Successful Surgical Treatment of a Patient with a Solitary Asymptomatic Cardiac Metastasis from Breast Cancer, Identified by Elevated Tumor Markers and Circulating Tumor Cells

Indroduction: Cardiac metastases are a not infrequent autopsy finding in patients dying of metastatic cancer, but are less commonly diagnosed during life (1). Although the autopsy incidence of cardiac metastases ranges may be as high as 25%, solitary cardiac metastases in the absence of metastatic involvement of other organs are rare (2).Case Presentation: We report here the case of a 66-year old woman with a history of bilateral breast cancer, where a solitary metastasis in the right atrium was successfully resected.Conclusion: In the absence of any symptoms or clinical findings on physical examination, the presence of metastatic disease was first suggested by the detection of elevated tumor markers and circulating tumor cells during routine follow up after treatment for early stage breast cancer.

PLoS One

Introduction Patient-centered care (PCC) is an approach to involve patients in health care delivery, to contribute to quality of care, and to strengthen health systems responsiveness. This article aims to highlight patient perspectives by showcasing their perceptions of their experience of PCC at primary health facilities in two districts in Uganda. Methods A mixed methods cross-sectional study was conducted in three public and two private primary health care facilities in rural eastern Uganda. In total, 300 patient exit survey questionnaires, 31 semi-structured Interviews (SSIs), 5 Focus Group Discussions (FGDs) and 5 feedback meetings were conducted. Data analysis was guided by a conceptual framework focusing on (1) understanding patients’ health needs, preferences and expectations, (2) describing patients perceptions of their care experience according to five distinct PCC dimensions, and (3) reporting patient reported outcomes and their recommendations on how to improve quality of care. Results Patient expectations were shaped by their access to the facility, costs incurred and perceived quality of care. Patients using public facilities reported doing so because of their proximity (78.3% in public PHCs versus 23.3% in private PHCs) and because of the free services availed. On the other hand, patients attending private facilities did so because of their perception of better quality of care (84.2% in private PHCs versus 21.7% in public PHCs). Patients expectations of quality care were expressed as the availability of medication, shorter waiting times, flexible facility opening hours and courteous health workers. Analysis of the 300 responses from patients interviewed on their perception of the care they received, pointed to higher normalized scores for two out of the five PCC dimensions considered: namely, exploration of the patient’s health and illness experience, and the quality of the relationship between patient and health worker (range 62.1–78.4 out of 100). The qualitative analysis indicated that patients felt that communication with health workers was enhanced where there was trust and in case of positive past experiences. Patients however felt uncomfortable discussing psychological or family matters with health workers and found it difficult to make decisions when they did not fully understand the care provided. In terms of outcomes, our findings suggest that patient enablement was more sensitive than patient satisfaction in measuring the effect of interpersonal patient experience on patient reported outcomes. Discussion and conclusion Our findings show that Ugandan patients have some understanding of PCC related concepts and express a demand for it. The results offer a starting point for small scale PCC interventions. However, we need to be cognizant of the challenges PCC implementation faces in resource constrained settings. Patients’ expectations in terms of quality health care are still largely driven by biomedical and technical aspects. In addition, patients are largely unaware of their right to participate in the evaluation of health care. To mitigate these challenges, targeted health education focusing on patients’ responsibilities and patient’s rights are essential. Last but not least, all stakeholders must be involved in developing and validating methods to measure PCC

Field Quality Measurements in a Single-Aperture 11 T Nb3Sn Demonstrator Dipole for LHC Upgrades

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SO₂ emission rates and incorporation into the air pollution dispersion forecast during the 2021 eruption of Fagradalsfjall, Iceland

