This paper presents the first type system for statically analyzing security protocols that are based on zero-knowledge proofs. We show how certain properties offered by zero-knowledge proofs can be characterized in terms of authorization policies and statically enforced by a type system. The analysis is modular and compositional, and provides security proofs for an unbounded number of protocol executions. We develop a new type-checker that conducts the analysis in a fully automated manner. We exemplify the applicability of our technique to real-world protocols by verifying the authenticity and secrecy properties of the Direct Anonymous Attestation (DAA) protocol. The analysis of DAA takes less than three seconds.
Pulmonary vein (PV) isolation can be performed at different levels in the ostium. Initially, segmental isolation, targeting individual strands of atrial myocardial tissue in PV ostia, was performed using the combination of a circular mapping catheter and a standard ablation catheter.1 In most centres, clinical success rates were moderate. Soon, however, it was recognized that wider encircling improved success and reduced complications.2 Additional ablation lines and substrate modification may further increase success, but may also create a substrate for left atrial flutters.3–5 The creation of a long continuous ablation line around a PV antrum using a single ablation electrode is technically challenging. Kistler et al. described a prospective randomized study to investigate the contribution of image integration to catheter ablation of atrial fibrillation.6 The value of Cartomerge® was investigated on the basis of an incomplete Carto map. It is highly remarkable that even then, image integration did not affect the quality of the procedure. The study suggests that an anatomically correct geometry does not facilitate the creation of continuous transmural lesions. Such geometry definitively helps to outline the desired course of the ablation lines, but apparently it does not improve the continuity of that line. Use it if you like it, but don't expect any miracles. The ablation procedure was performed using an irrigated ablation electrode to create the long ablation lines around both pairs of PV ostia.6 Wall contact during ablation, precise catheter manipulation, and the delivery of sufficient radiofrequency (RF) power are the most important determinants of successful electrical isolation. While irrigated catheters are highly advisable to reduce the risk of blood clot formation during RF ablation, electrode cooling greatly eliminates the electrode temperature increase as feedback for tissue contact. This may have been the reason for the investigators using a remarkable irrigation protocol: the flow rate was maintained at 2 mL/min unless the 50°C target temperature was reached with <20 W. One should remember that a flow rate of 2 mL/min may only be sufficient to keep the irrigation holes open, not to prevent blood clot formation on the heated tissue surface.7 Even with standard non-irrigated electrodes, detection of wall contact and lesion formation on the basis of electrode temperature response remains difficult. A high electrode temperature increase at low power may be caused not only by intimate electrode–tissue contact, but also by low blood flow. Local electrogram characteristics and amplitude, impedance drop during ablation, fluoroscopic imaging, and intracardiac echocardiography (ICE) are alternative ways to judge wall contact, but they all have important limitations or add significant complexity. A combination of these methods and 3D mapping systems are used in most labs, but even then, multiple acute gaps in the lines are more the rule than the exception. Moreover, a large number of patients experience a recurrence after a first procedure because of resumed conduction through the antrum lines despite the fact that the observation time after isolation often is lengthened by additional ablations.8 Persistent continuity of ablation lines should be our main goal for future developments. A 30 W/50°C setting was originally used for segmental PV isolation where myocardial sleeves may be relatively thin. To prevent collateral damage, one should always try to limit RF power, but with low power it may sometimes be very difficult to achieve complete electrical isolation of the PV antrum that includes sections with thicker myocardium and the appendix ridge where catheter stability is a major challenge.9 Kistler et al. used an electrogram amplitude <0.1 mV or amplitude reduction >80% as endpoint during ablation.10 Reduction of the local unipolar electrogram clearly is an indicator for lesion formation. Often, however, electrograms <0.1 mV still can be found inside the PV ostia and some of these can be proven to be true local activations. Conversely, an electrogram >0.1 mV within PVs can be a remote signal from the bulk of the left or right atrium, left atrial appendage, or superior caval vein. The latter signals, very misleadingly, sometimes also show decremental properties with atrial extrastimuli. Consequently, a simple amplitude criterion is not sufficient to declare PVs electrically silent. If the goal is complete electrical isolation then one should meticulously investigate the origin of all electrograms distal from the ablation line and continue the search for leaks until all local signals have disappeared. Adenosine may reveal latent leaks, but mapping of those leaks can be very difficult.11 Kistler et al. speculate that image fusion in NavX could result in more reduction in fluoroscopy time than with Carto. With NavX, an accurate geometry can be created in 15 min, with only a few minutes of fluoroscopy. With image fusion, only these few minutes are at stake and it is unlikely that image fusion will reduce fluoroscopy time more than Cartomerge®. Reduction in radiation exposure, however, always remains a valid argument to investigate new technologies. Many electrophysiology (EP) labs are equipped with fluoroscopy systems that were originally designed to visualize tiny arteries and stents. EP procedures, however, do not require that image quality; we mainly have to see the contrasting catheters. Fluoroscopy systems in EP labs can therefore use extra primary beam filtration and lower pulse rates. In addition, one is obliged to use standard measures such as lower body-protecting lead flaps and an upper body-protecting glass screen. With a badge on the collar above the apron, the total annual dose of all operators performing catheter ablation procedures in a single EP lab can then stay below 5 mSv. Any team with a significantly higher total operator badge dose for catheter ablation procedures alone should seek advice from the fluoroscopy system manufacturer. Most modern systems have three different dose rate settings that are individually programmable by the manufacturer. Both electrophysiologists and interventional cardiologists can then be satisfied when they have to share the lab, and often operator and patient dose rates can be reduced by a factor of 5 or more without any impact on the quality of EP procedures. As a method for reducing fluoroscopy exposure, the application of advanced technologies, such as ICE, robotic or magnetic catheter navigation, image integration, and even 3D mapping systems alone, only makes sense when basic measures such as optimized fluoroscopy settings have been put in operation. Conflict of interest: F.H.M.W. is a consultant for St Jude Medical.
Complex business contracts are notoriously difficult to write and read. Certainly, when litigation arises, courts scarcely have an easy time interpreting them. Indeed, contracts don't look at all as though they are written to tell a court what the parties want. Why can't smart, well-motivated lawyers do a better job? My article argues that they rationally don't try. I argue for a view of contracting in which parties aren't principally trying to set forth an agreement for a court to enforce. Rather, by leaving inartful language and ambiguity in the agreement, parties are bonding themselves not to seek precipitous recourse to litigation. The agreement entered into provides each party with grounds to bring a lawsuit if it so desires. Thus, if one party sues, the other party will virtually always have grounds to countersue. The complex transacting community has a norm against litigation in any event; bonding encourages and bolsters this norm, as well as norms of appropriate conduct throughout the contracting relationship. The contracting process, and the contract that results, thus serves importantly to create the parties' relationship and to set the stage for dispute-resolution consistent with preserving the relationship, as well as to keep available the backstop of enforcement if needed.
To be able to maintain the continuity of organizational life, needed by various important information is which is good for consideration in taking a decision. A lot of information, one of them is accounting information. The Relationship between accounting information with the performance managerial happened by decentralization, manager given the right to take the decision by supervisor and implementation, Based on background of above, hence this research take the problems that is how influence decentralize to information of system accounting management (broad scope, timeliness, aggregation, integration) with the performance managerial at manufacturing business in area of industry of port Semarang. Result of the research show that information which is consisted in characteristic of information system of accounting management and decentralization can be exploited by manager for the planning of, controlling, and making decision improved their ability comprehend the environmental situation in fact and identified relevant activities. There were authority delegation in decentralize system made manager needed information broad scope including (external and internal factors, non economic, non finance information, events in come period. The timeliness information made manager responded every problem and anticipated environmental uncertainty quickly so managerial performance can improved. Aggregation information made manager responded every problems in their responsibility unit. Integration information made manager evaluated managerial performance. Key words: Management Accounting Information System (Broadscope, timeliness, aggregation, integration), decentralization, managerial performance.
