussed and rejected. The (...) thesis that thought experimentation consists in manipulations of mental models is examined and found to be of limited epistemological relevance. It is argued that thought experiments are associated with characteristic arguments in a manner similar to ordinary experiments. It is further argued that thought experiments function in the same way as experiments in general: by providing premises for their associated arguments. Like other experiments, a thought experiment is successful when the premises it provides are true. This holds both for philosophical and scientific thought experiments. An argument schema is proposed and shown to be a formal analogue to that associated with ordinary experiments; similar in being subject to epistemological holism; but differing in being modal: in employing statements about possibility and necessity. The evaluation of thought experiments thus depends on how modal statements may be justified. Intuition and conceivability are discussed as sources of modal justification and found problematic. Instead it is suggested that evaluation proceed by accommodation of the statements describing the experiment's hypothetical scenario. The method of accommodation is developed and applied to five influential thought experiments in philosophy: the brain in a vat; Putnam's Twin Earth; Burge's arthritis example; Searle's Chinese Room; and Newcomb's problem. Its application shows some of these to be failed, others to be successful only relative to controversial philosophical doctrines. (shrink)

Philosophers of language have tended to focus on examples that are not politically significant in any way. We spend a lot of time analyzing natural kind terms: We think hard about “water” and “pain” and “arthritis.” But we don’t think much about the far more politically significant kind terms (natural or social—it's a matter for dispute) like “race,” “sex,” “gender,” “woman,” “man,” “gay,” and “straight.” In this essay, I will try to show, using the example of “woman,” that it's (...) worth thinking about terms like these, for at least three reasons: (1) There are some interesting puzzles. (2) Politically significant terms matter to people's lives— and it's worth spending at least some of our energy thinking about things that matter in this way. (3) Most importantly, interesting methodological issues emerge at the intersection of philosophy of language and politics. (shrink)

Surgical clinical trials have seldom used a “sham” or placebo surgical procedure as a control, owing to ethical concerns. Recently, several ethical commentators have argued that sham surgery is either inherently or presumptively unethical. In this article I contend that these arguments are mistaken, and that there are no sound ethical reasons for an absolute prohibition of sham surgery in clinical trials. Reflecting on three cases of sham surgery, especially on the recently reported results of a sham-controlled trial of arthroscopic (...) surgery for arthritis of the knee, I present an ethical analysis that focuses on the methodological rationale for use of sham surgery, risk-benefit assessment, and informed consent. (shrink)

Surgical clinical trials have seldom used a "sham" or placebo surgical procedure as a control, owing to ethical concerns. Recently, several ethical commentators have argued that sham surgery is either inherently or presumptively unethical. In this article I contend that these arguments are mistaken and that there are no sound ethical reasons for an absolute prohibition of sham surgery in clinical trials. Reflecting on three cases of sham surgery, especially on the recently reported results of a sham-controlled trial of arthroscopic (...) surgery for arthritis of the knee, I present an ethical analysis that focuses on the methodological rationale for use of sham surgery, risk-benefit assessment, and informed consent. (shrink)

Over 1.3 billion people in the world are challenged to access good and cheap healthcare when become ill. Health insurance policies are a fantastic strategy to assist people who can't afford medical care. For middle- and low-income nations, there hasn't been much research on the ability to pay for health insurance for public employees like school teachers. Therefore, this cross-sectional questionnaire based research has been undertaken to explore the reflection of health insurance among 383 Bangladeshi school teachers of 5 divisional (...) city center primary school and were being surveyed online between 1st August to 30th August 2022. According to survey, monthly average (mean) health expenditure of respondents were 7668.93 BDT (Bangladeshi Taka equivalent to $80.72) with 95% confidence interval. Of 35% responders suffered from high blood pressure, approximately 8% people were suffering from arthritis and asthma, 7.8% people have heart disease and 8.1 % people suffer from cholesterol problem. Maximum respondents (80%) agreed that health insurance is burden for them. About 51% teachers had no idea about health insurance. However, there was no significant relation in between educational status and health insurance perception for male and female teacher respondents. Moreover, the comparative data highlighted that more awareness and more exploration might be needed in health insurance perception for primary school teachers. This result can contribute to form people’s choice-oriented health insurance policy. (shrink)

