Standard Answer Research Articles

Clinical Trial Data Sharing for COVID-19-Related Research.

This paper aims to provide a perspective on data sharing practices in the context of the COVID-19 pandemic. The scientific community has made several important inroads in the fight against COVID-19, and there are over 2500 clinical trials registered globally. Within the context of the rapidly changing pandemic, we are seeing a large number of trials conducted without results being made available. It is likely that a plethora of trials have stopped early, not for statistical reasons but due to lack of feasibility. Trials stopped early for feasibility are, by definition, statistically underpowered and thereby prone to inconclusive findings. Statistical power is not necessarily linear with the total sample size, and even small reductions in patient numbers or events can have a substantial impact on the research outcomes. Given the profusion of clinical trials investigating identical or similar treatments across different geographical and clinical contexts, one must also consider that the likelihood of a substantial number of false-positive and false-negative trials, emerging with the increasing overall number of trials, adds to public perceptions of uncertainty. This issue is complicated further by the evolving nature of the pandemic, wherein baseline assumptions on control group risk factors used to develop sample size calculations are far more challenging than those in the case of well-documented diseases. The standard answer to these challenges during nonpandemic settings is to assess each trial for statistical power and risk-of-bias and then pool the reported aggregated results using meta-analytic approaches. This solution simply will not suffice for COVID-19. Even with random-effects meta-analysis models, it will be difficult to adjust for the heterogeneity of different trials with aggregated reported data alone, especially given the absence of common data standards and outcome measures. To date, several groups have proposed structures and partnerships for data sharing. As COVID-19 has forced reconsideration of policies, processes, and interests, this is the time to advance scientific cooperation and shift the clinical research enterprise toward a data-sharing culture to maximize our response in the service of public health.

Validity and reliability of the South African Triage Scale in prehospital providers

BackgroundThe South African Triage Scale (SATS) is a validated in-hospital triage tool that has been innovatively adopted for use in the prehospital setting by Western Cape Government (WCG) Emergency Medical Services (EMS) in South Africa. The performance of SATS by EMS providers has not been formally assessed. The study sought to assess the validity and reliability of SATS when used by WCG EMS prehospital providers for single-patient triage.MethodsThis is a prospective, assessment-based validation study among WCG EMS providers from March to September 2017 in Cape Town, South Africa. Participants completed an assessment containing 50 clinical vignettes by calculating the three components — triage early warning score (TEWS), discriminators (pre-defined clinical conditions), and a final SATS triage color. Responses were scored against gold standard answers. Validity was assessed by calculating over- and under-triage rates compared to gold standard. Inter-rater reliability was assessed by calculating agreement among EMS providers’ responses.ResultsA total of 102 EMS providers completed the assessment. The final SATS triage color was accurately determined in 56.5%, under-triaged in 29.5%, and over-triaged in 13.1% of vignette responses. TEWS was calculated correctly in 42.6% of vignettes, under-calculated in 45.0% and over-calculated in 10.9%. Discriminators were correctly identified in only 58.8% of vignettes. There was substantial inter-rater and gold standard agreement for both the TEWS component and final SATS color, but there was lower inter-rater agreement for clinical discriminators.ConclusionThis is the first assessment of SATS as used by EMS providers for prehospital triage. We found that SATS generally under-performed as a triage tool, mainly due to the clinical discriminators. We found good inter-rater reliability, but poor validity. The under-triage rate of 30% was higher than previous reports from the in-hospital setting. The over-triage rate of 13% was acceptable. Further clinically-based and qualitative studies are needed.Trial registrationNot applicable.

The method of observing the student’s behavior in the educational environment

This paper aims to highlight the efficiency of using the method of observing student behavior in the educational environment. Observation is one of the most widely used research methods in the social sciences. The characteristics aimed at constructing the instrument were: accuracy, focus, duration of observation, awareness of the presence of the observer, the level of information of the subject. In order to observe the student’s behavior in the school environment, the observation grid with standardized answers was designed on the Likert scale (scale from 1 to 10), following the degree of expression of the described behavioral manifestations. The observation grid of the student’s behavior in the school environment aims at supervising 4 dimensions (each with 5 items: observable behaviors): interest in school activities, organization of activity / punctuality in the school environment, resistance to intellectual effort, socio-affective relationships. Following the application of the research tool, depending on the scores obtained, it is recommended the targeted psycho-pedagogical intervention at the level of the deficient dimension / behaviors, as well as the monitoring of the results through the periodic application.

