Boskoop en Bollenstreek. Hoe innig is de samenwerking

In het kader van de streekplanherziening Zuid-Holland Oost is in opdracht van de provincie Zuid-Holland onderzoek gedaan naar de autonome ontwikkeling van het boomteeltcomplex Boskoop en de interacties met het bloembollencomplex 'De Bollenstreek'. Om het belang van het boomteeltcomplex binnen het sierteeltcomplex Zuid-Holland te duiden zijn ook de interacties met de bloemisterij in kaart gebracht. De interacties tussen Boskoop en de Bollenstreek blijven beperkt tot een gecombineerde afzet van bloembollen en een beperkt assortiment boomteeltproducten, met name vaste planten. Mede door het groeiende belang van de bloemenveilingen in de afzet van boomteeltproducten en de toenemende vraag naar visueel aantrekkelijke boomteeltproducten is de interactie tussen Boskoop en het bloemisterijcomplex Zuid-Holland veel sterker. Vanwege de aanwezigheid van een groot assortiment aan boomteeltproducten, de beschikbaarheid van veel kennis en vakmanschap, korte transportlijnen naar de veilingen en de centrale ligging heeft Boskoop een belangrijke meerwaarde binnen het sierteeltcomplex Zuid-Holland

SOILS Ammonium and Nitrate Nitrogen in Soil Profiles of Long-Term Winter Wheat Fertilization Experiments