Two types of interleukin 1 (IL‐1α and IL‐1β) have been defined by purifying the molecules from activated human peripheral blood cells, followed by cloning and expressing the molecules in Escherichia coli. Both types of IL‐1 stimulate proliferation and differentiation of T‐ and B‐lymphocytes and induce cartilage proteoglycan degradation but differ in other properties. For example, demineralization and appears to be a major mediator in the pathogenesis of joint erosion in rheumatoid arthritis. Synthetic adjuvants elicit the production of IL‐1 separate (...) from endogenous pyrogen, and this property is required for the new generation of vaccines based on antigens produced by recombinant DNA technology. (shrink)

Dr. M is a fifty-nine-year-old internist with a successful practice in a major Eastern United States city. He has lived in this city his whole life and is a highly esteemed citizen. Because of his broader social concerns and energetic support of activities to improve access to health care and quality of care for the underserved, Dr. M became involved in a number of local and regional medical organizations and quickly rose to prominence as as a director of a board (...) of a major national organization. In this position, he was an effective, articulate spokesperson, highly respected for his integrity and thoughtfulness.Before one of the meetings of thithis s board, Dr. M personally contacted the organization's other directors, including me, to warn us that we might be hearing some scandalous news about him. He wanted us first to hear it from him personally. This was the scandalous news.Dr. M had assumed the care of a patient of a recently retired colleague. The patient was an older woman with multiple musculoskeletal complaints related to lumbar stenosis and advanced degenerative arthritis of the spine, which left her in immense pain. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“We Need to Cut the Neck!”Confronting Psychological and Moral Distress during Emergency Cricothyrotomy1Stephanie CooperEnoughYou didn’t die in the ER, but rather, began your inexorable demise. The last, first, and only words I ever heard you utter was the weak mewl “tight, tight” as the blood pressure cuff constricted your left arm. You were 98–years–old, bed–bound, at the end. Your world was already partitioning itself from us, your brain tunneling (...) down the uneven corridors of consciousness. A concretion of otoliths muffled your hearing, and fatigue burdened your ancient heart.Your name–band encircled your skinny ankle like a bird. Deformed by arthritis, you were caged within yourself, imprisoned by senescence. You could not declare yourself to us. Words disintegrated into moans and your grimace became animal.When you came back from x–ray—hypotensive with multiple neck fractures confirmed—you could speak no more. Your pulse slowed, your blood pressure plummeted. I jammed a gloved finger against your femoral pulse, faint and tired. [End Page E5]“What’s her DNR status?” I gravely asked your nurse.The DNR paperwork for once had arrived with the patient. “No CPR” she said with relief. But then the paperwork went on, forcing me—the waitress of tragedy—to serve up the hash of an impossible menu.As health care providers, we are all often tasked with performing contradictory actions: the pain of IV insertion followed by the morphine push, drilling deeper into broken bone in order to plate it, the inadvertent cracking of ribs during chest compressions. We sometimes must perform violent action in the hope of sustaining and resurrecting life. We are asked to perform the impossible, the contradictory, the painful. And sometimes the actions we must take catalyze an inexorable chain reaction of actions, which can end in death–prolonging and painful interventions that we did not intend.Although our culture may imagine that one can choose one’s meal at the end–of–life fast–food franchise of death, such is not the case. You can’t suddenly decide you’re a vegetarian. You can’t order the cheeseburger without the cheese—and we all are getting the burger, in the end. Ordering the heart–squeezing drugs without the CPR to circulate them, or the antibiotics without the fluid to counter dehydration, is like ordering the burger without the bun. Sometimes the possible choices are not necessarily realistic choices. You get served what you get served, and perhaps we should question the assumption that we have the ability to choose at all.Your DNR form proclaimed no CPR but then said that antibiotics and intubation were okay—the cheeseburger without the cheese. An unfortunate choice for you, me, and the rest of us, as your death menu led to a very unhappy meal.You were comatose. I stuck a tongue blade deep into your desiccated throat. You did not gag. This means I should have intubated you, but morally, I couldn’t. To what end? You were 98 years old, broken, moribund. If you hadn’t suffered multiple neck fractures, or if you were a vibrant elder who had just walked off Mt. Rainier, maybe the story would have been different. But you? I doubted that you truly had a chance of ever feeling joy again. You were somebody’s wife, somebody’s mother. I knew this step would lead to the domino of unstoppable steps. I refused to flog your corpse.I called your daughter Kay on her cell phone, told her that you were in critical condition and that she should come to the ER immediately. But how to begin to tell a daughter her mother is dying, let alone over a cell phone? Gentle but surreal and impersonal, my voice tried to tell your daughter that the interventions you needed would likely kill you. I have seen enough human suffering to know. To me, the choices were clear: death by nature’s irrefutable course, versus a more painful, protracted, and violent death by what we’d do to you.Kay arrived in a wheelchair and scooted up to your bedside. Like all daughters, she wasn’t ready for you... (shrink)