A Catholic chapel stands above the town of Amecameca, built into the top of a tree-covered hill called the Sacromonte. A doorway in the back of the chapel leads to a cave of volcanic rock, where an effigy is located that depicts the deceased, reclining Christ. This Christ in the cave is an image of Santo Entierro, the Holy Sepulcher of Christ, and it is believed to be miraculous. Native leaders in Amecameca helped to establish the site in the 1580s and benefited from their founding of the place throughout the colonial period. Spanish friars and Nahuas had different ideas of what was actually miraculous about the location and the image, and each understanding involved different senses of history. For the original residents, the hill, the cave, the territory around the shrine, and the beneficent human beings who directed the construction of the chapel all played roles in an astonishing moment in the history of the town when the polity miraculously did not perish but, instead, found a place in the new Christian order. In this article, I place the European Catholic tradition of miracle narra tives within the ethnohistorical cultural context of indigenous political, literary, and territorial experiences and show how such marvels acquired uniquely Mexican meanings.When the Franciscan Order arrived in New Spain just three years after the fall of Tenochtitlán to Hernán Cortés, its members brought their devotion to the Passion, believing that miracles of the cross represented the triumph of Christ in the New World. Indigenous leaders and communities soon began to accept Christological symbols and reports of the apparitions of saints in Chalco in their own locally triumphal way. I argue that one cannot understand the whole meaning of colonial Mexican miracles unless they are interpreted in terms of their importance to indigenous territorial and leadership concepts and historical thinking. Where the wondrous events happened and who they happened to were of equal, if not greater, importance as the theological message of apparitions or particular Christian symbolism of objects, which the Franciscans emphasized. The gravitational cultural force that held land, power, and holiness in the orbit of the shrine was cyclical history. I show how this Mesoamerican way of making sense of the past is also displayed in colonial indigenous written traditions such as the títulos primordiales, the maps of the Relaciones geográfícas of 1580, oral histories taken in the Relaciones geográficas del Arzobispado de México, 1743; and the Séptima relación, an early seventeenth-century Nahuatl history by Don Domingo de San Antón Muñón Chimalpahin Quauhtlehuanitzin. The títulos primordiales are written and painted documents that established the preconquest foundations of indigenous towns and their legitimacy as loyally Christian in the postconquest era; they usually included maps of which were to Spanish as of the and written the of the hill and its cave in the of Amecameca of the foundations of the indigenous in to from the the were of of the roles of territory and This the that Franciscan and indigenous historical in in the new Mexican were in in the of Christ the and the of I arrived a of Nahuatl Spanish and a in indigenous in colonial this is not devotion or the of this of Christ and indigenous of miracle were to colonial Native and in the of Chalco and believed that which how members of the were of the of the miracles are not the of in which the the of the the of Catholic in indigenous in to of their to the and the meaning of Christ symbols the of the Nahuas of Amecameca, history the and after the hill as the and the around it were in the and of the The town of Amecameca is of in the and that the of the of the town of Amecameca are the and In one particular of the of Amecameca the the Chalco and the called held the Chalco in the of the of was in the of the of the of The was a in which to the and to a of In the of the the represented the The the of was the and were the the where human beings the The Nahuas to be and of were to the and were and human from the the who it were and and also had The the was a hill a the which is in as and in the were the of the and as the in the of of Amecameca, that a of the called to a an where they were the to and to and is written that the was the of the colonial period. from Amecameca documents a not place the the Sacromonte. the of Amecameca to the de that locally as in the of in Amecameca in San had the of the of the and the indigenous of were to was throughout the Chalco as a de of and the indigenous as a of had making around a the from when this was to the in Nahuatl which did not The in in a and the The was a place where indigenous leaders as I it was not a location of to but, instead, an of the of into the colonial indigenous and the who the hill of Amecameca to the hill of and its cave the of Christ. in the the of Amecameca the of the of the throughout the of where the cross miraculously in the the the the hill was an site indigenous as as of In the site was located within the of the town of de Amecameca, which was a town of San The in the the as did its of the towns that were Chalco was a to Amecameca and were located the from to the of by way of by from all The of to the site was the of events their the Christian of the of the in the were in the of the that they were in the This by the In the of that the of the Holy and Holy Sepulcher was one from of Chalco was the of and and each had which the indigenous of from devotion to and as of of into to the leaders of Amecameca, leaders benefited from In 1580, within the of a of into the of a who was in a place called a The and to In the about image of the of called de an indigenous directed who the and when the their they of miraculous of and by devotion and of the of was in Chalco and in and the of were the were miraculous image in the of and the that who brought and from and were of the Passion, or Holy Sepulcher of in in and in the of the The had a of miraculous in San in in in and in the de a of and its were by devotion to the In communities in the of and the displayed a that represented of Passion, and of the colonial miracle of the of Amecameca, was to the of Christ, and the Franciscan Order and its in the New de were in it in the the of Spanish the cave located the was an of the of the indigenous of New was the of a triumphal Spanish Catholic of miracles indigenous that the Franciscan and in the brought to such as the of postconquest New as the arrived in from Spain in they brought to the indigenous their devotion to the of Christ, the of which they had helped to in their de and of the de their to the of Christ This the of Christian in the and to of into the that de of in and of the and of and de that as a in was in and of the Holy the Franciscan of the of the the way the to indigenous The not Nahuatl and the Nahuas Christian and the Franciscan the the friars to the the of the and the which the and to the of was one of the of new concepts to the indigenous of New Spain just after their in In to of the the symbols of the the of the Franciscan indigenous in New San de in from the of de de San de indigenous or the de San in the in and it to as a This of is from of and and three an which Christ stands in are the cross and of the Passion, each in a that is of the of early colonial Mexican the de San is to an the around its its to in who had the of de The of the also of which they to in the of the they one in which Christ a its the of a by the symbols and of the 1580s and the of the had the indigenous of and had to the of Chalco the of the Franciscan and Franciscans of the and the of or in and this In Chalco the of Christ as miraculous the Santo de in and the Santo effigy de in had as a Christian site throughout the of that de from The of miracles the which are in Franciscan historical by de de and de European about the cross in cave above the Franciscan in to Amecameca, where saints and to as a in in the cave the Sacromonte. the of and to the the of Christ as into a the hill and in from the a from after from Chalco to that in the of was Franciscan a of their and and the of their in New the established a in Amecameca the the Franciscans to be a in their the a in Amecameca the location of and the of a from that the and the The were to the in a of and in believed in the of of a of the of The of the Franciscan to to the of the in New and the of in the that had the of 1580, to the of the and reports that when arrived in Amecameca from the in in the to and and that the Nahuas had it as a they believed it to the from an who had it in The also and and the chapel within the cave in the Christ effigy and in an and the Nahuas a in the are to as or of their they are to be of and The Franciscan as as the of were of the indigenous who their to the of not the of the indigenous the construction of the chapel in as the early seventeenth-century from the Nahuas did not in Nahuatl about miraculous events that the of New from the the indigenous of of the Sacromonte. interpreted in the of show that the cave was a of indigenous throughout the colonial period. In Séptima relación, a who was not a of in Nahuatl the miracle of the making of the The moment in of the is the of the chapel in which as a miraculous of Nahuatl how an indigenous historical was in which the of Amecameca the site into just a of European the Franciscan had the of the indigenous in the Séptima Chimalpahin the of the friars in the to that was a New as of Chimalpahin the and importance of the indigenous and Spanish in the in The miracles are found in the human that place the of the Chalco are as in the astonishing in which they into a chapel and of in the leaders the friars as they not to a triumphal Catholic Indigenous from Amecameca their to the friars in to to the in the of the of de in Amecameca, as the Franciscan the the of the cave chapel in the in the the de the cave it is in the context of events that the leaders of are that cave, and in is where the Holy Sepulcher of where they and In to are also in the what was miraculous about the In to the Franciscan Chimalpahin not the of saints and the of in a as they de and In this Chimalpahin the tradition of of one this in to of de in the Amecameca, Chimalpahin that the miracle in the cave was the of Amecameca as the place to an Chimalpahin not the that it was a who brought the image to the shrine above of the human of the the to the a of In the Chimalpahin the events the in of the who and of in the and three the Santo image in the cave, to to the terms and miracles that Chimalpahin did not the events as The miraculous were and For which is usually as the of In the it is in