Consideraciones sobre Dios para nuestro tiempo

Este artículo nos presenta en cinco tópicos algunas consideraciones en el estilo de desafíos para hablar de Dios en nuestro contexto actual. La tensión entre fidelidad al mensaje y escucha de las nuevas exigencias del tiempo es una preocupación que atraviesa todo el artículo. El objetivo es advertir acerca de algunos aspectos a los que debemos prestar atención en nuestros lenguajes y métodos de abordaje. Los lenguajes y los métodos condicionan las conclusiones, por lo que el camino que recorramos, aunque creativo, puede arribar a puertos ya estandarizados. En este sentido, aunque nuestro equipaje sea clásico, si nos animamos a recorrer nuevos espacios, es probable que advirtamos desafíos inéditos. A su vez, dialoga con algunos momentos destacados del magisterio de Francisco, quien expresa su preocupación por una fosilización ideológica, funcional y clerical del mensaje evangélico. Los cinco puntos se inician con el desafío por confesar la fidelidad de un Dios, aparentemente, esquivo y distante. Continúa con el planteo de la verdad desde las dos tentaciones que han atravesado la cuestión: entenderla como sólida, inmóvil y acabada, o abordarla como un dinamismo dionisiaco e inaferrable y etéreo. El tercer momento es el ingreso en la cuestión de la verdad de Dios como aquel que existe en comunión y se revela a la humanidad como quien persevera en su presencia. Este misterio de presencia y comunión abre a la tratativa de la cuestión de la persona y la diferencia en Dios como fundamento también del diálogo y la tolerancia. Finalmente, y como olvido de estas dinámicas, se advierte sobre la siempre actual lógica de la idolatría.

Automatic scoring of Chinese fill-in-the-blank questions based on improved P-means

Chinese fill-in-the-blank questions contain both objective and subjective characteristics, and thus it has always been difficult to score them automatically. In this paper, fill-in-the-blank items are divided into those with word-level or sentence-level granularity; then, the items are automatically scored by different strategies. The automatic scoring framework combines semantic dictionary matching and semantic similarity calculations. First, fill-in-the-blank items with word-level granularity are divided into two types of test sites: the subject term test site, and the common word test site. We propose an algorithm for identifying an item’s test site. Then, a subject term dictionary with self-feedback learning ability is constructed to support the scoring of subject term test sites. The Tongyici Cilin semantic dictionary is used for scoring common word test sites. For fill-in-the-blank items with sentence-level granularity, an improved P-means model is used to generate a sentence vector of the standard answer and the examinee’s answer, and then the semantic similarity between the two answers is obtained by calculating the cosine distance of the sentence vector. Experimental results on actual test data show that the proposed algorithm has a maximum accuracy of 94.3% and achieves good results.

Design and implementation of electronic health record common data elements for pediatric epilepsy: Foundations for a learning health care system.

Common data elements (CDEs) are standardized questions and answer choices that allow aggregation, analysis, and comparison of observations from multiple sources. Clinical CDEs are foundational for learning health care systems, a data-driven approach to health care focused on continuous improvement of outcomes. We aimed to create clinical CDEs for pediatric epilepsy. A multiple stakeholder group (clinicians, researchers, parents, caregivers, advocates, and electronic health record [EHR] vendors) developed clinical CDEs for routine care of children with epilepsy. Initial drafts drew from clinical epilepsy note templates, CDEs created for clinical research, items in existing registries, consensus documents and guidelines, quality metrics, and outcomes needed for demonstration projects. The CDEs were refined through discussion and field testing. We describe the development process, rationale for CDE selection, findings from piloting, and the CDEs themselves. We also describe early implementation, including experience with EHR systems and compatibility with the International League Against Epilepsy classification of seizure types. Common data elements were drafted in August 2017 and finalized in January 2020. Prioritized outcomes included seizure control, seizure freedom, American Academy of Neurology quality measures, presence of common comorbidities, and quality of life. The CDEs were piloted at 224 visits at 10 centers. The final CDEs included 36 questions in nine sections (number of questions): diagnosis (1), seizure frequency (9), quality of life (2), epilepsy history (6), etiology (8), comorbidities (2), treatment (2), process measures (5), and longitudinal history notes (1). Seizures are categorized as generalized tonic-clonic (regardless of onset), motor, nonmotor, and epileptic spasms. Focality is collected as epilepsy type rather than seizure type. Seizure frequency is measured in nine levels (all used during piloting). The CDEs were implemented in three vendor systems. Early clinical adoption included 1294 encounters at one center. We created, piloted, refined, finalized, and implemented a novel set of clinical CDEs for pediatric epilepsy.

