The dream as prediction seems inherently improbable. The bizarre occurrences in dreams never characterize everyday life. Dreams do not come true! But assuming that bizarreness negates expectations may rest on a misunderstanding of how the predictive brain works. In evolutionary terms, the ability to rapidly predict what sensory input implies—through expectations derived from discerning patterns in associated past experiences—would have enhanced fitness and survival. For example, food and water are essential for survival, associating past experiences (to identify location patterns) predicts where they can be found. Similarly, prediction may enable predator identification from what would have been only a fleeting and ambiguous stimulus—without prior expectations. To confront the many challenges associated with natural settings, visual perception is vital for humans  and often responses must be rapid. Predictive coding during wake may, therefore, be based on unconscious imagery so that visual perception is maintained and appropriate motor actions triggered quickly. Speed may also dictate the form of the imagery. Bizarreness, during REM dreaming, may result from a prospective code fusing phenomena with the same meaning—within a particular context. For example, if the context is possible predation, from the perspective of the prey two different predators can both mean the same  and require the same response . Prospective coding may also prune redundancy from memories, to focus the image on the contextually-relevant elements only, thus, rendering the non-relevant phenomena indeterminate—another aspect of bizarreness. In sum, this paper offers an evolutionary take on REM dreaming as a form of prospective coding which identifies a probabilistic pattern in past events. This pattern is portrayed in an unconscious, associative, sensorimotor image which may support cognition in wake through being mobilized as a predictive code. A particular dream illustrates. There is a long standing idea that, based on prior experience, the brain generates predictions (or expectations) to interpret and, thereby, identify sensory input . This image-based code may be retained at an unconscious level and mobilized to predict the immediate sensory environment and interpret the causes of sensory input during wake.This paper focuses on the In relation to this hypothesis, two points are worthy of note. First, there is agreement with Stickgold  who arguIn evolutionary terms, any animal which can move must predict where food, predators, and mates can be found , therefore, they engender representations that are quintessentially fictive or counterfactual. In this sense, this paper equates prospective coding with the encoding of counterfactual representations which can inform in the future, which is one step further than classical predictive coding theory .A key aspect of prospective codes is that because they portray associative visual patterns REM dreaming is argued to be conducive to prospective coding. Such coding may require the core characteristics which REM dreaming shares with the wake state: active consciousness during which a world appears with  an embodied, agential self at its center Llinás, .During off-line states, people contemplate the past to anticipate the future Bar, . Sleep iDreaming hyperassociates different memories Hobson, . Whole munder conditions of sleep deprivation.Personally significant, past and future events will be emotionally charged. Indeed, anticipatory affect may be an integral aspect of prediction  in, for example, three out of ten approaches to a waterhole (the place) would have been a personally significant pattern which could give rise to a probabilistic prediction. Even if the pattern of sightings of a predator was regular, for example on the third, sixth and ninth visits, predictions about the behavior of this predator, would still be probabilistic because patterned behavior can always vary. A pattern of predator sightings on three out of ten approaches to a waterhole may be driven by another non-obvious, meaningful association. For example, the predator only visits this waterhole when it anticipates that prey will be abundant. In such a circumstance, identifying an association between “waterhole” and “abundance of prey” and “presence of a predator” would enhance survival because the animal could visit at less populous times. As mentioned earlier, unconscious predictions are particularly relevant in situations of potential danger.However, unconscious predictions are also important whenever speed is crucial for success. For example, identifying a probabilistic pattern in the presence of mates at a landmark place would enhance reproduction and speed would be necessary to secure a mate against competitors. Unconscious learning of probabilistic patterns to predict future events benefits from sleep  are associated in the mind/brain when their meaning is the same or similar. For humans, meanings may be culturally shared Bruner,  but meanolkowski  point ouolkowski  i.e., whfor fruit eating animals, see Turvey  enable abstraction or generalization-as noted by Hobson et al. . PruningThe scene discontinuities which Rittenhouse et al.  identifyIn the next section I use a dream to illustrate (a) how pattern identification amongst dream memory elements may enable prospective coding and also, sometimes, fuse associated memory elements (b) how vagueness in dreams may be engendered by pruning redundancy and (c) how apparent scene discontinuities may result from transitions between image-based codes which are connected by an underlying emotional theme.The illustrative dream was collected in the home and recorded in a dream diary. There are no claims that it is typical in any way. It is self-identified as a REM dream because it conforms more to REM dream characteristics than NREM. Distinctions between REM and NREM dreams are debated and differences may resemble a continuum rather than reflect discrete binary oppositions. Nevertheless, REM dreams have been found to be more story-like, hyperassociative and bizarre, spatially defined, animated, characterized by vivid internal imagery, driven by primary emotions  and typified by more threatening interactions than NREM dreams, which are shorter, more literal, and thought-like, perseverative, verbal, and feature more friendly interactions  aware that I have to go somewhere else. I tell a nurse that I can't see properly, that my vision isn't right. She says that I have to see someone in the other building. I am anxious about getting there and getting lost.Scene 2I am in another building and walking toward some carpeted steps. Someone (a man?) is close behind me, is he helping me or threatening me in some way? I am getting anxious again. He is gray-haired. I think