the that it or to Christ. The is to the Nahuatl that de as in the place of de The of to the that it to be in a to to or to This that Chimalpahin was making the the image and the Christ, which the image is a Chimalpahin did not the of the that which they were from of such of an image was not were that of the of a Nahuatl in the is which I as of miraculous The of is and it or which or the The of be found in the of de of The by the of the which of of the the image of the The of is a to the of image were Nahuatl the that to the of an or that an did not the of of the of that one Christian that of its and The meaning of the in the context of the is that human beings had a in the place the of which one Chimalpahin of the European Catholic tradition in of the be found in de of and that the of this The Spanish found in was when the of a miraculous image a of a a meaning to the Spanish is not found in the Franciscan histories of the Sacromonte. the terms are the Nahuatl that Chimalpahin the that human beings played in making the image as they were in miraculous to wondrous one of the indigenous to a new which was a that had a throughout the colonial period. of the of Amecameca who was as in the the of The Don de was the indigenous in which was an of the of In the the one Chimalpahin the indigenous the of the of the and their The which the new the leaders of as in the town leaders they in the which their the legitimacy of a In the of the who the of that a the new Christian and the preconquest This is in of Amecameca, the Don de of as as the de of and Don de of to and to and it cave top of the of which I as the which to the is the the or is this in the A as a by and of In this particular the three indigenous leaders are as of the who all to the as in Amecameca was to the cave where miracles their in an of by the as a a to the that the of the place particular and of the of the to were and The leaders were the of the and of and was an of in the preconquest and Christian The and of such of are when an in which Chimalpahin from Amecameca who of Franciscan in and to the of the of the as an of the in to the the of the Don de leadership as the of Amecameca and of the as a way of of The three communities represented by the three leaders were communities that to Amecameca also had each its own In the each had a that when it its to the as a in this In terms of was in the of that the top of and of Amecameca, Don de to the and was as a of the In the were the who as of the shrine were who were in the Don de the the leaders of the who the of of this site in and their this is by that to the of the de The of and of began in the of the chapel Sacromonte. indigenous leaders a of that the to the of the Catholic the of the colonial period. the Spanish that the to the Catholic and order. This in their in when the of Amecameca, Don de a of to of the from the also this period. Don de to cave into the Holy Sepulcher of the was the that the of of the Spanish colonial the the de to of their from the colonial In Don Don de to a to a a and to in a Spanish from Amecameca a of the years Don de a of located and of the town of was the by and the by the of the which included the This was its the and the the de which after Mexican leaders did not of the their own miracle the that Nahuas were and early in their of the Christian of the Franciscan and who to the New World. This was to in Chimalpahin established the colonial legitimacy of such as the de by their from preconquest the of the cave chapel in if the leadership the of of to a of and not a that indigenous the friars in the image of Christ in the they de cave into and it the Sacromonte. This was a the the Christ in the cave, which was the of their they their of place and which were in preconquest In the leaders of the by and making it the of their in their own this to they also helped to establish the new The the new Christian of their and by the Spanish Catholic order. The cave, which had the of the a of the the and throughout the colonial miracle and established the territorial of the For the of Amecameca, the Santo image of Christ, their of de to the cave and the into a Christian the as the in the of the Mesoamerican the Christ and in in the and 1580s established that as to which the Nahuas historical about the that they had making to the colonial the The Relaciones geográficas maps 1580, the and the of miraculous were all indigenous of which in the and early The in the Relaciones geográficas of towns and territory Catholic in the were to legitimacy to Spanish as as of of and the miraculous to the of towns and legitimacy in the of from the of the written cannot be the they early of such as of the they of a and tradition in which Mesoamerican to in the of are documents written and that indigenous documents and The and the all documents in their and the oral that the written were to be or indigenous included and in European and indigenous territory and events that had the founding of the the the the message that their communities were and the to how had in and the to they to colonial as of and the preconquest of who in the colonial Mesoamerican established that communities had to their the that they had not the of legitimacy the Catholic Catholic the history of the which were in the early they were written the of the friars and who to their towns and and their communities to the the of the a to the new colonial order. The that the of their towns the new is their of of are such as the of Catholic and of to Christian or histories the sense that leaders and the new and the the documents to oral events or or and the of are into a is and to a in the of history. The the the the of miraculous and the in their helped members their in a by their and the the of historical of the of experiences of to a past when the of oral and written miracle and the which they in and in how miraculous arrived in their communities in The in which they were the a Holy and their did not as in the were of the in the of the shrine of de in the a of a chapel which a miraculous image of was In the of San the of that an indigenous of as the to the miracles of their their image in the original where it in their all the members from the of The of San did not the of the they did and that had the miracles of the cross in had an sense of the past that it a the indigenous of the had their and who to In they as a the of Holy of the of Christ the of power, to the that the which in had its in the of the the the a the Christ effigy in the the indigenous in the and the new town the In indigenous the de a around the a Spanish in the the indigenous who had the own to the the town the and in of the was a the of their of founding events the sense of that the of the in the did and The of members to in the In and were from and town the founding which the of a and of miracle indigenous and of the founding of the the the of and a sense of the message that the had an to that involved the and of the of the to indigenous miracle that the as if they had to in a particular The miracles of the were that they not to from their communities of This in a in the Relaciones geográficas of a Santo image from that to In the of this image of the Christ, a of from had it in a to where they to it to in a cave in the way. they in the they found that the had to to the of they the and to the The that the be and they found that the image was had miraculously into the the built a chapel of the and the by it The Spanish who this that was written of the of the image in the and that had the from the indigenous a by the de in and in the image of de in a way. Don de who was as an the of the Holy the image a a hill called the of Don it it in a shrine or and it the image and found it in the place where the to Don de that to a chapel to the image the site of and of Spanish the chapel was built around which Don was In the Nahuatl of the found in de the image to in the was all by to the as is and as is in all of the image its own in one called and which to their documents symbols in to that that they and the by their to after the when was making and For in to a of the of in a a painted to colonial in as of the and territorial In the of town of who is painted as an a of the in as in the the the of their the and their to their territory a This is by a in which the are are to as in Nahuatl or as in the Nahuatl of or of which Chimalpahin in to de the the of the was from its as the from which members had territory and to in and established the of Amecameca the postconquest maps from and the the hill as the that the of the The that the from to by each of the The is from a that Don de in and and the is from the of the top of the Sacromonte. the hill was the place to all of the and of was the that the human the one to all the of the by the to the The this of the and the effigy of Christ in the back of the chapel are the as miraculous Christ effigy and the hill and chapel of Amecameca the the of and the of a of the colonial Nahuas the hill as a that to their such the that that they were The and miraculous image were of indigenous that a particular of as European of the in the indigenous the in the and the of indigenous of in the of triumph of did not the land, indigenous and the colonial period. This was a of the but, in the Franciscan of had the indigenous history. In the early to the Franciscans their the of the and this was into of leaders the that the leaders to the of Franciscan leaders de and de the of the and of to this of their in Amecameca the that as of legitimacy Catholic and of the of their which back to the colonial and of legitimacy by the indigenous were concepts of legitimacy in to their of as the colonial their of the miraculous image the the of their a new miraculous image of the of in the indigenous a of to that of A from the de the and how and the indigenous in to a miracle cross in a of the of such the of the of San a of the of a cross in the The to the as from the of also that were Spanish as in the the of the as and the the cross the of the of the the had arrived from to the of this The of the of Chalco from the de who was also an to the Don a of had the cross into the chapel of its had to the of the and the of who to understand if the miracle was or the indigenous town to to a chapel the were three from the and that they had the the indigenous of the that it to the de In to to a they to the that were after years of Catholic The be the site of their that triumph of their the indigenous the miracle in was by the that one of the communities of had a miraculous cross in the to in had an image of to be to a cross to the located in San In soon after the the members of the the image of Santo