Ways of going on:An analysis of skill applied to medical practice

Humans do two types of actions, polimorphic actions and mimeomorphic actions. The ability to carry out polimorphic actions cannot be mastered outside of socialization. Mimeomorphic actions, however, can be learned in other ways; sometimes, they can be learned away from the context of practice. Polimorphic actions cannot be mimicked by machines, but some mimeomorphic actions can. Other mimeomorphic actions are too complex to mechanize. Actions that cannot be mechanized because they are physically complicated should not be confused with actions that cannot be mechanized because socialization is needed to master them. The analysis has implications for recent debates concerning the differences and similarities between humans and machines. The implica tion of the analysis is that much more can be understood about the relationship between humans and machines if the difference is treated as being a consequence of the unique properties of human societies. In this article, the analysis is applied to cardiac catheteriza tion, pacemaker implantation, simulation of bodies, and work in a medical "SkillsLab.

p53 overexpression is a predictor of local recurrence after treatment for both in situ and invasive ductal carcinoma of the breast

Background. Several biological markers have been related to prognosis in mammary ductal carcinoma. The aim of the study was to determine biological markers that could predict local recurrence following treatment for all stages of primary operable ductal carcinoma of the breast. Materials and methods. A consecutive series of patients treated for pure ductal carcinoma in situ (DCIS, n = 110) and invasive ductal carcinoma (IDC, n = 243) was studied. Twenty-three patients with DCIS were excluded because of lack of original paraffin embedded tissue. All patients had been treated between July 1996 and December 2001. Median follow-up was 49.8 mo. From the original paraffin embedded tumors, tissue microarrays (TMAs) were constructed. On these TMAs, immunohistochemistry was performed for estrogen-receptor (ER), progesterone-receptor (PR), Her2/neu, p53, and cyclin D1. Main outcome was the event of LR. All analyses were stratified for diagnosis (DCIS or IDC) and pathological grade. Results. In univariate analyses, Her2/neu overexpression (hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.1-8.7, P = 0.032) and p53 overexpression (HR 3.5, 95% Cl 1.3-9.3, P = 0.014) were associated with LR in patients treated for both DCIS and IDC. In multivariate analysis, p53 overexpression (HR 3.0, 95% CI 1.1-8.2, P = 0.036 and HR 4.4,95% Cl 1.5-12.9, P = 0.008) and adjuvant radiotherapy (HR 0.2, 95% Cl 0.1-0.8, P = 0.026) were independent common predictors of LR in patients who had received treatment for both DCIS and IDC. Conclusions. p53 overexpression is a common predictor of LR following treatment for all stages of primary operable ductal carcinoma of the breast. This marker may help in planning optimal treatment and follow-up. (C) 2007 Elsevier Inc. All rights reserved

Cooperative spontaneous emission in nonuniform media

The subject of this paper is modification of cooperative spontaneous emission by a nonuniform medium, with nonuniform distributions of electromagnetic field. A brief analyzis is presented and it is postulated, that if spontaneous emission from an atom is strongly suppressed, cooperative emission with another atom may be a preferred emission channel and counteract the suppression.Comment: The final publication is available at http://www.epj.or

Important differences between quality of life and health status in elderly patients suffering from critical limb ischemia

Introduction Critical limb ischemia (CLI) patients are often of advanced age with reduced health status (HS) and quality of life (QoL) at baseline. Physical health is considered as the most affected domain due to reduced mobility and ischemic pain. QoL and HS are often used interchangeably in the current literature. HS refers to objectively perceived physical, psychological, and social functioning and in assessing QoL, change is measured subjectively and can only be determined by the individual since it concerns patients' evaluation of their functioning. It is important to distinguish between QoL and HS, especially in the concept of shared decision-making when the opinion of the patient is key. Goal of this study was to examine and compare QoL and HS in elderly CLI patients in relation to the used therapy, with a special interest in conservatively treated patients. Methods Patients suffering from CLI and ≥70 years old were included in a prospective study with a follow-up period of 1 year. Patients were divided into three groups; endovascular revascularization, surgical revascularization, and conservative therapy. The WHOQoL-Bref was used to determine QoL, and the 12-Item Short Form Health Survey was used to evaluate HS at baseline, 5-7 days, 6 weeks, 6 months, and 1 year. Results Physical QoL of endovascularly and surgically treated patients showed immediate significant improvement during follow-up in contrast to delayed increased physical HS at 6 weeks and 6 months (P<0.001). Conservatively treated patients showed significantly improved physical QoL at 6 and 12 months (P=0.02) in contrast to no significant improvement in physical HS. Conclusion This study demonstrates that QoL and HS are indeed not identical concepts and that differentiating between these two concepts could influence the choice of treatment in elderly CLI patients. Discriminating between QoL and HS is, therefore, of major importance for clinical practice, especially to achieve shared decision-making