ABSTRACT Accumulation of NH~ -N and NO3 -N in soils has not been thor. oughly evaluated in long-term continuous winter wheat (Triticum aes. tivum L.) production systems. The objectives of this study were to determine long-term response of winter wheat to N fertilization and to evaluate accumulation of NH~ -N and NO3 -N in the soil profile. Four long-term winter wheat soil fertility experiments on thermic Ustoll soils that received annual applications of N for > 18 yr at selected N rates were sampled. At each location, one soil core 4.4 cm in diameter was taken to a depth of 240 cm from plots receiving variable N rates. Cores were separated into 30-cm increments and analyzed for 2 M KCI-extractable NH~ -N and NO~-N. At all locations, NH~ -N levels were not significantly different from the check (no fertilizer N) when rates were applied at or below yield goal requirements (90 or45 kg N ha -~ vs. 0 N). At N rates >90 kg N ha -~, surface (0-15 cm) NH~ -N increased compared with the check, while subsurface NH~ -N did not. Similarly, when N rates were <90 kg N ha -~, no significant differences in either surface or subsurface NO 3 -N were found. At N rates >90 kg N ha -1, NO5 -N accumulated in the subsurface soil profile (>30 cm). Estimates of N rates determined from simultaneous solutions of NO5 -N accumulation minimums and yield maximums generated from quadratic regression were greater than N rates currently recommended to achieve yield goals at all locations. For these long-term continuous winter wheat experiments, no accumulation of NH~ -N and NO5 -N occurred at recommended N rates where near maximum yields were obtained. p AST AND PRESENT use of N fertilizers for winter wheat production has been related to the potential for NOA--N contamination of surface and subsurface water. Although N fertilizers are essential for economic grain production, long-term N accumulation as a result of excessive N rates has not been monitored closely. Work by Liang et al. (1991) found that residual soil NO~--N did not increase in the soil profile (0-60 cm) over a 4-yr period when comparing N rates of 170 and 400 kg ha -1 applied to corn. MacDonald et al. (1989) indicated that following harvest, unfertilized wheat plots had inorganic N contents equal to those where 234 kg N ha -1 had been applied. This work further suggested that almost all of the NO~--N at risk to leaching over the winter period comes from mineralization of organic N and not from unused fertilizer applied in the spring; therefore, even a drastic reduction in N fertilizer use would have little effect on NO~--N leaching. Lamb et al. (1985) reported that the addition of N fertilizer increased the amount of NO~-N accumulated but did not change the accumulation pattern. Tillage system (no-till, stubble mulch, and plow) did not affect the time at which the NOA--N started to accumulate during the fallow period nor the rate of accumulation (Lamb et al., 1985). Sharpley al. (1991) reported no evidence of N accumulation the soil profile (0--180 cm) after 5 yr for either no-till or reduced-till cultural practices with N fertilizer applied to sorghum at recommended rates (0--146 kg ha-1 yr-1), although annual total N in surface runoff . was 0.76 kg N ha -1 for no-till, 0.99 kg N ha -1 for reduced-till, and 7.28 kg N ha -1 for conventional till. Smika (1990) reported that time must be allowed for the equilibration of soil conditions before evaluating NO~--N accumulation, citing research that showed less NO~--N accumulation to 120 cm for reduced-till methods compared with conventional tillage for short-term studies, but more NO~--N accumulation for reducedtill methods in long-term studies. Tracy et al. (1990) noted that tillage method (conventional, no-till) did not affect NO~--N accumulation below 5 cm; differences in NO~--N in the topsoil were attributed to organic matter incorporation over 16 yr of winter wheat farming. Varvel and Peterson (1990) reported that high N application rates (180 kg N ha-1) resulted in greater residual soil NO~--N to 150 cm for continuous corn and grain sorghum systems than for other cropping systems. This same study found that all systems had similar NO~--N accumulation at lower N application rates. Work by Liang et al. (1991) found that under irrigation, 100 kg NOA--N ha -~ was lost from the rooting zone (0-60 cm) during four growing seasons, with the majority coming from the surface 40 cm. The effects of N fertilizer rate (90 and 180 kg ha -x) and nitrification inhibitors on urea lSN leaching and balance on a irrigated sandy loam were summarized by Waiters and Malzer (1990). The higher N application rate resulted in 3.4 times more N leached over a 3-yr period (206 vs. 88 kg ha -1 to 1.2 m depth). Nitrification inhibitors delayed N losses, but did not decrease the total N lost. Westerman and Tucker (1979) noted that the presence of organic residue can lower denitrification by increased immobilization of inorganic or mineralized N. Immobilization was thus considered to be an N conserving process competing with denitrification for nitrate. Nitrate studies in field microplots showed that 17% of applied 15N (120 kg N ha -~ equivalent) was still in the 45-cm soil profile after 1 yr (Kowalenko, 1989). Webster et al. (1986) evaluated the movement (92 and 102 kg NHnNO 3 ha -~) in clay and sandy loam field microplots and found that < 1% of the fertilizer was leached beyond 130 cm in the first winter following application. Response of wheat grain yields to N fertilization has been documented in numerous soil fertility experiments. However, very few of these experiments have included evaluation for more than 3 to 5 yr that also accounted for accumulation of NOA--N and NH~--N within the soil profile. The objectives of this study were to determine the long-term response of 9

Treatment sequences and drug costs from diagnosis to death in multiple myeloma

Novel therapies for multiple myeloma (MM) have improved patient survival, but their high costs strain healthcare budgets. End-of-life phases of treatment are generally the most expensive, however, these high costs may be less justifiable in the context of a less pronounced clinical benefit. To manage drug expenses effectively, detailed information on end-of-life drug administration and costs are crucial. In this retrospective study, we analysed treatment sequences and drug costs from 96 MM patients in the Netherlands who died between January 2017 and July 2019. Patients received up to 16 lines of therapy (median overall survival: 56.5 months), with average lifetime costs of €209 871 (€3111/month; range: €3942–€776 185) for anti-MM drugs. About 85% of patients received anti-MM treatment in the last 3 months before death, incurring costs of €20 761 (range: €70–€50 122; 10% of total). Half of the patients received anti-MM treatment in the last 14 days, mainly fully oral regimens (66%). End-of-life treatment costs are substantial despite limited survival benefits. The use of expensive treatment options is expected to increase costs further. These data serve as a reference point for future cost studies, and further research is needed to identify factors predicting the efficacy and clinical benefit of continuing end-of-life therapy.</p

Peer assessment of outpatient consultation letters – feasibility and satisfaction