de to their in The of the cross did not the that the image had in In the a to the image that they believed and In the de that the of the cross in which the to a chapel their found original held a in the of as in of the of miraculous cave in the histories miracle and the from members of their town leaders and to miracles and as the of legitimacy to by to in the and to indigenous as the image or the original the that their miraculous image in their particular the context of New the of the was the of European triumphal and Mesoamerican of the postconquest The of the of the the site its historical the the of Amecameca to the traditions of and such as that of of The of Catholic symbols and into the of apparitions that and indigenous to the all into of the the Christian the of in Spain that are and to the events in New Spain that are in this to of and towns of New symbols that had represented the of the and of For of Christ and of all this to the a in the of the and the years of in the to the in of the to in Holy and of were their in the to the and when Spain was and the was from Christian the cultural to to by the of of and were the of such devotion in soon as the and such was and towns of the of Amecameca as a of European traditions is to the such a site the and was to the who were different in Spain and the to New indigenous was its by years of and to was and from European Catholic tradition is one of cultural the historical meaning of the Amecameca A the Spanish and the Mexican miracle traditions is the of and of miracles and miraculous in the New In Spain and to miraculous all of the miracles that indigenous to the of and did not the apparitions of The was in New who had miraculous as that miraculous image where were had the as the títulos primordiales, and the Relaciones the and early Nahuas their that their had this and to in and the of the this moment in and they a sense of In Franciscan the apparitions of the saints and miracles of de in Amecameca, that the Nahuas of Amecameca believed in a that miraculously their in a wondrous chapel the of this was not to the history of Mexican by to be the found in indigenous written and I that and historical to be indigenous and Franciscan the triumph of their in the and if one is in of the historical the of that and in New land, and did not that the of was to of European histories and the of indigenous above to the indigenous and of New Spain the of the miraculous cultural and indigenous The of the indigenous in the of the triumph of indigenous
This is part of an occasional series that recalls some of the stories reported 10 years ago in the News section of the Journal. In 1998, JNCI published a two-part feature about efforts to overcome multidrug resistance in cancer, which at the time was thought to be governed chiefly by a superfamily of molecular transporters, known as ATP-binding cassette (ABC) proteins. ABC transporters act as efflux pumps, which expel toxins and drugs from a cell. By reversing those transporters in cancer cells—particularly P-glycoprotein (Pgp), which was, and still is, the best-characterized among them—researchers hoped to overcome drug resistance, a primary cause of treatment failure. A decade later, efforts to reverse Pgp have proven futile, in part because the transport protein is also expressed by healthy tissues—leading to unacceptable side effects when its activity is knocked out. Furthermore, dozens of other ABC transport proteins identified within the last 10 years can take over for Pgp when its activity is reversed in cancer cells. Scientists are still studying clinical opportunities with ABC transporters, but drug resistance in cancer remains as much a problem now as it ever was. Even so, scientists have new leads to follow. Advances in molecular biology, driven by genomics and related fields, have revealed new resistance mechanisms and broadened opportunities to overcome it, said Michael M. Gottesman , M.D., head of the National Cancer Institute's molecular cell genetics section. “We just have to apply the mechanistic knowledge we’re gaining in the laboratory towards progress in the clinic.” Michael M. Gottesman, M.D. Today, those efforts are proceeding on dual fronts. Whereas scientists 10 years ago were concerned only with multidrug resistance against chemotherapy, those working today must also contend with single-drug resistance to newer, targeted therapies such as imatinib (Gleevec), a drug for chronic myelogenous leukemia (CML) and other cancers that inactivates a cancer-inducing protein called Bcr-Abl. Unlike chemotherapy—which kills rapidly dividing cells regardless of whether they’re cancerous—targeted therapies interfere with specific molecules involved in cancer and tumor growth. The new era of targeted therapy was supposed to leave chemotherapy behind and multidrug resistance behind with it. That's because researchers associated such resistance almost exclusively with efflux pumps, which act against a broad array of natural and synthetic toxins. By using nontoxic compounds targeted against specific molecules in carcinogenesis, scientists hoped that they could avoid resistance. But those expectations were dashed when clinicians found that although patients typically respond well to imatinib—among the first targeted drugs to reach the market—many also relapse within 3–5 years. Confronted with that distressing problem, scientists were reluctant to blame mechanisms like efflux, which were generally attributed to multidrug resistance and chemotherapy, for imatinib resistance. Instead, their explanations veered toward gene mutations that, by chance, might allow CML cells to survive imatinib exposure. In that scenario, most CML cells are killed by the drug, but those with mutations that favor survival multiply over time, leading to relapse. Scientists call this type of drug resistance “acquired.” To an extent, subsequent research has borne out this hypothesis, which was proposed when imatinib resistance was first observed, within a few years of the drug's approval by the U.S. Food and Drug Administration in 2001. More than a dozen gene mutations have since been implicated, of which the most effective is T315I, according to Susan Bates, M.D., director of the NCI's molecular therapeutics section. This simple variation alters Bcr-Abl's three-dimensional binding site, thus blocking imatinib's access to the target protein. But Bates argues that mutations alone can’t account entirely for imatinib resistance. Patients whose leukemic cells have identical mutations can vary with respect to the degree of resistance, she said, which suggests that other factors—including mechanisms linked to multidrug resistance—are also at play. “For example, interindividual variation has been found in the amount of Gleevec that winds up in the bloodstream, which could reflect differences in cellular absorption of the drug,” Bates explained. “We can’t rule out that ABC transporters might be involved, given that Gleevec is a substrate for at least two: Pgp and breast cancer resistance protein. In CML cells, those transporters reduce the amount of Gleevec that reaches the protein target, and that fosters resistance.” (However, variation in resistance among patients could also be due in part to behavioral factors, such as adherence to the drug regimen [ see JNCI 2008; 100: 912–3 ].) While researchers work to tease out resistance mechanisms against targeted therapies, efforts to overcome multidrug resistance to chemotherapy are making headway. Researchers in Gottesman's lab at NCI, who are among the leaders in this area, approach the problem by using three general strategies. Gottesman's research team collaborates with pharmaceutical companies to develop drugs that circumvent known resistance mechanisms. Compounds that evade ABC transporters—of which there are 48, according to current estimates—fall into that general category. Epothilones, for example, a new class of cytotoxic molecules identified as potential chemotherapy agents, aren’t recognized by Pgp. “This provides proof of concept that new classes of anticancer agents that don’t interact with multidrug transporters can be developed,” he said. This approach is currently in early developmental stages, with no compounds in clinical trials. Applying an alternate approach, the team strives to block resistance by inhibiting or reversing it. Clinical applications based on this approach would involve drug combinations: one drug to inhibit the resistance mechanism and another to kill the cancer cell. This strategy already has a long and unsuccessful history, exemplified by compounds such as PSC-833, a Pgp-reversing agent tested often in clinical trials. PSC-833 failed in part because of unpredictable pharmacokinetic interactions, leading to underdosing in some patients and overdosing in others. Scientists now hope to overcome that problem with third- and fourth-generation inhibitors designed for low pharmacokinetic interactions, as well as tight binding with target proteins. According to researchers in Gottesman's laboratory, promising candidates include tariquidar, a compound that offers extended Pgp inhibition, now in phase III clinical trials, and CBT-1, a plant alkaloid that inhibits Pgp in addition to an ABC transporter known as MRP1. The third strategy exploits certain unique features of multidrug-resistant cells, such as high surface expression of Pgp or a paradoxical hypersensitivity to a range of compounds. These features make it possible to target these cells directly, Gottesman said. For instance, thiosemicarbazones—a class of compounds with known antiviral, antimicrobial, and anticancer activity—kill resistant cells through Pgp-related mechanisms. This approach has not yet produced compounds for clinical trials. Scientists have also focused on the influx mechanisms that cells use to absorb certain compounds, including cancer drugs, instead of the efflux pumps that they use to expel them. Solute-carrier (SLC) protein transporters, recognized as the largest superfamily of membrane proteins, participate in these influx processes. Jeffrey Moscow, M.D., chief of pediatric hematology/oncology at the University of Kentucky Medical Center in Lexington, is now working to identify SLCs expressed uniquely by cancer cells. By harnessing these proteins, he hopes to pump drugs into a cancer cell faster than efflux transporters can pump them out. He's already identified an SLC expressed uniquely by lung and gastrointestinal malignancies, known as OATBIB3, and another expressed by leukemia, known as SLC22A16. “In these cases, the specificity of therapy would be determined by the expression of the solute carriers,” he said. Efforts