he is East European, maybe he is a Pole? Also he may be the ophthalmologist.Scene 3I am sitting at a desk. The ophthalmologist is testing my eyes. He produces a saggy, stripy cat- a kind of large, soft toy. But I can't see properly what it is. I have to identify some black signs (like the letters on an eye chart but they may not be letters) that are under the cat's skin. I can't see them properly. So the ophthalmologist pushes the toy cat closer to show me. I know that I have failed the eye test. I feel very anxious.In July 2009 a few evenings previous to the Bagpuss dream I went out to dinner with my partner and D, his brother. D was talking about walking in the countryside with his “pole.” I felt confused and had to ask for clarification because, prior to this conversation I had never heard of a walking stick being called a “pole.” For some reason, the “pole” discussion which ensued caught my imagination.About 2 weeks prior to this dream I went to the Eye Hospital to have a test for glaucoma. I was very anxious about this test. Glaucoma results in loss of peripheral vision and is common in the elderly. I usually get my eyes tested at the local optometrist. This was the first time I had been back to the Eye Hospital since I was a child. The visit made me feel old. I went to the building that I used to visit as a child but, on approaching the steps, realized that this old building  was actually closed down. The new Eye Hospital was around the corner but I was uncertain exactly where. Scene 1 reflects this- in the sense that in waking I went to the wrong building. In the dream, however, I am in the original Eye Hospital building and see a nurse. PB did not go with me to the Eye Hospital either as a child or an adult. I worked with PB, however, in the Main Hospital—which adjoins the old Eye Hospital when we were both young women.The steps I approach in Scene 2 could reflect the ones at the entrance to the old Eye Hospital. The positioning of the gray-haired man and me in Scene 2 resembles the sign used in the UK to indicate that elderly people may be crossing the road  reference may be a memory of East European immigration which (at the time) was a political issue in the UK.In Scene 3 the action resembles memories of many of the eye tests I have undergone in the sense that there is an ocular specialist, a means of eye testing and me.As discussed above, Scene 1 may portray associations amongst my recent appointment at the Eye Hospital with the ones I had as a child where I did enter, wait and then see a nurse. As discussed above, prospective coding must rely on discerning patterns in the world. The pattern, here, may be “not being able to see” accompanied by anxiety. As a child I had to remove my glasses to have my eyes tested whereas as an adult I take out contact lenses but in both cases because I am so short-sighted it engenders anxiety about moving around. Another possible related pattern is “fear of blindness.” As a child, I wore glasses from the age of five. I used to fear that the increasingly strong spectacles I was prescribed indicated I may go blind. As an adult I am being tested for glaucoma which can cause blindness.In Scene 2 the non-obvious pattern appears to be “pole” or “Pole.” Various associations to “pole” may be distinguished in this scene. Blind people, like the elderly, need sticks or “poles” to walk. The gray-haired man behind me who is helping me to walk (or may be threatening in some way) may reflect the elderly man in the road sign using a walking stick or “pole.” One of my former colleagues, who specialized in geriatrics, very much disliked this sign. She said that it stigmatized older people as bent and incapable and also looked as if one was a pickpocket- in that it portrayed the couple as though one was taking money from the other, this association may explain why, in the dream, I am uncertain if the man is helping or threatening. At the time of the dream, many UK nationals thought Poles were a threat to “their” jobs and were, therefore, taking money from them. This issue was much discussed on the news.https://www.youtube.com/watch?v=dpwhohWhrEE). Glaucoma involves a loss of peripheral vision. Therefore, in the sense of an image-based code for visual field restriction, Bagpuss is a non-obvious association with glaucoma. To me, Bagpuss and glaucoma both mean visual field restriction.In Scene 3 the non-obvious pattern may be “loss of peripheral vision.” The eye chart is fused with a soft, cat toy creating a bizarre image. “Bagpuss” is a 1970s children's television character: an old, pink striped, saggy cloth cat. Bagpuss is always shown in scenes that fade out into hazy, blankness , REM dreaming may portray the associations between the memory elements which make up the pattern. These associations may constitute new memory content. During REM sleep, Landmann et al.  report tA self-organizing brain may both engender and identify meaning through making associations. As argued earlier, meaning is often idiosyncratic to the individual, being derived from prior experiences (and knowledge) and the individual's needs, desires, and goals—all of which may be opaque- even to those intimate with them. For this reason, the dreamer should have privileged insight into meaningful dream associations, which is not equivalent to asserting that the dreamer is necessarily correct. Hill et al.  found inIn psychology the term “elaborative encoding” designates the process of discerning meaning in past events and the binding together of meaningfully associated elements of past experience to enable inferences to be drawn , there would have been key landmark places which were used regularly, for example, dependable food sources and refuges from predators , whilst avoiding aggression (Valeix et al., In contrast to prospective coding during REM dreaming, which may associate and encode “temporally discontiguous events” Rawlins,  to engenThis paper offers a hypothesis: REM dreaming is one form of prospective coding which evolved from identifying a loose or non-obvious associative pattern in personally significant events at a frequently visited landmark place. Dreaming also occurs during NREM sleep, however. Although, as discussed above, NREM dreams are rather different, being, inter alia, shorter, less hyperassociative, more literal, and thought-like.their relationships to one another (O'Keefe and Nadel, It is suggested above that prospective coding during wake may encode associative sequences, evolving from the encoding of the pathways which linked the omnidirectional landmark places. However, the theory of cognitive mapping encompasses landmark locations and There would also have been an imperative to encode associations between what could be found at different landmark places. For example, if