<p>Abstract</p> <p>Background</p> <p>Written correspondence is one of the most important forms of communication between health care providers, yet there is little feedback provided to specialists. The objective of this study was to determine the feasibility and satisfaction of a peer assessment program on consultation letters and to determine inter-rater reliability between family physicians and specialists.</p> <p>Methods</p> <p>A rating scale of nine 5-point Likert scale items including specific content, style items, education value of the letter and an overall rating was developed from a previous validated tool.</p> <p>Nine Internal Medicine specialists/subspecialists from two tertiary care centres submitted 10 letters with patient and physician identifiers removed. Two Internal Medicine specialists, and 2 family physicians from the other centre rated each letter (to protect writer anonymity). A satisfaction survey was sent to each writer and rater after collation of the results. A follow-up survey was sent 6–8 months later.</p> <p>Results</p> <p>There was a high degree of satisfaction with the process and feedback. The rating scale information was felt to be useful and appropriate for evaluating the quality of consultation letters by 6/7 writers. 5/7 seven writers felt that the feedback they received resulted in immediate changes to their letters. Six months later, 6/9 writers indicated they had maintained changes in their letters.</p> <p>Raters rank ordered letters similarly (Cronbach's alpha 0.57–0.84) but mean scores were highly variant. At site 1 there were significant differences in scoring brevity (p < 0.01) between family physician and specialist raters; whereas, at site 2 there were differences in scoring of history (p < 0.01), physical examination (p < 0.01) and educational value (p < 0.01) of the letter.</p> <p>Conclusion</p> <p>Most participants found peer assessment of letters feasible and beneficial and longstanding changes occurred in some individuals. Family physicians and specialists appear to have different expectations on some items. Further studies on reliability and validity, with a larger sample, are required before high stakes professional assessments include consultation letters.</p

GEM: Scalable and flexible gene-environment interaction analysis in millions of samples

MOTIVATION: Gene-environment interaction (GEI) studies are a general framework that can be used to identify genetic variants that modify the effects of environmental, physiological, lifestyle or treatment effects on complex traits. Moreover, accounting for GEIs can enhance our understanding of the genetic architecture of complex diseases and traits. However, commonly used statistical software programs for GEI studies are either not applicable to testing certain types of GEI hypotheses or have not been optimized for use in large samples. RESULTS: Here, we develop a new software program, GEM (Gene-Environment interaction analysis in Millions of samples), which supports the inclusion of multiple GEI terms, adjustment for GEI covariates and robust inference, while allowing multi-threading to reduce computation time. GEM can conduct GEI tests as well as joint tests of genetic main and interaction effects for both continuous and binary phenotypes. Through simulations, we demonstrate that GEM scales to millions of samples while addressing limitations of existing software programs. We additionally conduct a gene-sex interaction analysis on waist-hip ratio in 352 768 unrelated individuals from the UK Biobank, identifying 24 novel loci in the joint test that have not previously been reported in combined or sex-specific analyses. Our results demonstrate that GEM can facilitate the next generation of large-scale GEI studies and help advance our understanding of the genetic architecture of complex diseases and traits. AVAILABILITY AND IMPLEMENTATION: GEM is freely available as an open source project at https://github.com/large-scale-gxe-methods/GEM. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online

Applying a User-centred Approach to Interactive Visualization Design

Analysing users in their context of work and finding out how and why they use different information resources is essential to provide interactive visualisation systems that match their goals and needs. Designers should actively involve the intended users throughout the whole process. This chapter presents a user-centered approach for the design of interactive visualisation systems. We describe three phases of the iterative visualisation design process: the early envisioning phase, the global specification hase, and the detailed specification phase. The whole design cycle is repeated until some criterion of success is reached. We discuss different techniques for the analysis of users, their tasks and domain. Subsequently, the design of prototypes and evaluation methods in visualisation practice are presented. Finally, we discuss the practical challenges in design and evaluation of collaborative visualisation environments. Our own case studies and those of others are used throughout the whole chapter to illustrate various approaches

“It’s hard to tell”. The challenges of scoring patients on standardised outcome measures by multidisciplinary teams: a case study of Neurorehabilitation