to overcome single-drug resistance to targeted therapies differ from those applied to multidrug resistance. Instead of circumventing, inhibiting, or targeting mechanisms that cancer cells use to avoid poisons, scientists try to augment their treatment options with additional molecular targets, said Jeffrey Settleman, Ph.D., a professor at Harvard Medical School and scientific director of the Massachusetts General Hospital Cancer Center. Settleman's laboratory has accumulated the largest collection of human cancer cell lines in existence—more than 1,000 in all, representing all the major tissue types. With automated screening technology, he and his colleagues test putative targeted therapies until they find a positive hit in a sensitive cell line. Those lines are treated with the drug until only the resistant cells remain. By culturing those cells, Settleman's team can look for mutations that confer resistance, as well as for new targets to which the cells might be sensitive. The clinical strategy for managing resistance in targeted therapy, Settleman said, entails drug combinations to inhibit several targets sequentially. “The scenario could be that we convert cancer to a chronic disease by giving drugs in succession; as resistance develops to one drug, we shift to another,” he said. This approach is already being used now. For instance, CML patients who become resistant to imatinib can be treated with dasatinib (Sprycel). In a melanoma cell line, Settleman's laboratory recently modeled the acquisition of resistance to a candidate Raf kinase inhibitor. They found that resistant cells merely switched their metabolic dependency from Raf to another related kinase. “Raf kinase inhibitors are being tested clinically now,” Settleman said. “It's early days for these compounds, and we’re not sure they’re going to work. But if they do, we may have zeroed in on the resistance mechanism in advance.” The ability to switch from one kinase to another shows how adaptable cancer cells are in the face of drug pressure. But fortunately, it appears that cancer cells have at most three to four resistance mechanisms that they can direct against any particular compound, Settleman said. “And that shows we’re ultimately dealing with a manageable problem,” he said. “It indicates how important it is to tackle resistance from more than one angle. We’re faced with the same resistance mechanisms that infectious microbes use to evolve and mutate their way around a drug. We treat [human immunodeficiency virus] with multidrug cocktails, and we’ll be doing more of the same with cancer; our aim is to cut off the cells’ options to adapt.” So, although the previous 10 years revealed new mechanisms in cancer cell biology, including roles played by cancer stem cells that could offer the best therapeutic targets of all, accelerated research during the coming decade might bring the problem of resistance under better control. But doing that won’t be easy, Settleman admitted. “Cancer cells are crafty organisms in their own right,” he said. “And resistance is still the final frontier in treatment.”
Charles R. Hankla Assistant Professor Department of Political Science Georgia State University PO Box 4069 Atlanta, Georgia 30302-4069 chankla@gsu.edu Phone: 404-413-6172 Fax: 404-413-6156 Abstract What political factors influence the allocation of economic patronage in democracies? Answering this question is vital to improving our knowledge of how states and markets interact. In this paper, I argue that changing levels of party centralization can drive important changes in the allocation of state largess. When governing parties are centralized, national party leaders will control sources of patronage, targeting benefits to particularly influential regions and industries. By contrast, when governing parties are decentralized, influential sub-national party leaders will advocate for their constituents, allocating patronage evenly through a national logroll. I find evidence for these relationships by comparing India‟s distribution process for industrial licenses and government finance under a decentralized Congress Party (1954-61) to its distribution process under a centralized Congress Party (1969-75).
This chapter argues that the conflict in southern Philippines has not led to any serious radicalization of Islamic education. On matters of religious schooling, parents and educators alike show a level-headed pragmatism. Parents appreciate Islamic education for its ability to instill piety and a religious identity in an unstable world in which neither can be taken for granted. At the same time, parents want their offspring to acquire marketable skills. Islamic schools aim to strike a balance between these two valued ends. No less surprising, and again notwithstanding the thirty-year insurgency, no political party or umbrella organization has been able to seize control of the decentralized religious school system. Until the recent establishment of the Autonomous Region of Muslim Mindanao (ARMM), Islamic schooling was managed at the local level, and school directors were justly famous for their independent-mindedness.
We consider the question of whether P ne NP implies that there exists some concept class that is efficientlyrepresentable but is still hard to learn in the PAC model of Valiant (CACM '84), where the learner is allowed to output any efficient hypothesis approximating the concept, including an "improper" hypothesis that is not itself in the concept class. We show that unless the polynomial hierarchy collapses, such a statement cannot be proven via a large class of reductions including Karp reductions, truth-table reductions, and a restricted form of non-adaptive Turing reductions. Also, a proof that uses a Turing reduction of constant levels of adaptivity would imply an important consequence in cryptography as it yields a transformation from any average-case hard problem in NP to a one-way function. Our results hold even in the stronger model of agnostic learning. These results are obtained by showing that lower bounds for improper learning are intimately related to the complexity of zero-knowledge arguments and to the existence of weak cryptographic primitives. In particular, we prove that if alanguage L reduces to the task of improper learning of circuits, then, depending on the type of the reduction in use, either (1) L has a statistical zero-knowledge argument system, or (2) the worst-case hardness of L implies the existence of a weak variant of one-way functions defined by Ostrovsky-Wigderson (ISTCS '93). Interestingly, we observe that the converse implication also holds. Namely, if (1) or (2) hold then the intractability of L implies that improper learning is hard.
Being able to make payments conveniently and securely is an essential ingredient in modern life and commerce. It enables economic livelihoods and supports many social relationships, communal support actions, and public welfare programs. Yet most people and micro enterprises in developing countries must rely on physical delivery of cash or actual goods to make payments. This imposes large costs and risks on those beyond the reach of modern payment networks. Access to payment facilities is a major enabler for achieving universal access to finance. In this paper the author further develop a broad vision for financial inclusion sketched out in Mas (2008), where payments can be easily made through an electronic network. What makes visioning such a payments utility possible is the technology author have today, which can be used to bridge distances, close information gaps, contain settlement risks, and generally reduce transaction costs. The author is confident that today's technology can do the job. Now the challenge is to develop attractive services that engage customers and workable business models that enable decentralized, largely private, and institutions to build this payments utility.
Horst F. Wedde, Sebastian Lehnhoff, Christian Rehtanz, Olav Krause
In the DEZENT project we had established a distributed base model for negotiating electric power from widely distributed (renewable) power sources on multiple levels in succession. Negotiation strategies would be intelligently adjusted by the agents, through (distributed) reinforcement learning procedures. The distribution of the negotiated power quantities (under distributed control as well) occurs such that the grid stability is guaranteed, under 0.5 sec. The major objective in this paper was to deal, on the same level of granularity, with short-term power balance fluctuation, in terms of a peak demand and supply management exhibiting highly dynamic, self-organizing, autonomous yet coordinated algorithms under fine-grained distributed control. Our extensive experiments show very clearly that these short-term fluctuations could be leveled down by 70 - 75 %. In this way we have tackled, for the quickly increasing renewable power systems, a crucial problem of its stability, in a novel way that scales very easily due to the completely decentralized control.
Abstract—Large numbers of heterogeneous sensors the collect and fuse information in dynamic environments are envisioned in domains, such as military operations, disaster response or border surveillance. Depending on the dynamically evolving needs, operators will submit to groups of these sensors information acquisition and fusion goals that must be fulfilled within time constraints. To fulfill these goals, the sensors must autonomously and dynamically form coalitions. The problem that this paper addresses is the dynamic coalition formation problem and the evolving performance of coalitions over time. Coalition formation is an NP complete problem. One of the ways to mitigate the computational cost is to constrain the decentralized coalition formation problem by taking into consideration the underlying network structure. [1] has showed (a) that the network topology has a significant effect on the quality of the formed coalitions and their performance, and (b) that it is possible to develop agents that intelligently adapt the network structure to increase the ability of the organization to form good quality coalitions. However, that work used unrealistically simple coalitional models and did not perform an analysis of the network topologies and adaptation policies that could result. In this paper we make three contributions. First we present an analysis and results on the underlying network topologies that are formed. Second, we develop and analyze a more realistic coalition formation model. Third we present two new network adaptation policies. Experimental evaluation of our contributions are presented. I.