EFFICIENCY OF NATIVE LANGUAGE EDUCATION IN THE TRANSCARPATHIA BASED ON A REPEATED QUESTIONNAIRE SURVEY (2008–2018)

During our research, we wish to find out whether the native language education reform of 2005 brought any positive changes in teaching the common language norm in the Hungarian schools in Transcarpathia. The research conducted last year (20 schools, 280 students) proved that additional native language education has a spectacular result: young people have a far more positive, objective attitude towards non-common language versions. By all means it is also worth to know whether any such changes can be discovered concerning the use of language phenomena observed with the help of the three task types. Based on an earlier survey it was proven that changes can actually be observed concerning the opinion about lan- guage dialects since the Hungarian language curriculum of 2005 became effective. This change is clearly positive. Students showed benevolence concerning language dialects, dialect speakers in far larger proportion than earlier. And it is not only present in the field of numbers. Their explained opinion also shows a more objective, rational view. Whether we look at the approach to, perspectives of the concept of language dialects, or the reasoning of their answers based on emotional attitude (e.g. Would you feel sorry if dialects died out?). It is clearly an efficient change compared to the earlier data that while in the course of the previous survey the situation of the minorities, borrowed elements were not mentioned concerning the local language variants (or if they were, then in a negative context). These changes are clearly due to the additive attitude and the secondary school textbooks prepared in this view.Such clear changes cannot be observed concerning tasks about common language norm awareness. Small differences can be seen concerning a few phenomena in the percentage of standard answers: in the case of using -nák, the future tense of the predicate kell. Studying the adverb of place suffix -nál/-nél used instead of -hoz/-hez/-höz and -tól/-től in a comparative function only shows an increase in percentage in the case of sentence correction tasks. This indicates that in the past 10 years representatives of the studies age group became somewhat more aware.The changed attitude that can be found in the Hungarian language curriculum in Transcarpathia and in the Hungarian language textbooks is by no means favorable for this positive change.

The Standard Story of Action and the Problem of Agential Guidance

The problem of agential guidance consists in explaining the possibility of guiding an action in purely reductive causal terms. After examining Harry Frankfurt’s articulation of this problem, the standard systemic reductive causal answer is explored and found wanting. Two general explanatory challenges are singled out as decisive in assessing the viability of a causal answer to the problem of agential guidance: first, the correct identification of the actual sources of action guidance in the form of guiding intentions, and, second, the recognition of the limitations of a content-based strategy to identify an action under guidance.

Auswirkungen der COVID-19-Pandemie auf die klinische Versorgung, Arbeitsprozesse und Mitarbeitenden in der Universitätsmedizin: Ergebnisse einer Interviewstudie am UKE

Zusammenfassung Ziel der Studie Die Studie beschreibt die Auswirkungen der COVID-19-Pandemie mit Blick auf Bereiche mit und ohne spezifische Versorgung von COVID-19-Patientinnen und -Patienten aus Sicht der Klinikdirektorinnen und -direktoren am Universitätsklinikum Hamburg-Eppendorf (UKE). Methodik Im Zeitraum vom 30. April bis 12. Mai 2020 wurden mit den im UKE verantwortlichen Klinikdirektorinnen und -direktoren Interviews per Telefon, Video bzw. face-to-face mithilfe eines teilstandardisierten Fragebogens durchgeführt. Die standardisierten Antworten wurden deskriptiv analysiert. Freitextantworten wurden einer qualitativen Inhaltsanalyse unterzogen. Die entwickelten Kategorien wurden quantitativ nach Häufigkeiten analysiert. Ergebnisse Alle leitenden Ärztinnen und Ärzte mit einer Verantwortung für die stationäre und ambulante Versorgung am UKE konnten für die Interviewstudie gewonnen werden (N=38). Diese berichten von gravierenden Veränderungen in der medizinischen Versorgung, v. a. im Bereich der Bettenbelegung, der Patientenzusammensetzung, den klinischen und Arbeitsprozessen sowie den diagnostischen und Behandlungsprozessen. Zusätzlich mussten viele neue Regelungen getroffen werden, um den Präventions-, Behandlungs- und Nachsorgebedarf von Patientinnen und Patienten sowie den Schutz der Mitarbeitenden zu gewährleisten. In den meisten klinischen Bereichen zeigte sich stationär wie ambulant phasenweise eine starke Reduktion in den Belegungszahlen und der Arbeitsauslastung. Teilweise stiegen aber auch Arbeitsaufwände, z. B. durch die Anpassung von Arbeitsabläufen, veränderte Kommunikations- und Personalstrukturen sowie zusätzliche Hygienemaßnahmen. Viele Befragte äußerten sich positiv über den effizienten Aufbau einer digitalen Kommunikationsstruktur. Das Personal war durch die Pandemie an sich, aber auch durch die damit verbundenen Maßnahmen vielseitig gefordert. Schlussfolgerung Die Ergebnisse helfen, die Auswirkungen der aktuellen COVID-19-Pandemie auf die Versorgung und Arbeitsprozesse besser zu verstehen. Zudem können sie dabei unterstützen, zukünftig Maßnahmen für pandemische Krisensituationen noch besser anzupassen. Weitere Studien könnten untersuchen, wie die Mitarbeitenden unterhalb der Leitungsebene diese Krise und ihre Auswirkungen erlebt haben.