In 2006, Bill Crain was a psychology professor and his wife, Ellen, a pediatrician. They purchased a run-down farm in upstate New York, and two years later opened Safe Haven Farm Sanctuary. It is now home to over 170 animals rescued from slaughter. In Animal Stories, Bill writes about how he and Ellen decided to start the sanctuary and tells the stories of 25 animals and their many surprising behaviors. Read about Katie, a hen who cared for a little partridge; (...) Cesar, a little goat who constantly gets into trouble; Reggie, a rooster who instilled fear in all the staff; Milo, a goat who suddenly charged the dominant Duncan to defend his mother; four rambunctious young turkeys who quietly listened to a reverent Girl Scout ceremony; Ducky, a turkey who, despite severe arthritis, walked from her barn to greet a Buddhist monk; Ethel, an elderly cow who assumes the responsibility of a matriarch; and many others. In addition to enjoying the stories, readers will learn a great deal about nonhuman animals. (shrink)

A certain direction in cognitive science has been to try to “ground” public language statements in some species of mental representation. A central tenet of this trend is that communication – that is, public language – succeeds (when it does) because the elements of this public language are in some way correlated with mental items of both the speaker and the audience so that the mental state evoked in the audience by the use of that piece of public language is (...) the one that the speaker wanted to evoke. The “meaning”, therefore, of an utterance – and of the parts of an utterance, such as individual sentences and their parts, the individual words, etc. – is, in this view, some mental item. Successful communication requires that there be widespread agreement amongst speakers of the same public language as to the mental entities that are correlated with any particular public words. Such a view of meaning is variously called “internalist” or “cognitive” or “subjectivist” or “solipsistic” or (sometimes) “representationalist” (these terms having, however, further connotations which set them apart from one another in other ways), and can be found in a wide variety of writers who do not agree on many other things. It is opposed to views that take the meaning of an utterance to be an item of “reality,” however defined. In different writers this latter view is called “externalist” or “objectivist” or “realist” or (sometimes) “represent-ationalist,” always with the idea that there is something other (or at least, more) than the mental state of speakers and hearers that determines meaning. The literature is rife with arguments between internalists vs. externalists, subjectivists vs. objectivists, cognitivists vs. realists, on such topics as “truth” and “synonymy” and “twin earth” and “arthritis” (to mention only a few).. (shrink)

We are living through a demographic transition from a world in which there were lots of young people and very few older adults to one in which the numbers in these age groups are becoming more evenly balanced. One reason for this is that more of us are living into our seventies, eighties, nineties, and beyond. That is the good news. Unfortunately, the chance of developing chronic illnesses (including diabetes, arthritis, and dementia) is typically higher for people in these (...) older age groups than for those who are younger. Because we do not know how to cure these illnesses, many of us will spend at least some of this extra time with one or more chronic illness. While we are more likely than in the past to live into older age, we are likely to be living with illness when we get there. That raises a challenge: how should we respond to this change? (shrink)

The year 2020 is facing one of the worst public health situations in decades. The world is experiencing a pandemic that has triggered significant challenges to healthcare systems in both high and low‐middle income countries (LMICs). Government policymakers and healthcare personnel are experiencing real‐life ethical dilemmas and are pressed to respond to these situations. Many possible treatments are being investigated, one of which is the use of hydroxychloroquine or chloroquine. These drugs are approved for use by patients with systemic lupus (...) erythematosus (SLE), rheumatoid arthritis, and malaria. The demand for these products has increased, and the stocks are depleting for the patient population for whom the drugs are intended initially. Although both innovator and generic pharmaceutical manufacturers are making plans for increased production, there are challenges with global supply chains disruption and the retention of supplies for local markets. This may cause countries that rely on the importation of pharmaceuticals to be out of stock of supplies for an extended period. There are allegations of off‐label prescribing and hoarding. Pharmacists are the custodians and dispensers of medications and are faced with the task of assessing prescriptions and making decisions about the allocation of these products. This paper seeks to 1) highlight some of the ethical challenges of dispensing hydroxychloroquine by pharmacists during the COVID‐19 pandemic, 2) identify some of the responses to these issues from various regulatory authorities in the USA, and 3) recommend approaches to assist pharmacists in their decision‐making process, especially in LMICs. (shrink)