The implementation of the regional autonomy as a form of the governmental policy is expected to be able to solve the financial crisis of the central governments. Before the regional autonomy has been implemented, the financial resources of the regional or local governments depended on the ability of the central finance which was allocated in the form of subsidy and the financial aids for regional for financing the development and public services. The extensive and responsible regional autonomy is aimed to give the allowance to the regional governments to develop and manage their own region. By regional autonomy, the regional governments should be more independent on their own finance and more efficient in managing their own financial resources. This study is empirical which is aimed to obtain the proof of significant diffence on the financial performance of the regional governments after autonomy compated to before autonomy. Using the sample of the research on the regional government in Nanggroe Aceh Darussalam and North Sumatera, and the different statistical method for the paired sample (Paired T-Test). The results generally show the existences of the significant differences on the financial performance before and after autonomy. Financial performance which measured passing fiscal decentralization, fiscal effort, and level of ability of defrayal have differences, but for level of efficiencies of usage of budgets don't have difference which significant.
William R. Schlinker, William E. Kelley, Mary H. O'Phelan, Sharon Spall
Legislation has directed schools to convene school councils that typically address issues related to curriculum, instruction, budget, and governance as one means to improve schooling. However, the expectation for improved schools through this involvement remains a challenge. The study examined issues connected to council operation in two large Kentucky school districts. Seventy-six former council members responded to twenty-nine items on a mail-out questionnaire. The areas investigated included training, support, and member effectiveness from the perspective of community members and teacher members. The findings include suggestions to improve council effectiveness and new emphasis for principal and member training. Keywords: School councils; Council effectiveness; Training and support; Decision-making; Parent; Teacher involvement A Nation At Risk (National Commission on Excellence in Education, 1983) called for substantial educational reform in the areas of expectations for student achievement, assessment, use of instructional time, and curriculum. Of the many recommendations in the report the authors emphasized an increase of citizen involvement in oversight of school reform efforts and in school governance. Decentralization of decision making was a central tenet of education reform. Decentralization of authority was not new to school restructuring proposals and was influenced by societal drive to decentralization in business and government (Rallis, 1990). School based-decision making refers specifically to the decentralization of authority from the district to the school-level, including teachers, parents and administrators (Riesgraf, 2002). Hallinger, Murphy, and Hausman (1991) identified four things that have to change during restructuring: (a) decentralize, both administratively and politically, (b) empower those closest to the students, (c) create new roles and responsibilities for all the stakeholders, and (d) restructure the teaching-learning process. From this cauldron emerged the concept of the locally controlled schools, so that decisions that most affect the local school are actually made at the school level. Most of these local governance structures at the schools consist of the principal, teachers, and parents. The Chicago school system initiated one of the first efforts to pursue a major decentralization. In describing the Chicago initiative Hess (1991) stated that Local School Councils (LSC) were established at each school site to make decisions regarding the goals of this law and to utilize allocated resources to support school improvement. In 1985, sixty-six of the one-hundred seventy-six school districts in Kentucky filed a lawsuit claiming that the finance system for education violated the state constitution because it did not provide an efficient system of education for all students in the commonwealth. In 1989, in Rose v. Council for Better Education, 790 S. W. 2d 186, the Kentucky Supreme Court ruled that the state's school system was unconstitutional. The court ordered the General Assembly to reform the property tax system and to provide an adequate education for every child. In defining an adequate education, the court specified learning goals. In 1990, the Kentucky legislature used the court ordered education reforms to enact a comprehensive package of education reforms known as the Kentucky Education Reform Act (KERA), which focused on three areas: curriculum and instruction, school finance, and school governance. Among the many provisions, the act (a) created an equitable funding formula for education state-wide, (b) established a standardized state curriculum, (c) set academic expectations for student learning, (d) initiated a state-wide testing system, (e) set goals for student attendance, successful transition to adult life and retention, and (f) provided for additional professional development for teachers. Petrosko (1993) claimed that KERA had the greatest impact on education reform efforts in recent history. …
Cindi Noel, John R. Slate, Michelle Brown, Carmen Tejeda-Delgado
With the implementation of decision-making occurring in schools, an understanding of the views of secondary school principals and of secondary school teachers would provide valuable information. In the study, six principals and six teachers, from either high performing or low performing schools, were purposefully selected for their views of decision-making at their respective campuses. For the first research question in which campus characteristics associated with decision-making committees were sought, respondents provided three themes: collaboration; voice/communication; and application/procedures. Regarding ways in which decision-making committees were influencing the decision-making process on the campus level, the themes of decision-making team member composition, empowerment, and negative power were present. Concerning how campus culture was influenced by decision-making, participants responded in terms of the themes of acceptance and of dissatisfaction. Findings and implications are discussed. Keywords: Site-based decision making; Principals; Teachers ********** As part of educational reform efforts, decentralizing school management to individual campuses making decisions has been advocated for some time (Rodriguez & Slate, 2005a, 2005b). Site-based decision-making (SBDM), a process of decentralization in which the school becomes the primary unit of management of educational improvement, creates an avenue for the input of teachers, support staff, parents and the community--individuals who have first hand knowledge of relevant issues related to schools and schooling (Everett, 1998). In this process, school boards and superintendents are being asked to turn over control of decisions concerning curriculum, finance, and school operations to the local school community (Riley, 1999). Beck and Murphy (1998), in describing proponents of SBDM, asserted that conditions for excellence are dependent upon decision-making systems that can establish organizational performance goals and develop policies, procedures, and systems to ensure their attainment. In her extensive research on The Who, What, Why of Site-Based Management, David (1995/96), maintained that site-based management may be the most significant reform of the decade--a potential force for empowering educators and communities, yet no two people agree on what is, how to do it, or even to do it (p. 4). In her research, David attempted to differentiate between what management is and is not by indicating that SBDM comes in so many forms that no single definition can capture them all. This leads to the question, why do it? Reasons for initiating management cover many areas, yet David stressed that virtually all reasons are cloaked in the language of increasing student achievement. Regardless of educators' perception, the shift in authority is moving towards shared power (Rodriguez & Slate, 2005a, 2005b). This shared power encourages stakeholders at all levels to be involved in making decisions without feeling manipulated (Kowalski, 1993). As stakeholders take part in the decision-making process, helps educators manage the school, and holds them responsible for results (Texas Education Agency, 2002). As a result, principals, teachers, and other school personnel at the local site are substantially changing the way they have traditionally conducted routine business. The emphasis on shared decision-making practices at the campus level has led to numerous mandates from states for the implementation of some form of management (Howell, 1999). Texas responded to this emphasis by passing Senate Bill 1 in 1990, which mandated the implementation of decision-making (SBDM). Senate Bill 1 established new funding patterns, student and school accountability procedures, and a management program for Texas public schools (Kemper & Teddlie, 2000). …
I wanted to like this book, and tried hard, but ultimately failed. I have recently written several papers on inappropriate corporate influences on the funding and conduct of epidemiological research, and have discussed several examples of hazards where the epidemiologic findings were strongly, and unethically, opposed by industry and by academic epidemiologists funded by industry.1–3 This book provides ‘the other side of the coin’ and discusses in depth four examples (environmental causes of breast cancer, electromagnetic fields and cancer, residential radon exposure and lung cancer and passive smoking) where, in the author's opinion, the health risks were low or non-existent, but were hyped by researchers and policy makers thus resulting in unnecessary research, inappropriate funding decisions and unjustified public concern. Such things certainly happen, and we need books like this which attempt to discuss them objectively, and which point out that academic researchers may also be affected by a range of influences including career and funding opportunities, even if they only accept peer-reviewed government funding and do not accept corporate funding. Thus, they may have incentives to overstate the evidence, just as industry and industry-funded epidemiologists may have incentives to negate or understate the evidence of health risks from environmental exposures. The book states its case well, is clearly written and discusses complicated issues in a relatively simple and readable way. It makes the case that ‘each side tends to cite the evidence that supports its point of view in order to influence public policy’ (p. 6) and that ‘the tendency to overstate the evidence, for whatever purpose, actually strengthens the opposing party's hand. It sanctions the partisan use of science that should be rejected, no matter who is engaging in it.’ (p. 7) The book also makes the important points that: (i) we have to some extent reached the limits of ‘risk factor’ epidemiology and have identified the strong risks (e.g. active smoking and lung cancer) and are now trying to assess weak risks (e.g. passive smoking and lung cancer), which are much more difficult to assess and much more prone to be overwhelmed by bias; (ii) for many of these risks (e.g. residential radon exposure and lung cancer) it is not possible to directly estimate the risks from low exposures, and it is necessary to make theoretical assumptions to interpolate from the findings of studies of highly exposed occupational populations (e.g. miners exposed to radon); and (iii) many of these risks are very small and have received perhaps excessive funding and scientific attention in comparison with other public health risks. So far so good. I agree with all of the above statements, and started reading the book in a positive frame of mind, with the expectation that it was an important book that would be an essential antidote to the writings of myself and others who have tended to emphasize the hazards of corporate influences. However, I became more frustrated and less impressed as I worked my way through the book, particularly when coming to discussions of issues that I had been involved in (e.g. electromagnetic fields and cancer). This probably reflects my own influences and prejudices. However, it became increasingly difficult, as I worked my way through the book, to avoid the conclusion that the discussions of these issues were, for want of a better word, ‘biased’, as well as being rather ‘grumpy’ and unpleasant in parts. It seems that no one can get it right. No single study is good enough or big enough, but meta-analyses should be discouraged because they combine studies from different exposure settings and with different methodologies. Researchers are criticized for arguing that ‘one must rely upon the evaluation of the data as a whole using expert judgement and the meta-analyses as a guide’ (p. 101), because this simply reflects their vested interests to continue researching a topic when an individual study is inconclusive. The findings of individual studies are dismissed because they are ‘not statistically significant’, even if they are consistent with previous findings. Significant associations are dismissed because they involved multiple comparisons, even if the specific associations were the a priori reason for the study and had been found previously [e.g. ‘the reported association [of EMFs with childhood] leukaemia was one of a very large number of comparisons made by the researchers and hence could well have arisen by chance’ (p. 100)]. Studies that show interesting dose-response associations verging on statistical significance, such as the National Cancer Institute childhood leukaemia study,4 are not only dismissed, but also researchers are condemned for not accepting the findings as proof of lack of risk (‘it is hard to escape the impression that the reluctance of the NIEHS working group to close the door on the possibility of EMF as a cause of leukaemia had more to do with its members’ stake in this area of research than with scientific rigor’ (p. 101). While every academic researcher who wants to study these issues apparently has a vested interest, even if their university salary is already funded, critics of the research are apparently unbiased, reasonable and objective, even if their criticisms are directly or indirectly funded by industry. Researchers into radon and lung cancer are biased because they do not repeatedly emphasize that tobacco smoking is the major cause of lung cancer, and that most cases of radon-induced lung cancer involve joint effects with smoking (the corollary that some cases of lung cancer in smokers are due to joint effects with radon exposure is never mentioned, nor is it mentioned that the same arguments could be applied to many other important lung carcinogens such as asbestos). The book gives particular emphasis to issues of biological plausibility, even though there are many historical examples of associations that were not biologically plausible when they were first discovered by epidemiologists, and the aetiological mechanisms involved were only subsequently discovered in laboratory-based studies. This is why, for example, all of the 30–40 known occupational causes of cancer (as classified by the International Agency for Research on Cancer) were first discovered in epidemiological studies, not in the laboratory. If it had been plausible that these substances caused cancer, then they would not have been used in the workplace. So epidemiology will always be in front of mechanistic research with regards to discovering new environmental and occupational causes of disease. The book also fails to mention that there are many historical examples of risks (dioxin and cancer is one example) where the evidence was initially weak and inconsistent but has strengthened over time (leading to the classification of dioxin as a carcinogen by the International Agency for Research on Cancer in 1997). So what are we supposed to do about ubiquitous environmental exposures that may carry weak risks, but which may account for a substantial number of cases of disease on a population level? Kabat's solution is nihilistic, namely that we simply should not study such exposures, or at least not attempt to quantify their effects: ‘it is entirely plausible that in some cases exposure to ETS may account for a few cases of lung cancer in nonsmokers, but … it is not possible to quantify the excess risk with any certainty’ (p. 150). The argument is essentially that the risks are too small to quantify accurately, and therefore should not be studied, or at least should not be estimated quantitatively. We are never told how we should decide if a risk is too ‘small’ to be concerned about if we do not first attempt to estimate its magnitude. And how are we supposed to tell the public that the risks are small (and their concerns are unimportant) without attempting to estimate them? And who decides what is a ‘small’ risk? The book finishes, literally on the last page, by advocating a ‘broader/integrative vision of epidemiology—one that can accommodate social, economic, and ecological/environmental realities … as well as rapidly evolving knowledge of the mechanisms of disease at the molecular level’ (p. 186).5–8 Such developments are to be encouraged, but they are intended to be inclusive, not exclusive, and we will have to continue to grapple with problems of studying weak risks from ubiquitous environmental exposures, even if they receive less attention than they have in the past. It is important to consider the influences on such research, including influences on academic researchers with regards to career opportunities and funding, even though these will continue to be relatively minor compared with the massive and pervasive influences of corporate funding of research and of critics of research.1–3 This book could have made a major contribution in this regard, but its lack of balance means that it fails to make such a contribution.
Rarely in medicine does one observe the adoption of a new technology as it moves from infancy (and a domain of early adopters) into the realm of widespread, general use. Anesthesiologists may be an exception; they have long been in the vanguard of new technology adoption as a part of an ongoing quest for improved patient safety. More recently, however, technological developments in anesthesiology have involved information systems. These systems' potential to improve patient care is not so traditionally obvious as something such as a new physiologic monitor or a better anesthesia machine. Hence, the adoption of anesthesia information management systems (AIMS) has been slow, in part, because they are regarded as expensive, “optional” technology with little direct patient benefit. However, a new study by Halbeis et al. indicates a sharp uptick in the number of academic anesthesia departments that are either in the process of installing an AIMS, or have allocated resources to do so in the near future.1 The authors suggest that adoption of AIMS in academic departments is passing through a “tipping point,” as defined by Gladwell, wherein a new idea catches on and penetrates the culture widely.2 In other words, AIMS appear on the verge of completing the adoption lifecycle. Suddenly, anesthesia departments are finding themselves heavily involved in information systems (IS) either as clients or, in many cases, as the “business owners” of their own IS groups. Once installed, AIMS applications quickly become critical to the department's financial health and daily clinical activities. This focuses a sharp lens on the resources required to operate an AIMS. Limited IS funds and competition for priority are frequently cited reasons for delayed or deferred AIMS adoption in the Halbeis et al. study.1 This state of affairs commands attention from potential AIMS adopters, as every center with any substantial AIMS experience has learned that the acquisition and implementation costs are only part of the total cost of AIMS ownership. There is also a continuing requirement for application and system support that must be reliably met, so that the AIMS continues to meet changing clinical and administrative demands. What are the resources required to ensure initial and ongoing AIMS success? An AIMS requires dedicated personnel, not just for implementation, but also for ongoing support of the software, the associated hardware, maintenance and modifications of the user interface, and development and implementation of new functionalities. The specifics of how these resources are provided, which budget(s) they are supported by, and under whose jurisdiction they fall in the organizational chart differ widely, ranging from all support provided by hospital-wide IS departments to all AIMS activities being supported by the anesthesia department. Despite the disparate organizational features of the AIMS-dedicated IS resources, there are key roles that are common and easily identified in organizations with a successful AIMS. These roles must be anticipated and filled by departments considering an AIMS installation. First, there must be a competent, committed clinical champion—an individual familiar with the anesthesia workflow of the department who can both set up the AIMS interface and keep the interface up to date as the needs of the department change. This person must understand the capabilities and limitations of the AIMS well enough to know what can and cannot be accomplished when setting up the AIMS in order to match the operating room workflow. Almost always, this person is an anesthesiologist with facility in software, computer hardware, medical device interfaces, or database management. Given that none of these topics is addressed during anesthesia residency, such individuals are rare. The AIMS clinical champion should participate