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This work presents a case study of waste incorporation, where precast concrete block rejects were reincorporated into the production of new recycled concrete blocks which stands for a technically and environmentally viable alternative to natural aggregates. This study therefore evaluated the technical feasibility, first, and the leaching performance, after, of recycled vibro-compacted dry mixed concrete blocks using different percentages of substitution of recycled aggregates (RA) coming from precast concrete block rejects in order to identify those that presented a better technical performance. According to the results, concrete blocks with a 20% of RA incorporation presented an optimum physic-mechanical behaviour. The environmental evaluation based on leaching tests was carried out to identify the most conflictive elements legally regulated according to their pollutant release levels and investigate their different release mechanisms. The leaching study performed in concrete monoliths showed that in blocks with 20% of RA incorporation: Mo, Cr, and sulphate anions presented a higher mobility during the diffusion leaching tests; Sb and Cu presented an average mobility; Ba and Zn exhibited lower mobility levels and their corresponding release mechanisms for each of them. However, the limits for pollutant release in construction materials in a monolithic state were not surpassed by far.

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Extensive green roofs are urban construction systems that provide thermal regulation and sound proofing for the buildings involved, in addition to providing an urban heat island mitigation or water retention. On the other hand, policies towards reduction of energy consumption, a circular economy and sustainability are core in the European Union. Motivated by this, an experimental study was carried out to evaluate the environmental risk assessment according to release levels of polluting elements on leachates of different green roof substrate mixtures based on recycled aggregates from construction and demolition waste through (i) the performance in laboratory of two procedures: compliance and percolation tests and (ii) an upscaled experimental leaching test for long-term on-site prediction. Four plots were built on a building roof and covered with autochthonous Mediterranean plants in Córdoba, South of Spain. As growing substrate, four mixtures were used of a commercial growing substrate with different proportions of a fine mixed recycled aggregate ranging from 0 to 75% by volume. The results show that these mixtures were classified as non-hazardous materials according to legal limits of the Landfill Directive 2003/33/CE. The release levels registered in extensive green roofs were lower compared to the laboratory test data. This shows how laboratory conditions can overestimate the potential pollutant effect of these materials compared to actual conditions.

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BACKGROUND: Pain management in hospitalized patients remains a priority area for improvement; effective strategies for consensus development are needed to prioritize interventions. OBJECTIVE: To identify challenges, barriers, and perspectives of healthcare providers in managing pain among hospitalized patients. DESIGN: Qualitative and quantitative group consensus using a brainstorming technique for quality improvement-the nominal group technique (NGT). SETTING: One medical, 1 medical-surgical, and 1 surgical hospital unit at a large academic medical center. PARTICIPANTS: Nurses, resident physicians, patient care technicians, and unit clerks. MEASUREMENTS: Responses and ranking to the NGT question: "What causes uncontrolled pain in your unit?" RESULTS: Twenty-seven health workers generated a total of 94 ideas. The ideas perceived contributing to a suboptimal pain control were grouped as system factors (timeliness, n = 18 ideas; communication, n = 11; pain assessment, n = 8), human factors (knowledge and experience, n = 16; provider bias, n = 8; patient factors, n = 19), and interface of system and human factors (standardization, n = 14). Knowledge, timeliness, provider bias, and patient factors were the top ranked themes. CONCLUSIONS: Knowledge and timeliness are considered main priorities to improve pain control. NGT is an efficient tool for identifying general and context-specific priority areas for quality improvement; teams of healthcare providers should consider using NGT to address their own challenges and barriers.

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CONTEXT: The Dreyfus model describes how individuals progress through various levels in their acquisition of skills and subsumes ideas with regard to how individuals learn. Such a model is being accepted almost without debate from physicians to explain the 'acquisition' of clinical skills. OBJECTIVES: This paper reviews such a model, discusses several controversial points, clarifies what kind of knowledge the model is about, and examines its coherence in terms of problem-solving skills. Dreyfus' main idea that intuition is a major aspect of expertise is also discussed in some detail. Relevant scientific evidence from cognitive science, psychology, and neuroscience is reviewed to accomplish these aims. CONCLUSIONS: Although the Dreyfus model may partially explain the 'acquisition' of some skills, it is debatable if it can explain the acquisition of clinical skills. The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want to explain 'acquisition' of clinical skills. The idea that experts work from intuition, not from reason, should be evaluated carefully.