Ageing causes progressive decline in metabolic, behavioural, and physiological functions, leading to a reduced health span. The extracellular matrix (ECM) is the three‐dimensional network of macromolecules that provides our tissues with structure and biomechanical resilience. Imbalance between damage and repair/regeneration causes the ECM to undergo structural deterioration with age, contributing to age‐associated pathology. The ECM ‘Ageing Across the Life Course’ interdisciplinary research network (ECMage) was established to bring together researchers in the United Kingdom, and internationally, working on the emerging field (...) of ECM ageing. Here we report on a consultation at a joint meeting of ECMage and the Medical Research Council / Versus Arthritis Centre for Integrated Research into Musculoskeletal Ageing, held in January 2023, in which delegates analysed the key questions and research opportunities in the field of ECM ageing. We examine fundamental biological questions, enabling technologies, systems of study and emerging in vitro and in silico models, alongside consideration of the broader challenges facing the field. (shrink)

Tyler Burge has argued that an incorrect understanding of a word can be sufficient for possessing the concept the word literally expresses. His well-known 'arthritis' case involves a patient who understands 'arthritis' incorrectly, but who nevertheless, according to Burge, possesses the concept arthritis. Critics of Burge have objected that there is an alternative concept that best matches the patient's understanding and that this, therefore, is the patient's concept. The paper first argues that Burge's response to this objection (...) is unconvincing. A better response is then developed. It is argued that there is no alternative concept that matches the incorrect understanding, since the patient thinks he has a partial understanding. This, together with points about ordinary psychological explanation and modes of presentations of concepts, establish that it is impossible to undermine Burge's social externalism by appealing to the idea that an alternative concept matches the incorrect understanding. (shrink)

Semantic externalism is the view that the meanings of referring terms, and the contents of beliefs that are expressed by those terms, are not fully determined by factors internal to the speaker but are instead bound up with the environment. The debate about semantic externalism is one of the most important but difficult topics in philosophy of mind and language, and has consequences for our understanding of the role of social institutions and the physical environment in constituting language and the (...) mind. In this long-needed book, Jesper Kallestrup provides an invaluable map of the problem. Beginning with a thorough introduction to the theories of descriptivism and referentialism and the work of Frege and Kripke, Kallestrup moves on to analyse Putnam’s Twin Earth argument, Burge’s arthritis argument and Davidson’s Swampman argument. He also discusses how semantic externalism is at the heart of important topics such as indexical thoughts, epistemological skepticism, self-knowledge, and mental causation. Including chapter summaries, a glossary of terms, and an annotated guide to further reading, _Semantic Externalism_ an ideal guide for students studying philosophy of language and philosophy of mind. (shrink)

Brandom (Citation1994) made inferentialism an intensely debated idea in the philosophy of language in the last three decades. Inferentialism is a view that associates the meaning of linguistic expression with the role said expression plays in inferences. It seems rather uncontroversial that the correct theory of meaning should distinguish between linguistic correctness and factual correctness. For instance, speaker S can be wrong in saying ‘I have arthritis’ in two distinct ways: (i) S fails to apply a word correctly to (...) make a true statement due to having made a factual error, and (ii) S uses an expression incorrectly because they are wrong about its meaning. In this paper, I show that properly understood normative inferentialism can make room for such a distinction. I propose that linguistic correctness is a structural issue: linguistic mistakes stem from the improper or insufficient acquisition of an inferential role. Factual correctness, on the other hand, is a one-off issue of the correct application of inferential rules to a particular situation. I argue that, by tying the issue of correctness to the game of giving and asking for reasons, inferentialism can establish a reliable method for distinguishing between two types of correctness (and mistakes). (shrink)