It’s All About the Prep: Improving Colonoscopy Bowel Preparation through Patient Instructions

Colonoscopy is the most effective modality to detect and prevent colorectal cancer. The quality of bowel preparation is an important quality indicator for colonoscopy. An adequate bowel preparation requires the patient’s compliance with the preparation instructions. Currently, patients receive a copy of the instructions including the phone number of the on-call GI fellow who answers calls after hours. We aim to improve patient education and compliance with bowel preparation, as well as to educate the GI fellows on commonly used preparations and to provide standardized answers to questions frequently asked by patients. We hope to improve the overall quality of bowel preparation of our patients undergoing colonoscopy. We documented all of the patient phone calls received by the on-call GI fellows for 3 months including the questions asked by the patients, answers provided by the fellows and the quality of the preparation. We then designed a "Frequently Asked Questions and Answers" page based on the questions received to add to the bowel preparation instructions distributed to the patients. We also designed a short course for the GI fellows to review and discuss bowel preparations. We plan to document patient phone calls after the above interventions to determine if the frequency or the quality of phone calls have changed, as well as the quality of the bowel preparation. We are using data from GIQuIC to measure the overall quality of bowel preparation before and after the intervention. A total of 47 phone calls by 43 patients were received from October 10 to December 20, 2018. Out of the 47 phone calls, 38 (81%) of them can be categorized into one of the following 3 groups: no bowel movements after taking bowel preparation (18 calls), frequent bowel movements hoping to not have to complete the preparation (14 calls), or nausea/vomiting after taking the preparation (6 calls). Out of the 47 phone calls, 22 (47%) of them occurred between the hours of 10pm and 6am. After the phone calls, 9 (21%) patients cancelled their colonoscopy appointment, and 2 patients (4%) underwent scheduled virtual colonography. Out of the 32 patients (74%) who underwent their scheduled colonoscopy, the quality of their preparation was reported as excellent to good for 27 patients (84%), adequate for 1 patient (3%), fair for 2 patients (6%), and poor for 2 patients (6%). Based on GIQuIC data, 723 out 816 (88.6%) reported colonoscopies in our institution had adequate bowel preparation from October to December 2018. Patients often have similar questions regarding their bowel preparation. By providing easily accessible answers to these frequently asked questions, we hope to improve compliance and ultimately improve the overall quality of bowel preparation for scheduled colonoscopies.

Responsibility and appropriate blame: The no difference view

AbstractHow do the fact that an agent is morally responsible for a certain morally objectionable action and the fact that she is an appropriate target of blame for it relate to each other? Many authors inspired by Peter Strawson say that they necessarily co‐occur. Standard answers to the question of why they co‐occur say that the occurrence of one of the facts explains that the other obtains. This article presents a third option: that they are one and the same fact. There is no difference between the fact that a person is an appropriate target of blame for an objectionable action and the fact that she is morally responsible for it. This view has the advantage of being metaphysically more parsimonious and of answering, in an elegant and plausible way, an interesting question about which many standard theories of responsibility keep silent: what is it to be morally responsible simpliciter?