Background Interest is increasing in the application of standardised outcome measures in clinical practice. Measures designed for use in research may not be sufficiently precise to be used in monitoring individual patients. However, little is known about how clinicians and in particular, multidisciplinary teams, score patients using these measures. This paper explores the challenges faced by multidisciplinary teams in allocating scores on standardised outcome measures in clinical practice. Methods Qualitative case study of an inpatient neurorehabilitation team who routinely collected standardised outcome measures on their patients. Data were collected using non participant observation, fieldnotes and tape recordings of 16 multidisciplinary team meetings during which the measures were recited and scored. Eleven clinicians from a range of different professions were also interviewed. Data were analysed used grounded theory techniques. Results We identified a number of instances where scoring the patient was 'problematic'. In 'problematic' scoring, the scores were uncertain and subject to revision and adjustment. They sometimes required negotiation to agree on a shared understanding of concepts to be measured and the guidelines for scoring. Several factors gave rise to this problematic scoring. Team members' knowledge about patients' problems changed over time so that initial scores had to be revised or dismissed, creating an impression of deterioration when none had occurred. Patients had complex problems which could not easily be distinguished from each other and patients themselves varied in their ability to perform tasks over time and across different settings. Team members from different professions worked with patients in different ways and had different perspectives on patients' problems. This was particularly an issue in the scoring of concepts such as anxiety, depression, orientation, social integration and cognitive problems. Conclusion From a psychometric perspective these problems would raise questions about the validity, reliability and responsiveness of the scores. However, from a clinical perspective, such characteristics are an inherent part of clinical judgement and reasoning. It is important to highlight the challenges faced by multidisciplinary teams in scoring patients on standardised outcome measures but it would be unwarranted to conclude that such challenges imply that these measures should not be used in clinical practice for decision making about individual patients. However, our findings do raise some concerns about the use of such measures for performance management

Exploring Large Digital Library Collections Using a Map-Based Visualisation

In this paper we describe a novel approach for exploring large document collections using a map-based visualisation. We use hierarchically structured semantic concepts that are attached to the documents to create a visualisation of the semantic space that resembles a Google Map. The approach is novel in that we exploit the hierarchical structure to enable the approach to scale to large document collections and to create a map where the higher levels of spatial abstraction have semantic meaning. An informal evaluation is carried out to gather subjective feedback from users. Overall results are positive with users finding the visualisation enticing and easy to use

The do's, don't and don't knows of supporting transition to more independent practice

Introduction: Transitions are traditionally viewed as challenging for clinicians. Throughout medical career pathways, clinicians need to successfully navigate successive transitions as they become progressively more independent practitioners. In these guidelines, we aim to synthesize the evidence from the literature to provide guidance for supporting clinicians in their development of independence, and highlight areas for further research. Methods: Drawing upon D3 method guidance, four key themes universal to medical career transitions and progressive independence were identified by all authors through discussion and consensus from our own experience and expertise: workplace learning, independence and responsibility, mentoring and coaching, and patient perspectives. A scoping review of the literature was conducted using Medline database searches in addition to the authors’ personal archives and reference snowballing searches. Results: 387 articles were identified and screened. 210 were excluded as not relevant to medical transitions (50 at title screen; 160 at abstract screen). 177 full-text articles were assessed for eligibility; a further 107 were rejected (97 did not include career transitions in their study design; 10 were review articles; the primary references of these were screened for inclusion). 70 articles were included of which 60 provided extractable data for the final qualitative synthesis. Across the four key themes, seven do’s, two don’ts and seven don’t knows were identified, and the strength of evidence was graded for each of these recommendations. Conclusion: The two strongest messages arising from current literature are first, transitions should not be viewed as one moment in time: career trajectories are a continuum with valuable opportunities for personal and professional development throughout. Second, learning needs to be embedded in practice and learners provided with authentic and meaningful learning opportunities. In this paper, we propose evidence-based guidelines aimed at facilitating such transitions through the fostering of progressive independence