there were two waterholes within reach of the animal these would be associated because water was afforded at both. Computer simulation produces cognitive maps encompassing both object-scene and scene-scene associations (Sato and Yamaguchi, The overall hypothesis is testable through observing the consequences of brain lesions which obliterate dreaming- if, indeed, such elimination occurs. For example, Solms  undertooPrime facie, “dream to predict” sounds implausible, not least because the bizarre events in dreams never materialize in the wake state. But if prediction involves prospective codes which fuse phenomena with the same meaning, given a particular context, and render other phenomena vague, if they are not essential to that context, one can entertain a role for REM dreaming in prospective coding. Dream bizarreness may be an aspect of the prospective coding process rather than a concrete signal of things to come. A prospective code, generated in REM dreaming, may identify a personally salient, non-obvious probabilistic pattern in past events and portray that pattern in an unconscious, sensorimotor image which, if mobilized as a predictive code in wake, supports cognition in wake through rapidly co-ordinating sensory input with appropriate action. The form taken by any prospective code may also relate to the ecological context for the predictive brain, where REM dreaming evolved to engender an image-based code which hyperassociates temporally discontiguous events at what was, in evolutionary terms, a frequently visited landmark place.Dreams are odd but as Dobzhansky  remarkedThe author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Enemies on the couch: A psychopolitical journey of war and peace, by Vamık D. Volkan. Durham: Pitchstone Publishing, 2013. 504 pp. ISBN 978-1939578037. $22.99 Hardback.Review of Enemies on the couch offers his recent observations and evaluations of societies both in conflict and postconflict. Although each chapter of the book deserves a distinct appraisal, this review is exclusively of the chapter regarding Cyprus entitled “A Return to Cyprus: The Presence of Invisible Walls.”Exploring societies in conflict or postconflict, which is relevant to conflict resolution, conflict management, peacebuilding, and peacekeeping initiatives requires an interdisciplinary research. Vamık Volkan who is considered to be a prominent expert in the psychology of war-torn societies works in an interdisciplinary framework of political psychology. Volkan's recent book entitled Volkan aims to illustrate in general that the basic aspects of individuals and large-group psychology in societies after major trauma remain immutable, and in particular this is valid for Cyprus as well. Within this context, he argues that the Cypriot Turks’ experience of living in enclaves in pre-1974 circumstances still continue to affect their large-group identity, and that other external factors have led to more identity confusion. However, Volkan's observations and evaluations on Cyprus seem to suffer from conceptual ambiguity, lack of evidence, and logical flaws.The scope of the study on Cyprus is limited to the Cypriot Turks, particularly those living in post-1974 era, which is characterized as a society in postconflict. Volkan begins his analysis of the Cypriot Turks on the basis of societal trauma, and distinguishes between the concepts of “concrete enclave” and “invisible enclave,” which are central ideas to his main argument. Accordingly, the concept of concrete enclave is defined by pre-1974 circumstances in which the Cypriot Turks were forced by the Cypriot Greeks to live in subhuman conditions in enclaves, geographically confined to 3% of Cyprus for 11 years. While the concept of invisible enclave refers to post-1974 conditions in which even though the Cypriot Turks declared independence and established a separate state in Northern Cyprus, they continued to live in isolation from the world community because their state was not recognized by any country except for Turkey.Although there are dramatic changes between the pre- and the post-1974 conditions in Cyprus, Volkan's distinction between concrete and invisible enclave is questionable. His choice of the word “invisible” is not obvious enough, because it may have several meanings depending on the context in which it has been employed. If it refers to post-1974 circumstances, what makes them invisible? If they are invisible indeed, how come Volkan has been able to discover such conditions? However, as he himself admits, for his study was “not a strictly scientific one, meaning [he] did not receive answers to specific questions and then measure them according to any designated methodology” (p. 365), it is not possible to find out through which methodology he has identified “invisible” enclave.On the contrary, if he insists on the existence of enclave even in post-1974 circumstances, then it can be accepted as a matter of size of the enclave. Although the size of the enclave was relatively small in the pre-1974 era, it has become relatively larger in the post-1974 era. Thus, the distinction between small and large enclaves would be more accurate to refer to the modifications of what he calls “enclave mentality” on the island.In addition to his distinction between the concrete enclave and the invisible one, Volkan has developed the concept of “enclave mentality” through his 2007 and 2008 study in which data are obtained from the interviews with older individuals and his daily activities. He claims that “enclave mentality continues to be present even after the traumatic environment no longer exists” among the Cypriot Turks (p. 367). Volkan suggests that even though the impact of massive social trauma is repressed or denied, it still manifests itself in multiple ways in new generations. Nevertheless, he argues that the younger generation born to parents with what he calls “enclave mentality” is not aware of this.However, the author provides no evidence to support this claim. He does not illustrate how massive trauma manifests itself in new generations. If the impact of massive trauma continues to be present, why are the new generations not aware of this, and how has he found it? Answers to these questions are not found in the study. Therefore, Volkan's claim remains just a hypothesis yet to be tested.On the contrary, for Volkan, some international actors’ efforts to construct a Cypriot “ethnic group” or “nation” within the context of finding a resolution to the Cyprus conflict is another external factor, which has modified and increased what he calls “identity confusion.”The author puts forward the debates over national identity in Turkey, what he describes as “the process of changing Turkishness” as another major external factor which “disrupted the large-group identity investments of Cypriot Turks” (p. 372). Through his interviews with dozens of young and old persons, he has found that there is no one primary large-group identity of Cypriot Turks, but different identities such as a Turk, a secular Turk as Kemal Atatürk, a religious Turk, a Cypriot who is like a Greek Cypriot, a Cypriot different from a Greek Cypriot, a European, and so on. And he concludes with his belief that revealing peoples’ emotions both in Northern Cyprus and Turkey has played a crucial role in “taming exaggerated emotions associated with identity confusion” (p. 374).Nevertheless, there are several questionable points here. First, his diagnosis of “identity confusion” can be critically appraised in terms of relevant literature in general and Eriksonian theory in particular. Although there is a growing literature on identity which emphasizes that individuals may hold multiple identities or roles , and Kurd identities. That is to say that the most controversial debate in Turkey has been between Turkish and Kurdish identities, and in Northern Cyprus, it has been between Cypriot and Turkeyian identities. Thus, there is a problem of oversimplification inasmuch as there is no direct relationship between the recent national identity debates in Turkey and the identity issues among the Cypriot Turks.Moreover, the author's claim that the debates on national identity in Turkey as another major external factor “disrupted the large-group identity investments of Cypriot Turks” is open to question too. First of all, it is to be taken into consideration that the recent national identity issues in Turkey have been particularly debated around Turk, Turkeyian (Consequently, despite these criticisms, Volkan's work offers remarkable insights into the concept of enclave mentality, which refers to the psychology of individuals regarding their experience of living in enclaves, and its relation to large-group identity within the context of Cyprus. However, there exist conceptual ambiguity, lack of evidence, and logical flaws in the construction of his argument.Bülent EvreDepartment of Political Science Near East University, Lefkoşa, Turkey bulentevre@yahoo.com


There have recently been various empirical attempts to answer Molyneux’s question, for example, the experiments undertaken by the Held group. These studies, though intricate, have encountered some objections, for instance, from Schwenkler, who proposes two ways of improving the experiments. One is “to re-run [the] experiment with the stimulus objects made to move, and/or the subjects moved or permitted to move with respect to them” (p. 94), which would promote three dimensional or otherwise viewpoint-invariant representations. The other is “to use geometrically simpler shapes, such as the cube and sphere in Molyneux’s original proposal, or planar figures instead of three-dimensional solids” (p. 188). Connolly argues against the first modification but agrees with the second. In this article, I argue that the second modification is also problematic (though still surmountable), and that both Schwenkler and Connolly are too optimistic about the prospect of addressing Molyneux’s question empirically. Suppose him now to gain the use of his sight. And suppose him to be presented with a cube and a sphere, of nighly the same bigness. Quaere, will he be able to tell, by the use of his vision alone, which is the sphere, and which is the cube?William Molyneux, a Dublin Lawyer, once wrote to English philosopher Although this sudden restoration of sight involving no other concomitant issues may not be empirically realistic, several philosophers, and scientists have attempted to treat Molyneux’s question empirically; Here is a brief description of the Held experiment we will be focusing on. It involves five newly sighted subjects with 20 pairs of objects as stimuli, constructed from Lego blocks. The experimenters have ensured that the stimuli “are large enough … to sidestep any acuity limitations of the subjects” , p. 551.It turned out that participants had high performances in both the TT task (98% accuracy) and the VV task (92% accuracy). However, they did poorly in the crucial TV task (58% accuracy). After five days and without explicit training, the participants improved from 58% to circa 80% accuracy in the TV task. Based on their results, 1 let’s agree with Schwenkler’s criticism of the studies performed by Held et al. (2013):In the VV task, subjects needed only to make gross discriminations based on the overall appearance of the stimuli, which were presented from a single viewing angle. Intuitively, this can be done by attending to low-level visual features like colour, shadow and approximate overall contours. (p. 91)For the sake of argument,However, I share Connolly’s “worry about whether subjects can appreciate depth cues immediately post-surgery” . Given this worry, the plausibility of Schwenkler’s first suggestion, that we should “re-run [the] experiment with the stimulus objects made to move, and/or the subjects moved or permitted to move with respect to them” , is indeed weakened. Moreover, depth from motion  is only one of at least 13 cues used by the visual system to infer relative and absolute positions in-depth , p. 204.really 2D: Raised-line drawings are raised so that a distinction between the object and its background can be made, but the third dimension here is not relevant for object recognition: If the raised-line drawing in question stands for a pair of scissors, to change how much we raise the lines does not affect what is represented, though it might affect the difficulty of the task. Connolly’s suggestion here is not lacking its intelligibility. Some vision scientists might be puzzled by this suggestion, since the most interesting point in this area is whether the blind subjects have relevant 3D representations. However, the original Molyneux’s question concerns whether there is any shared amodal spatial representation between sight and touch, so given this purpose 2D stimuli are suffice for relevant experiments.2What I want to focus on here is Connolly’s elaboration of the second suggestion offered by Schwenkler, namely that running the experiment with two-dimensional (2D) stimuli can fix the problem because newly sighted individuals may not be capable of forming a three-dimensional (3D) representation of viewed objects. Connolly invokes raised-line drawings to make his point. These types of drawings are used to make graphical, typically 2D printed materials, accessible to individuals who are visually impaired or blind. Connolly’s proposal seems plausible if the Molyneux experiment were to be run in 2D: Raised-line drawings are exactly the kind of stimuli blind people encounter in the 2D context. Of