The politics of being a queer leader during the Ferguson uprising

The politics of being a queer leader during the Ferguson uprising

Structural Decompositions of Epistemic Logic Programs

Epistemic logic programs (ELPs) are a popular generalization of standard Answer Set Programming (ASP) providing means for reasoning over answer sets within the language. This richer formalism comes at the price of higher computational complexity reaching up to the fourth level of the polynomial hierarchy. However, in contrast to standard ASP, dedicated investigations towards tractability have not been undertaken yet. In this paper, we give first results in this direction and show that central ELP problems can be solved in linear time for ELPs exhibiting structural properties in terms of bounded treewidth. We also provide a full dynamic programming algorithm that adheres to these bounds. Finally, we show that applying treewidth to a novel dependency structure—given in terms of epistemic literals—allows to bound the number of ASP solver calls in typical ELP solving procedures.

Certainty in Action

Abstract When is it permissible to rely on a proposition in practical reasoning? Standard answers to this question face serious challenges. This paper uses these challenges to motivate a certainty norm of practical reasoning. This norm holds that one is permitted to rely on p in practical reasoning if and only if p is epistemically certain. After developing and defending this norm, I consider its broader implications. Taking a certainty norm seriously calls into question traditional assumptions about the importance of belief and knowledge. In particular, it raises the possibility that many epistemological jobs that are usually assigned to belief and knowledge should be reallocated to two related but importantly different states: psychological and epistemic certainty.

Peer Review Tool for General Radiography Technologists Improves Image Quality.

Quality improvement is vital to ensure health-care providers meet optimal patient care standards. Within our jurisdiction, accreditation requires image peer review as part of the quality assurance program. We propose a method to improve quality assurance in radiography by implementing a novel software-based peer review system for radiography technologists. This is a retrospective study. A peer review tool was developed in Microsoft Excel and Visual Basic. The tool has 14 image quality criteria, which were selected based on national and international criteria, each containing standardized answers ensuring a common scoring regime. The tool provides data analysis and storage of all peer reviews performed. Radiography supervisors utilized the tool to evaluate image quality of various body parts at 28 hospitals. The tool enabled each Medical Imaging Department to objectively score images at their own hospital. Approximately 2% of all radiographs were randomly chosen for peer review. Additionally, the tool allowed for regional analysis based on hospital, body part, and quality criterion. Initial findings exposed equipment-related issues such as worn imaging plates, artifacts, and poor exposures, which prompted increased preventative maintenance. Other documented issues included foreign objects, inadequate collimation and centering, and inconsistent usage of lead markers. After identifying quality assurance-related issues, hospitals implemented education, resulting in improved overall image quality scores in subsequent audits. The peer review tool helped identify and correct various issues affecting image quality and ensures our program meets required accreditation standards. Furthermore, staff found utilizing the tool to identify areas for improvement improved collaboration, ongoing education, and support between staff.

The norms of authorship credit: Challenging the definition of authorship in The European Code of Conduct for Research Integrity

ABSTRACTThe practice of assigning authorship for a scientific publication tends to raise two normative questions: 1) “who should be credited as an author?”; 2) “who should not be credited as an author but should still be acknowledged?”. With the publication of the revised version of The European Code of Conduct for Research Integrity (ECCRI), standard answers to these questions have been called into question. This article examines the ways in which the ECCRI approaches these two questions and compares these approaches to standard definitions of “authorship” and “acknowledgment” in guidelines issued by the International Committee of Medical Journal Editors (ICMJE) and the World Association of Medical Editors (WAME). In light of two scenarios and the problems posed by these kinds of “real-world” examples, we recommend specific revisions to the content of the ECCRI in order not only to provide a more detailed account of the tasks deserving of acknowledgment, but to improve the Code’s current definition of authorship.