During the low-effusion rate Fagradalsfjall eruption (19 March – 18 September 2021), the emission of sulfur dioxide (SO₂) was frequently measured using ground-based UV spectrometers. The total SO₂ emitted during the entire eruption was 970 ± 540 kt, which is only about 6% of the SO₂ emitted during the similar length Holuhraun eruption (2014–2015). The eruption was divided into five phases based on visual observations, including the number of active vents and the occurrence of lava fountaining. The SO₂ emission rate ranged from 44 ± 19 kg/s in Phase 2 to 85 ± 29 kg/s in Phase 5, with an average of 64 ± 34 kg/s for the entire eruption. There was notable variability in SO₂ on short timescales, with measurements on 11 August 2021 ranging from 17 to 78 kg/s. SO₂ flux measurements were made using scanning DOAS instruments located at different distances from and orientations relative to the eruption site augmented by traverses. Four hundred and forty-four scan and traverse measurements met quality criteria and were used, along with plume height and meteorological data, to calculate SO₂ fluxes while accounting for wind-related uncertainties. A tendency for stronger SO₂ flux concurrent with higher amplitude seismic tremor and the occurrence of lava fountaining was observed during Phases 4 and 5 which were characterized by intermittent crater activity including observable effusion of lava and gas release interspersed with long repose times. This tendency was used to refine the calculation of the amount of SO₂ emitted during variably vigorous activity. The continuous seismic tremor time series was used to quantify how long during these eruption phases strong/weak activity was exhibited to improve the calculated SO₂ flux during these Phases. The total SO₂ emissions derived from field measurements align closely with results obtained by combining melt inclusion and groundmass glass analyses with lava effusion rate measurements (910 ± 230 kt SO₂). Specifically, utilizing the maximum S content found in evolved melt inclusions and the least remaining S content in accompanying quenched groundmasses provides an identical result between field measurements and the petrological calculations. This suggests that the maximum SO₂ release calculated from petrological estimates should be preferentially used to initialize gas dispersion models for basaltic eruptions when other measurements are lacking. During the eruption, the CALPUFF dispersion model was used to forecast ground-level exposure to SO₂. The SO₂ emission rates measured by DOAS were used as input for the dispersion model, with updates made when a significant change was measured. A detailed analysis of one mid-distance station over the entire eruption shows that the model performed very well at predicting the presence of volcanic SO₂ when it was measured. However, it frequently predicted the presence of SO₂ that was not measured and the concentrations forecasted had no correlation with the concentrations measured. Various approaches to improve the model forecast were tested, including updating plume height and SO₂ flux source terms based on measurements. These approaches did not unambiguously improve the model performance but suggest that improvements might be achieved in more-polluted conditions

The Socio-Economic Value of Natural Riverbanks in the Netherlands

Ecologists and economists both use a different approach to determine the value of nature. Its ecological value can be measured using criteria like rarity and diversity of species in an ecosystem. The economic value can be determined using non-market valuation techniques. This paper focuses on an empirical application of the Contingent Valuation Method (CVM) to find out whether this valuation method is a suitable method to estimate the economic value of natural riverbanks in the Netherlands. Natural riverbanks will provide habitat for species that particularly depend on the land water transit area. Since common riverbanks do not provide this habitat, natural river banks increase biodiversity in the Netherlands. On the basis of technical and ecological characteristics nine different types of natural riverbanks were distinguished. For each type a laymen description was made. This description served as a basis for economic valuation by means of CVM. The results of the CVM study shows that the average willingness to pay for non-use of a natural riverbank varied between 16 and 25 Dutch guilders per household year. The willingness to pay for recreational use ranged from 1,07 to 2,50 guilders per visit. The generated outcomes proved to be consistent with results from other studies. At first sight, the economic value of natural riverbanks seemed to be higher than their construction and maintenance cost

Effecten ontwerp Klimaatakkoord.

FdR – Publicaties niet-programma gebonde

On Coalition Formation with Heterogeneous Agents

We propose a framework to analyze coalition formation with heterogeneous agents. Existing literature defines stability conditions that do not ensure that, once an agent decides to sign an agreement, the enlarged coalition is feasible. Defining the concepts of refraction and exchanging, we set up conditions of existence and enlargement of a coalition with heterogeneous agents. We use the concept of exchanging agents to give necessary conditions for internal stability and show that refraction is a sufficient condition for the failure of an enlargement of the coalition. With heterogeneous agents we can get a situation where a group of members of an unstable coalition does not deviate, neither within the coalition nor within the extended coalition. Hence, the possibilities of agreement are richer than in the standard analysis with homogeneous agents. Examples of industrial economics are used for illustration, and an application to climate change negotiations is discussed in more detail

A Climate-Change Policy Induced Shift from Innovations in Energy Production to Energy Savings

We develop an endogenous growth model with capital, labor and energy as production factors and three productivity variables that measure accumulated innovations for energy production, energy savings, and neutral growth. All markets are complete and perfect, except for research, for which we assume that the marginal social value exceeds marginal costs by factor four. The model constants are calibrated so that the model reproduces the relevant trends over the 1970-2000 period. The model contains a simple climate module, and is used to assess the impact of Induced Technological Change (ITC) for a policy that aims at a maximum level of atmospheric CO2 concentration (450 ppmv). ITC is shown to reduce the required carbon tax by about a factor 2, and to reduce costs of such a policy by about factor 10. Numerical simulations show that knowledge accumulation shifts from energy production to energy saving technology