course, it is not not able to judge distance. This case is not ideal as evidence here as SB did have residual vision in his first year, but at least this case chimes well with the current point.3 This contrasts with the visual recognition of 2D depictions, such as line drawings and photographs, which can be matched to 3D objects with no experience or training with 2D depictions . … All of this suggests that rather than indicating that a two-dimensional test for Molyneux’s question is a non-starter, the raised-line drawing studies point to constraints for such a test instead. , p. 509I agree with Connolly that this task is not impossible: Perhaps more intensive training for blind subjects with raised-line drawings before undergoing the relevant surgery and subsequent experiment would do. But I want to focus on the obstacles for this improvement: In the same paragraph, Connolly suggests that the reason why object-recognitions tasks involving raised-line drawings are so difficult is because often the objects in question are too complex. For the purpose of running the Molyneux experiment, using simple shapes such as circles and squares is sufficient (conceptual capacities. To be sure, this difficulty can be remedied empirically: Those subjects just need more extensive training. But I want to emphasise that the difficulties are more serious than some researchers might have supposed.4Connolly preempts this objection to some extent:fficient , p. 509.no clash with empirical laws. I said that “the sudden restoration of sight with no other concomitant issues may not be empirically realistic,” but it is still empirically possible to test it. In this regard, I agree with Held et al., Schwenkler, and Connolly. I also believe that the suggested modification concerning 2D stimuli is a constructive contribution to the discussion. However, Schwenkler and Connolly seem to think that, with the minimal adjustments they propose, the experiment would be ready to go. I hope to have shown that given blind subjects’ limited experiences even with tactile objects, although it is still empirically possible to test Molyneux’s question, the obstacles are more challenging than Schwenkler and Connolly imply.The conclusion to be drawn is this: Molyneux’s question, at least formulated in a certain way, is indeed an empirical question, but the empirical obstacles are more challenging than many have supposed. To say that a question is empirically testable is to say that the very idea of the relevant experiment does not violate empirical laws—such as physical laws. In Molyneux’s statement of the question, as quoted at the beginning of the article, there is


Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients.Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted.Seventeen semi-structured interviews were conducted . Three main, inter-related themes emerged . Patient complexity , as well as prescriber complexity  were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population.Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP.ISRCTN41694007Current controlled trials  People over the age of 65 years have a higher prevalence of multimorbidity , requiring multiple medications (polypharmacy) to manage symptoms and prevent future events.. These combined health care needs, coupled with age-related changes in pharmacokinetics and pharmacodynamics make prescribing in this population a complex task –3. ConseIn recent years, PIP in older patients has become an important public health concern, and a significant body of research has emerged on the topic. A recent systematic review identified 36 published tools to assess PIP in older people, the majority of which were explicit (i.e. lists of drugs to avoid) . There iRelatively few qualitative investigations into the phenomenon of PIP and the processes underlying it have been published to date. A recent meta -synthesis identified seven papers exploring PIP in older people qualitatively, highlighting that some doctors have self-perceived restrictions with regard to prescribing appropriately because of a combination of factors such as patient expectation, tension between experience and guidelines and prescriber fear . The majThis study is part of a larger research project conducted in Irish primary care: the OPTI-SCRIPT study . The detailed trial methods and results have been published elsewhere –20. BrieAll interview participants were recruited from the OPTI-SCRIPT study between January and July 2013. The lead study GP in all 21 participating practices, in both the intervention and control arms, was asked to participate in a semi-structured interview, 17 of whom were available for interview (two were on leave and two were unable to schedule an interview within the study time frame).Data were collected from one to one semi-structured interviews. Semi-structured interviews were the preferred method of data collection as it is a flexible approach, allowing interviewers to alter the sequence of questions or the way in which they are phrased in response to the participants . All intAll interviews were audiotaped and transcribed verbatim by one interviewer (BC). Because the intended analyses focused only on the content of what was said, the interviews were transcribed verbatim  but finer details such as brief hesitations or changes in intonation were omitted . All parn = 13, 76 %) and 70 % (n = 12) of interviews were conducted in person GPs felt that polypharmacy, multimorbidity, and patient heterogeneity, all contributed to complexity at the patient level. Potential side-effects and drug interactions, and perceived poor patient medication adherence, further compounded these difficulties from the GP perspective:“Yes the eh, constant evolution of a person’s prescription, the lack of stability, there must be a formula somewhere, that would be a nice formula to write, that eh, you know, the complexity of managing your patient’s repeat prescription increases exponentially in relation to the number of specialists they are seeing or something like that.” (GP13)In tandem with this, treating complex patients resulted in complexity at the prescriber level, particularly via fragmentation of care and the involvement of multiple prescribers. Multimorbidity resulted in the involvement of multiple prescribers and specialists in patient care, each adding to or amending a patient’s medication list:“Well it limits you eh, very much, the one that stands out there was a lady with [chronic condition], so all of her medication, apart from current illness, was in the hand of the consultant. And of course I had to provide the script through her medical card system, otherwise I probably wouldn’t have seen her because it wasn’t really my prescribing.” (GP9)Multiple prescriber involvement appeared to impinge