The ratio of C2–C7 Cobb angle to T1 slope is an effective parameter for the selection of posterior surgical approach for patients with multisegmental cervical spondylotic myelopathy

BackgroundTo our knowledge, laminectomy with fusion (LCF) and laminoplasty alone (LP) are both effective posterior surgical approaches for decompression of cervical spondylotic myelopathy (CSM). However, which one is suitable for patients has no standard answer. This study estimated whether the ratio of C2–C7 Cobb angle to T1 slope (CL/T1S) could be an indication of posterior surgical approach. MethodsWe retrospectively reviewed 128 patients with at least 6 months of follow-up who underwent LCF or LP. Radiological measurements, including C2–C7 Cobb angle, decompressed Cobb angle, T1 slope, cervical sagittal vertical axis, and curvature index (CI), and clinical outcomes, including Japanese Orthopedic Association score and visual analogue scale were evaluated. ROC curve analysis was used to identify discriminative power of CL/T1S ratio to predict kyphotic deformity and severe lordosis loss. The t-test and Mann–Whitney U-test were used to evaluate the difference between LCF and LP. Kruskal–Wallis H – test and ANOVA were used to evaluate the difference among different ratio CL/T1S groups. ResultsThe cervical lordosis decreased after LCF or LP (p < 0.001, p < 0.001, respectively). Based on ROC curve analysis, CL/T1S ratio had a good discriminative power to predict kyphotic deformity and severe lordosis loss (AUC = 0.70, AUC = 0.88, respectively). According to CI value changes, cervical lordosis losses in group LP were larger than that in group LCF (p = 0.006). However, there was no significant difference in CI changes of fair-ratio CL/T1S group between LCF and LP. For patients with low CL/T1S ratio or high CL/T1S ratio, CI changes in group LP were greater than that in group LCF (p = 0.037, p = 0.042, respectively). ConclusionsCL/T1S ratio could be an indication of posterior surgical approach. Compared with LP, LCF reduces postoperative cervical lordosis losses in low-ratio and high-ratio CL/T1S groups.

Examining sociocultural factors in assessing vocabulary knowledge of children from low socio-economic background

ABSTRACT The purpose of this evaluation study was twofold: to evaluate the overall impact of an intensive early childhood literacy project on children’s vocabulary knowledge and to examine the sociocultural context of the vocabulary assessment for the early literacy project. Children’s language development and vocabulary knowledge was measured with PPVT-IV and TOPEL at two time points. Significant gains were found in children’s print knowledge, but no significant difference was found with the definitional vocabulary and phonological awareness. Deductive content analysis was conducted to examine the sociocultural context of the standardized vocabulary test showing discrepancy between children’s responses and standard answers. Results from the current study provide helpful information for researchers to pay closer attention to the cultural and social context beyond the validity and reliability of a standardized assessment.

Multi-feature recognition of English text based on machine learning

At present, the recognition method based on character segmentation is not effective in recognizing English text, and the traditional methods are based on the structural features and statistical characteristics of strokes. In order to improve the recognition effect of in English text, from the perspective of machine learning, this study introduces multi-features to improve the lack of information caused by the small Chinese data set. Moreover, this study disassembles the character recognition problem into a text matching problem of question and answer, and the textual entailment problem of answer and standard answer and continues training on the data set of short text score. The final result has a certain improvement, which proves the usability of the mechanism designed in this paper. In order to study the performance of the model proposed in this paper, the model proposed in this paper and the neural network recognition model are compared in terms of recognition accuracy and recognition speed. The research results show that the algorithm proposed in this paper has a certain effect.

Echad: A D’var Torah on Parshat Vaetchanan

This talk explores two mysteries about the Shema, the great motto of Judaism, which begins “Shema Yisrael, Adonai Eloheinu, Adonai Echad.” The first mystery is familiar. What does it mean to say “Adonai Echad”, which literally means something like “God One”? The most familiar translation of the phrase is “God is one,” thus understanding it as a declaration of monotheistic belief. But this customary interpretation is both trivial and misleading. Some Biblical scholars translate the phrase as “God alone” so that it is a vow of loyalty to only one God. Or it might mean “God is unique.” Jewish mystics have taken “Adonai Echad” to be a token of the Unity between God and the universe. Or, as I suggest, Echad might be one of the names of God, a descriptive name to be sure, but not merely a description. The second mystery is why the first paragraph of the Shema is the piece of scripture inscribed in mezuzot and included (along with other passages) in tefillin. The standard answer is that these are the very passages that describe the commandments of mezuzot and tefillin. But we’re so used to this that we might not realize how odd it is. These are instructions about how to remember and memorialize God’s commandments. And we claim to obey those instructions by reciting and inscribing and packaging the instructions. In some sense, the Shema is like a Quine, a self-replicating computer program, or like an Escher staircase that goes up and up and lands on itself. It is an infinite regress. The talk tries to connect these two mysteries of the Shema to each other, and then to the commandments to love God and love our neighbors as ourselves.