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BACKGROUND: In the choice and definition of quality of care indicators, there may be an inherent tension between feasibility, generally enhanced by simplicity, and validity, generally enhanced by accounting for clinical complexity. OBJECTIVE: To study the process of developing quality indicators using an expert panel and analyze the tension between feasibility and validity. DESIGN AND PARTICIPANTS: A multidisciplinary panel of 12 expert physicians was engaged in two rounds of modified Delphi process to refine and choose a smaller subset from 36 indicators; these were developed by a research team studying the quality of care in ambulatory post-myocardial infarction patients with co-morbidities. We studied the correlation between validity/feasibility ranks provided by the expert panel. The correlation between the quality indicators ranks on validity and feasibility scale and variance of experts' responses was also individually studied. RESULTS: Ten of 36 indicators were ranked in both the highest validity and feasibility groups. The strength of association between validity and feasibility of indicators measured by Kendall tau-b was 0.65. In terms of validity, a strong negative correlation was observed between the ranks of indicators and the variability in expert panel responses (Spearman's rho, r = -0.85). A weak correlation was found between the ranks of feasibility and the variability of expert panel responses (Spearman's rho, r = 0.23). CONCLUSION: There was an unexpectedly strong association between the validity and feasibility of quality indicators, with a high level of consensus among experts regarding both feasibility and validity for indicators rated highly on each of these attributes.

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Por medicina alternativa se considera al conjunto de disciplinas terapéuticas y diagnósticas que existen fuera de las instituciones del sistema de salud convencional. El uso actual de esta 'clase' de medicina está muy extendido, tanto en el mundo industrial como el preindustrial. Parte del creciente uso de las terapias alternativas se debe a su reciente validación profesional; muchos textos de divulgación general claman y justifican su uso, basándose en información académica no necesariamente de rigor científico. En este ensayo, se analizará la evidencia científica disponible, así como también se analizará las bases lógicas y filosóficas de la medicina en cuestión.

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OBJECTIVES: To know opinions, attitudes and interest of medical students toward science and pseudoscience. DESIGN: A questionnaire was administered to 124 medical students of the San Marcos University in Lima, Peru. RESULTS: 173 students were surveyed. The response rate was 72%. Eighty-three percent (100/121) of respondents said that science is the best source of knowledge, 67% (82/123) said they were interested in science and technology news, 76% said they had not read any science magazine or book (other than medical texts and journals) in the last five years. Thirteen percent (16/124) of respondents said that astrology is "very scientific" and 40% (50/124) stated that it is "sort of scientific." 50% of respondents shared the opinion that some people possess psychic powers. CONCLUSIONS: Medical students' attitudes toward science are generally not favorable.

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BACKGROUND: All sciences share a common underlying epistemological domain, which gives grounds to and characterizes their nature and actions. Insofar as physicians depend on scientific knowledge, it would be helpful to assess their knowledge regarding some theoretical foundations of science. OBJECTIVES: 1. To assess resident physicians? knowledge of concepts and principles underlying all sciences. 2. To determine, to what extent physicians? epistemological beliefs and attitudes are compatible with the scientific paradigm. DESIGN: A questionnaire was administered to 161 resident physicians at three hospitals in Lima, Peru. RESULTS: 237 resident physicians were selected, 161 (68%) of whom agreed to answer the survey. 67% of respondents indicated they did not know what epistemology is, 21% were able to correctly define epistemology; 24% of the residents knew the appropriate definition of scientific theory. No respondents knew the philosophical presumptions of science; and 48% took a relativistic stand towards knowledge. CONCLUSIONS: There appear to be deficiencies in the knowledge of scientific theoretical foundations among physicians.