on GP prescribing autonomy. GPs reported feeling constrained as they were required to issue repeat prescriptions for patients on the General Medical Services Scheme (GMS) see Table “…the more complex their prescription, the harder it is for me to do my job, almost as if, the more specialist clinics that people are going to, the tighter the straitjacket I’m on. These elderly people who have a lot of symptomatic illnesses as well, you know, attend me, and I have less and less options. If all I had to do was just care about the person’s headache, or their back pain, or their pneumonia, I could just do what I would normally do. But because they are seeing 3 different specialists and because they are on 3 different suites of medicines, you know, I have to cognisant of… You know I’m not complaining about that, it’s just a fact that it does get difficult. You’ve less and less wiggle room you know.” (GP13)Multiple prescribers and multimorbidity further restricted GP prescribing autonomy in terms of the choice of medications to prescribe when older patients presented to primary care with acute conditions, with GPs feeling constrained in terms of their prescribing options:“The complexity of prescribing for the elderly is a lonely game.” (GP5)Patient and prescriber complexity contributed to a prescribing environment which was characterised as complex and isolating:“The real difficulty that we have, ok, is that we are basically transcribing hospital prescriptions in a lot of cases onto GMS [General Medical Services Scheme] scripts, ok, and a lot of the time when we get the prescriptions, it’s from an outpatient clinic. It might be in good cases 2 weeks later, in other cases, 5 or 6 months later when we get a letter of explanation for why the changes were made, ok, so do we ignore the prescription until we get an explanation for it?” (GP21)Within this environment, one of the biggest contributing factors to the occurrence of PIP and general prescribing errors was poor communication. Communication between primary and secondary care was identified as problematic in both directions. However, for the study participants, the most salient issue was that changes made in hospital/outpatient settings were often not communicated in a timely manner to inform decision making:“I mean they will take my lead on this, of course. I mean if this is what I tell them, em, they will say ‘Yes doctor, of course’.” (GP9)“Generally the older patients do as I asked them to do, and what I mean by compliance is that they mix up their tablets, but luckily, our local pharmacy now vacuum pack them for them…I mean I know, it sounds like baby stuff but to be honest with you, we have actually gone back to as if you were telling children when they have to take everything, and it works really well.” (GP23)Within a paternalistic doctor-patient relationship, the doctor is viewed as the authority figure, acting in the best interest of patient, while the patient cooperates . In gene“I mean it certainly amazes me how blindly they will take increases in their medications, it’s incredible you know, eh and you know, ‘Oh I’m going to increase your blood pressure tablet by one, I’m going to add another anti-cholesterol tablet, O you’re a little bit sleepless we’ll add another…’, you know, they could walk out of here with three new tablets on their eh, script, they just accept it.” (GP2)However, it is unclear if this paternalistic model was employed by choice, or if GPs felt compelled to take responsibility where patients adopted a more passive approach to their medication management:“…sometimes, people are on tablets and they don’t know why and the reason that they are on them has long since passed” (GP22)This passive approach may be a consequence of the complex medication regimen many patients had, without fully understanding which medications they were taking and why:“Because sometimes, if a tablet is upsetting them, some of them [patients] can be embarrassed to tell you, and they just don’t take them, and they end up with a stock pile, so I ask them to bring everything in.” (GP23)GPs also frequently reported that poor communication was problematic in this patient group, requiring GPs to take extra measures to get accurate information on patient adherence:“I’ve no doubt that there is, that we do prescribe inappropriately. Or that patients are inappropriately kept on medications for long periods when, in fact, that medication may have only been prescribed, or intended for a shorter term, a shorter duration.” (GP26)Most GPs accepted that inappropriate prescribing was occurring in primary care in these complex patients:“I think in the age group we are prescribing for, my X plus patients who are over 70, are all individuals. They are individuals themselves, but in fact, they are all on different cohorts of medications. So I don’t think you can be, when you look at best practice in prescribing one agent, you really have to say best practice in prescribing one agent with maybe, anti-coagulants and maybe, anti-hypertensives, and maybe, eh, multiple inhalers, and analgesics at the same time.” (GP5)Many GPs were not, however, aware of PIP as a concept and the published criteria such as the Beers criteria and STOPP (Screening Tool of Older Person’s Prescriptions) criteria were not often utilised in routine practice. While the GPs interviewed were receptive to receiving advice on prescribing and were keen to improve where possible, a number were sceptical of the utility of such criteria when it came to treating such a heterogeneous population:“Sometimes, however, for example, in relation to benzodiazepine, em, you know, somebody might be on benzodiazepines and has been for 40 years, which one of the patients actually was, I don’t think it’s appropriate to stop that. If they’re stable and they can get on with their lives then I think it would cause more hassle for them and so on and so forth, so, what might be generally inappropriate might be specifically appropriate.” (GP1)Furthermore, a tension existed between specific criteria, and the risk-benefit of altering medications in the context of individuals. Where the perceived risk of continuing a PIP was seen as lower than the potential complications from altering a medication, GPs were reluctant to make changes:“Inappropriate connotes carelessness, and I think very few of us are careless…” (GP5)The term ‘potentially inappropriate prescribing’ evoked mixed reactions in the GPs, with six of them reporting that they found the term particularly negative, value-laden and accusatory and did not incorporate the difficulties of prescribing for older patients faced by the GPs, as outlined above:“Potentially inappropriate prescribing, I think that’s quite good, actually, because it’s, it’s potentially. It’s not