Gebiedsgericht inzicht in effecten van landbouwmaatregelen op emissies van stikstof en fosfor

Met gebruik van gedetailleerde bodem- en bemestingsgegevens uit agrarische meetnetten en een integraal nutriëntenmodel is het mogelijk om gebiedsgericht inzicht te geven in de bodemkwaliteit én de landbouwkundige emissies van stikstof en fosfor naar het watersysteem

Trends and geographic variation in adverse impacts of nitrogen use in Europe on human health, climate, and ecosystems: A review

This paper presents a review of the trends and geographic variation of impacts of reactive nitrogen (N) inputs on in Europe through impacts on air, soil and water quality. It illustrates those impacts, by assessing temporal and spatial variation in air, soil and water quality indicators and their exceedances of critical thresholds in view of impacts on human health, terrestrial and aquatic ecosystems, during 1990-2019. Trends are derived from regular inventory and monitoring data and from simulated trends in air quality using the EMEP model. Well quantified adverse impacts of increased N use are: (i) the effects on human health due to increased tropospheric concentrations of NOx and ozone, and N-induced increases in fine particulate matter, (ii) the contribution of N2O to climate change and stratospheric ozone depletion, (iii) the loss of plant and faunal diversity both in terrestrial and aquatic ecosystems via direct and soil mediated impacts, (iv) the acidification of forest soils, with impacts on tree forest nutrition, tree growth and tree vitality, and (v) the eutrophication of marine ecosystems, and associated biodiversity loss and occurrence of harmful algae blooms. Over the period 1990-2019, N inputs to agriculture stayed relatively constant, but the emissions of ammonia (NH3) decreased by 27%, while emissions of nitrogen oxides (NOx) decreased by 57%. In response to those reductions, concentrations of NOx, and of N in particulate matter also declined, although less than 50%. In contrast, the reduction in NOx-induced ozone concentrations and ozone related indicators (AOT40, SOMO35 and POD) was much less (ca 15-20%). Exceedances of critical ozone concentrations for human health and of critical AOT40 and POD vales for vegetation reduced in a similar order of magnitude. Despite decreasing NH3 emissions, NH3 concentrations showed a slight and steady increase from 1995 onwards, due to the large reduction in SOx emissions. Nitrogen deposition and exceedances of critical N loads for terrestrial ecosystems decreased by ca 60%, but the area exceeding critical N loads only reduced by ca 10%. Unlike N, the area exceeding critical acid loads has declined by more than 90% due to high reduction in SOx and NOx emissions. Trends in nitrate (NO3) concentrations in groundwater varied across Europe, but showed overall limited changes over the last two decades. However, N concentrations in surface water and the area exceeding critical levels in view of aquatic biodiversity has decreased and the same holds for N concentrations in coastal regions. Nevertheless, the eutrophication condition of coastal waters has overall not improved due to adverse impacts of elevated phosphorus inputs. Finally the negative impacts of N induced N2O emissions on climate are estimated to be outweighed by the positive effects of N induced CO2 sequestration, mainly in forests, and this holds for the whole period 1990-2019. Nitrogen hotspots, being areas with high exceedances in critical levels and loads of N compounds in air and water, are concentrated in intensive agricultural areas with high livestock densities and in urban region with strong industrial and traffic activities. Cost-benefit analysis shows that environmental costs of reactive N release to the environment are substantial and tend to exceed the direct economic benefits for agriculture. Given the relevance of N for safeguarding food production it is key to develop integrated and targeted plant nutrition strategies following a food system approach and practices that minimize trade-offs between productivity and the environment. In addition, targeted strategies to further reduce NOx emissions are needed to reduce air quality related health and biodiversity impacts