in product selection, so that their expertise regarding local anesthesia workflow, practices, and expectations may influence the selection of an AIMS whose capabilities most closely match the clinical setting. Here we encounter a Catch-22. How would the AIMS expertise required to make an informed selection develop in a department preparing to select its first AIMS? Frequently, a clinician with some prior interest and acknowledged ability in personal computing is nominated, and an informal consultation network with existing AIMS users is established. The process repeats for each new department selecting an AIMS; very few centers have been through the process more than once. Fundamental questions such as “How much of the clinician's time will selection and implementation require?” are negotiated anew each time. Given the financial and practice-impact issues at stake, AIMS selection is an area ripe for the development of capability and professionalism. The clinical champion must either be capable of maintaining the AIMS software and databases themselves, or be assisted by a software engineer, database administrator or programmer analyst with sufficient cross-training to work in all of the aforementioned specialties. For a multi-specialty anesthesia practice, this “AIMS engineer” role typically requires a full-time professional. Increasingly, hospital IS include electronic health records, provider order entry systems, and computerized lab result systems, all of which must interface with the AIMS. This increases the complexity of the programming/engineering services required, and potentially calls for more than one full-time equivalent person in the AIMS engineer role. The AIMS is literally and figuratively at the interface between medical devices and medical information systems. Thus, a successful AIMS requires constant attention from biomedical personnel (usually a biomedical engineer) who has sufficient IS background to set up, maintain and troubleshoot the physical connections and interfaces between the anesthesia equipment, intraoperative monitors, and the AIMS. Problems with these connections have resulted in medico-legal liability and losses that offset the value of the AIMS.3 Because this maintenance and troubleshooting capability must be available, or at least on call during all times the AIMS is in use, multiple individuals are typically required. Behind the scenes, perhaps the largest end-user of any AIMS is actually the anesthesia billing office. Because the AIMS functions required to support a successful billing operation are quite distinct from the clinical implementation, maintenance and development efforts, one or more separate, dedicated programmer analysts are often required to support the business functions. As mentioned above, no two organizations are alike in the exact configuration, governance, and funding of the resources supporting the AIMS. However, each of the half-dozen departments with established, successful AIMS implementations have either provided or secured personnel to fill these roles. For many early adopters, the resources were secured “on the fly,” as it became clear that the AIMS would founder without them. In successful programs the resources applied are not aberrations but, practically speaking, are quite homogeneous with respect to full-time equivalent clinicians, engineers, programmers and analysts across the various institutions. Every organization contemplating an AIMS installation should plan for these requirements or risk appearing ill-prepared when they must be urgently met. Installing an AIMS brings the anesthesia department into the world of operating room medical information systems demanding new personnel and capabilities, and ongoing resources to support this new operation. Can there be additional benefits, beyond the obvious (better charting) from the new expertise and expense? The Halbeis et al. study provides a hint: upcoming AIMS adopters strongly value improved data collection for clinical, quality assurance, and safety purposes, and to support clinical research as reasons for installing an AIMS.1 The early adopters have demonstrated the added benefits of having an AIMS, with examples such as easy retrospective searches for Quality Assurance/Quality Improvement purposes, easy reporting for “pay-for-performance” purposes, a platform for active quality management (including documentation quality related to billing, which justifies the cost), and a platform for managerial decision support.4–10 However, in virtually every case reported, the “out of the box” AIMS product was insufficient to provide the extra value. Instead, the considerable resources applied by the early adopters were used to modify or extend the capabilities of the AIMS. In some cases, AIMS vendors have incorporated new functionalities into their products in response to user examples or demands.3 However, the current offerings still do not perform all of the functions that a department will desire. The take-home message is that when planning for AIMS acquisition, anesthesia departments and hospitals must specify in their requests for proposals the additional personnel and list the additional functionalities to be developed, in addition to the capital and software acquisition and installations costs. Departments should develop their own requirements for additional AIMS functionalities, but should start by searching the medical literature. Almost without exception, what is known about AIMS modifications and additional functionalities has been published in peer-reviewed journals. In other words, the fundamental proof-of-concept reports about various additional functionalities and their operational and/or financial impacts are readily available. This is not to say that there is nothing more to be learned; the available reports merely scratch the surface, but the current body of knowledge is available and searchable. Thus, when developing additional requirements, the key reliance should be on the applicable scientific literature. In addition to the selected examples cited above, review of the AIMS-related literature indicates that AIMS-mediated improvements in anesthesia are related to the process of care (e.g., on-time antibiotics), billing, managerial decision-support, etc. In contrast to electronic health record systems in primary care settings, the time course of the data flow from (input) → AIMS → (output) is seconds to minutes as compared to hours to weeks. This compressed time frame may be a key differentiator between AIMS and other electronic medical record systems. A traditional medical informatics approach may not be ideally suited to advancing knowledge and capabilities. Instead, the early AIMS adopters are moving towards automated process monitoring and process control. The general form is as follows: Process modeling to create a reference process against which actual process progress can be compared, seeking noteworthy exceptions. Data integration of multiple electronic sources and different data types. Continuous process monitoring by recursive queries of the AIMS and other databases to identify process exceptions. Pushing data to key stakeholders, seeking to provide the right information to the person who needs it, at the time when it is most useful. The skills required to build these capabilities are closer to industrial engineering and scientific programming than to medical informatics. Anesthesia departments contemplating AIMS adoption must also think about how to get that expertise into their organizations. There is a significant risk to AIMS success that is still at hand, but little discussed. All of the successful AIMS implementations that have produced added value beyond simpler charting have been systems that were either developed by the implementers themselves, were products that the vendors modified in response to customer requests, were products that allowed additional software to be run on top of the AIMS, or some combination of these. Each of these AIMS products could be considered an anesthesiology-oriented product, and is frequently a standalone application. However, many hospital IS departments are seeking to cover all of the hospital's needs with one monolithic solution from a single vendor. Thus, there is a potential conflict among AIMS-users and AIMS-purchasers (i.e., the hospital) over a fundamental choice between vendors producing systems that serve anesthesia well (but are mute with respect to the rest of the hospital's needs), and vendors producing systems that cover more areas but may not perform the AIMS function very well. Depending on the hospital IS department's orientation, the larger software vendors' products may have a significant sales advantage. However, the AIMS adopters who have reported value-adding successes in the peer-reviewed literature have, to date, voted with their feet in favor of products over which they have the most control. Although AIMS adoption may have tipped in favor of implementation at academic centers, the technology as a whole is still vulnerable, perhaps more so because of the increased exposure to demanding users and high expectations for benefits that the out-of-the-box products do not provide. The potential for frustration and missed opportunities is high, as not all centers will succeed in selecting an optimal product, or in securing the resources to adapt the AIMS to best meet their needs. Hence, AIMS vendors would be well advised to attend to the users' needs themselves.
This article presents a web oriented telehealth platform adapted to the social and economic conditions of a developing country like Colombia. The platform aims to satisfy health care needs integrating modules for telemedicine, where medical processes are modelled following the HL7 Reference Information Model which has allowed easy inclusion of many specialities such as dermatology, radiology, cardiology, pathology and infection diseases, among others. The system implements many security mechanisms such as Digital Signature and Zero Knowledge Proof for authentication. A telecare real-time module measures patient's vital signs such as blood pressure, electrocardiogram, oxygen saturation and sends them over the network to monitor patient's health. After 19 months of service, the system processed 4.751 actual telemedicine cases from 31 remote stations with an average response time of 1, 3 days, showing flexibility, security and scalability.
Huaxin Wang, Joris S. M. Vergeest, Jan Miedema, Frank Meijer · 6 authors
Synthetic environment equipped with user interfaces intuitive for direct 3D shape modification by non-designer stake-holders was proposed as a collaboration tool for design concept communication in dynamic prototyping of product design in early stages of the design process. After a survey of 3D user interaction techniques for SE, a simple user interface with hierarchical visual menu was proposed and a proof-of-concept implementation of it was tested to be intuitive with experiment, which serves as a base for further study to verify the hypothetical benefits of SE aided dynamic prototyping in terms of communication efficiency and accuracy.