giving you an absolute.” (GP22)The remaining GP interviewees did not express any negative feelings towards the terminology or find it to be problematic:This study highlights some GPs’ perspectives on PIP and polypharmacy in older patients. Three inter-related themes emerged, namely a complex prescribing environment, paternalistic doctor-patient relationships, and a limited relevance of the PIP concept for GPs. GPs highlighted that prescriber (e.g. multiple prescribers) and patient (e.g. multimorbidity) factors, and characteristics of a paternalistic doctor-patient relationship, contributed to a complex environment in which potentially inappropriate prescribing could occur. However, the utility of the PIP concept, and the criteria to measure it, was questioned by GPs as it often failed to take this complexity into account.Consistent with previous qualitative explorations, this study has highlighted that multiple, inter-related factors influence PIP , 28. PolOver the last century, the conceptualisation of the doctor-patient relationship has altered, moving towards models of shared decision making , 41, 42.Consistent with previous qualitative findings , 48, GPsThis study is an important contribution to the limited qualitative data in this area. The qualitative methodology used allowed an exploration of the complexity of PIP in primary care not accessible in the numerous quantitative, prevalence studies in the current literature. However, the present study has a number of limitations. These interviews were conducted as part of the OPTI-SCRIPT trial process evaluation, which limits the findings in two main ways. Firstly, the process evaluation was designed to explore elements of intervention implementation and study participation. Therefore, the topic guide was not designed to explore the issues outlined in this paper solely, and interviews were shorter on average (14 minutes) than may be expected to explore prescribing as a topic. While the themes presented here emerged strongly from the data, arguably, a more detailed interview on prescribing and prescription medication use alone may have produced a more nuanced account. Secondly, the sample was limited to only those GPs who participated in the OPTI-SCRIPT trial. While this resulted in a good response rate, the participants may not be representative of GPs nationally. Study participants were predominantly male, and urban based and as volunteers to this study, may be more informed about PIP than the general population. However, when compared to a national sample of GPs, the participants were broadly similar. Overall, d our results are consistent with the limited number of qualitative studies in this area, increasing confidence in the findings.PIP is common in older populations in primary care. This study identified several inter-related factors that contribute to the occurrence of PIP including a complex prescribing environment, paternalistic doctor-patient relationships and limited relevance of the PIP concept for GPs. Several of these have been highlighted as amenable to intervention, including improved management of polypharmacy and multimorbidity and decreasing PIP. However, there is a need for stronger evidence of the effectiveness of such interventions in resulting in clinically significant patient improvements in patient primary care , 34, 36.CME, continuing medical education; GMS, General Medical Services; HRB, Health Research Board; OPTI-SCRIPT, OPTImizing PreSCRIbing for Older People in Primary Care, a clusTer randomised controlled trial; PILs, patient information leaflets; PIP, potentially inappropriate prescribing; PPI, proton pump inhibitor; RCT, randomised controlled trial


We’ve been burning municipal solid waste (MSW) since the 1880s. But the dawning of the environmental movement eight decades later cast new light on the nitrous oxides, dioxins, and other chemicals emitted from as many as 600 mass-burn incinerators nationwide, which meanwhile had also grown in size.,,,,Now three new approaches to converting trash into energy—so-called waste-to-energy (WTE) technologies—look to leave mass-burn incineration behind by transforming how we think about MSW in the United States. Adherents of these emerging approaches—gasification, plasma gasification, and pyrolysis—promise cleaner emissions and more flexibility in terms of energy output, plus in some cases the virtual elimination of landfilling through a complex two-stage treatment process.But none of the technologies have yet been proven on a commercial scale on U.S. soil using a typical mixed MSW feedstock, says Monica Wilson, program director for the advocacy group Global Alliance for Incinerator Alternatives (GAIA). After years of delays and high-profile failures, the technologies remain stymied by challenges such as operational inexperience, high costs, lack of financing, and concerns about toxic emissions. Furthermore, the heterogeneous nature of MSW can make it a problematic feedstock for power plants, and some critics believe it is more important to assess what materials are actually in MSW and the best uses associated with each of those materials—for instance, recycling, composting, reducing, or redesigning the materials before they enter the waste stream.Negative public perception of incineration also could prevent acceptance of newer WTE technologies in the United States. Modern mass-burn facilities are a huge improvement over the dirty plants that first drew public outrage. Beginning with the Clean Air Act in 1970, tightened regulations and sophisticated air pollution controls significantly reduced the levels of harmful chemicals emitted by incinerators.,,Today, 70 mass-burn plants in 21 statesYet by the 1980s the damage to incineration’s reputation was done, as far as many environmental groups and the public at large were concerned. And the battle lines drawn all those years ago remain largely intact today. So claims that these new technologies offer a panacea to waste management and a source of clean, renewable energy have met with skepticism and organized opposition in dozens of communities nationwide faced with proposals in recent years.Ultimately, if the new technologies are to take hold in this country, developers must find a way to not only support their performance claims, but also demonstrate compatibility with established recycling and composting efforts and achieve financial feasibility in areas experiencing no shortage of landfill space.Those advocates may as well start by getting their facts straight, believes veteran waste-industry consultant and gasification expert Steve Jenkins. Given the technologies’ novelty, developers are prone to misrepresent their projects to the public and to regulatory agencies, he says, often leaving them painted with the same brush