Following the announcement in 1949 in the USA that cortisone offered rheumatoid arthritis sufferers effective treatment for their crippling disease, the Ministry of Health came under considerable pressure from the medical profession and the public to make cortisone available in Britain. The Ministry, therefore, urged British companies to start manufacturing cortisone. Among the several pharmaceutical firms responding to the Ministry’s request, Glaxo’s expertise in the field of vitamins gave them a head start. This paper describes the varied and flexible (...) strategy that enabled Glaxo to maintain this head start, and the scientific and technical capabilities which the company subsequently built up, enabling them to dominate the market for corticosteroids in Britain.Among the drugs to emerge out of the Glaxo project to manufacture cortisone, which began in 1950 and later became a wider R&D programme on steroids, was the topical steroid Betnovate, launched in 1963, which remains a best-seller today. However, although it led to successful new products, Glaxo’s programme had limitations. The paper identifies a missed opportunity, in the shape of the biosynthetic route to steroid drugs, often considered as a milestone in the development of the new biotechnology. Whether or not this missed opportunity proved costly to the company is uncertain. However, it illustrates the role of technological path-dependence, and the importance of the integration between different scientific disciplines, in this case chemistry and biology, in pharmaceutical innovation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My Patient, TeacherMarissa BlumI remember meeting Beatriz about 12 years ago when security was called to her office visit room by the fellow doctor-in-training who was seeing her. She was yelling loudly about her pain medications, causing a terrific commotion. I stepped in to relieve the fellow and tried to calm her down and move the visit along without anyone getting hurt or further upset. And from then on, (...) Beatriz was moved to my schedule from the fellow's for her monthly visits for her knee pain and refills of fentanyl and oxycodone. She had terrible knees and walked with a cane, almost always accompanied by her son. At one point, she came to our clinic asking to be seen but couldn't, and then fell onto her knees and rolled onto her back in the wait-room, clutching and waiving her cane, expelling expletives and railing at anyone who wanted to help but denying them that privilege. It was as though she relished exposing her pain and a lifetime of hardship for all to confront. I came down from my office to talk with her and when I couldn't convince her to get up on her own, we called EMS to assist and they took her away in an ambulance.For the first few years, I recoiled seeing her name on my schedule each month. I knew I would have to endure a barrage of labile emotions and complaints not just about her constant pain and feelings of inadequacy of her pain medications, but also about her other doctors and how they don't respond to her, or about how the rest of her family shows no care for her. Initially, these visits were hard because they were unpredictable and Beatriz also had bipolar disorder and maybe borderline personality too. I never knew which type of Beatriz I would walk in to see: Angry, tearful, lamentful, and all of those faces were difficult for me. But we met every month for years. During those visits, which almost always were attended by her son, who quietly sat by to either gently rebuff or passively agree with her, I learned so much about her and her very hard life. She was left to raise two children alone, unskilled and ill with hepatitis C, which led to liver cancer, followed later by breast cancer. She chose not to pursue additional therapy for breast cancer, expressing a fatalistic view of her life and intimating she in some way deserved the ailments that she developed. She saw me for disabling knee and hip arthritis that took away her independence and ability to scale the outdoor steps to her second-floor apartment and required the assistance of her son to dress, bathe and care for her. Beatriz never knew this, and I didn't share [End Page 18] it with her, but on one of my early morning drives into North Philadelphia, I saw her on a sun-baked unfriendly street, struggling to move around with her walker. She had many reasons to be angry, and the 30 minutes I spent with her every month became a catharsis for her to unload all that she felt.During my medical training, I encountered hundreds of patients—mostly all in the hospital setting—who might be characterized as difficult and understandably; no one who is relegated to the hospital setting, acutely or chronically ill and requiring inpatient care, could possibly be in the best mood of their lives. Somehow, it was easier for me to care for patients in these snapshot encounters that I controlled. I dictated my time in the room and didn't necessarily have to encounter the same challenging patient longitudinally, which made certain encounters much easier to bear. I realize now I wasn't fully processing the burdens carried by these patients in a way that enabled me to be a compassionate and fully present physician to them. It was an adaptation to the fast-paced life of residency, where one just has to get the job done and move on to the next task without time to process or reflect on difficult patient interactions. This is a... (shrink)