as mass-burn incinerators.Jenkins addressed the issue through a recent presentation to industry representatives reiterating the basic differences between gasification and incineration.Gasification, plasma gasification, and pyrolysis are closely related and for the purposes of this article are referred to collectively as “conversion technologies” . They involve the super-heating of a feedstock—be it MSW, coal, or agricultural residues—in an oxygen-controlled environment to avoid combustion. The primary differences among them relate to heat source, oxygen level, and temperature, from as low as about 600°F (300°C) for pyrolysis to as high as 20,000°F  for plasma gasification.,,,In these low-oxygen environments the production of dioxins and furans from waste can be significantly reduced compared with incineration,Conversion technologies are further distinguished from conventional MSW incineration by the production of synthesis gas (or syngas) composed mainly of hydrogen and carbon monoxide, a product of the thermal reactions that take place during the processes. The syngas can then be burned in a boiler system to generate electricity. It can also be processed into fuel for an efficient, low-emissions natural gas generator or refined into other valuable products.On paper, these differences make conversion technologies cleaner, more efficient, and more valuable than mass-burn incineration. But that doesn’t mean the technologies always perform as advertised. “Engineers from the industry side are evaluating the situation from steady state at maximum temperature,” says Peter Orris, a professor at the University of Illinois who has tracked WTE technologies from a public health perspective. “I don’t have any reason to doubt those estimates are correct, but they’re not necessarily real-world.” That’s because performance is highest and emissions lowest when a facility is running at full steam, he says. Start-up, cool-down, and loading feedstock into the facility’s reactors are when many problems occur.Waste Management. This is due primarily to the lack of an affordable solution for syngas cleaning, he believes.A gap between potential and actual performance is evident at plants currently operating outside the United States, says Umberto Arena, a researcher based in Italy and associate editor of the journal ,,As it stands today, the cleaning of contaminants and impurities from syngas produced via conversion technologies is often cost-prohibitive.On top of that, the newer systems must be finely tuned and, in some cases, tend to require a more uniform, pre-sorted feedstock than mass-burn incinerators, Arena says. This can add expense to the operation.,Despite these shortcomings, conversion technologies do have a clear benefit in that they leave behind safer solid residues—and less of it—than burning MSW. Incinerators produce significant amounts of a waste called bottom ash, of which about 40% must be landfilled. The remaining 60% can be further treated to separate metals, which are sold, from inert materials, which are often used as road base. The newer technologies, by contrast, offer immediate recovery of metals and inert slags, with smaller volumes of landfill.“If your main interest is to produce electric energy, so far the combustion-based systems are clearly better,” Arena says. “If your interest is to strongly reduce the material that is sent to landfill, as in Japan or Denmark or some other areas of Europe, then you could be very interested in gasification.”Even if the newer conversion technologies have yet to make an unequivocal case that they’re better than their mass-burn predecessors, some argue there’s another comparison that may be more relevant—and ultimately more convincing.In the United States today, landfills have a big advantage when it comes to economics. Sending trash to the dump is almost always cheaper than burning it, with tipping fees paid by haulers averaging about 33% less at landfills than at existing incinerators, according to one analysis.But that’s not necessarily a deal-breaker in areas with limited landfill space, such as Los Angeles. “Our focus is to develop an alternative to landfills,” says Coby Skye, a senior civil engineer for the County of Los Angeles Department of Public Works.,In addition to six operating landfills, Los Angeles County already has two mass-burn incinerators and plans to launch multiple commercial-scale anaerobic digesters, which can produce both energy and compost from wet organic wastes.A studyThe second scenario involved sending the same 1,000 tons per day of post-recycled residuals to a so-called integrated materials recovery facility. This would include advanced recycling of additional materials followed by processing of residuals via gasification and anaerobic digestion, leaving 136 tons per day for the landfill.The latter is “what we would call a dream facility,” says Eugene Tseng, an environmental attorney and engineer whose consulting firm helped prepare the report. “You have to have a suite of technologies for what we call the integrated approach. You take the most appropriate technology for the type of waste that’s being generated.”The study concluded that the landfill scenario would produce a net increase of 1.64 million metric tons of carbon dioxide equivalent emissions over the entire 125 years, while the integrated scenario would result in a net savings of 0.67 million metric tons. This difference of 2.31 million metric tons is comparable to 480,000 fewer passenger vehicles driven for one year. The reduction is achieved in two key ways: 1) through the displacement of emissions from fossil fuel combustion due to the electricity generated; and 2) through increased recycling efforts involved in the extensive pre-processing of materials required before feeding the two plants.,,One critical assumption embedded in the study is that biogenic carbon dioxide emissions resulting from the digestion, decomposition, or processing of biologically based materials are considered part of the natural carbon cycle and therefore carbon neutral with zero net greenhouse gas emissions, in accordance with current state, national, and international standards.However, a growing community of scientists and others feel it is inappropriate to consider all of these emissions carbon neutral.The deepest divide between ardent critics and defenders of conversion technologies, and the one that evokes the most passion on both sides, doesn’t have to do with dioxins or energy production or carbon accounting, but rather with philosophies about how to handle our society’s trash—and what, in fact, trash really is.MSW is a mix of all kinds of materials: not just combustible carbon-based materials but also glass, metals, and more. Proponents of a decades-old philosophy called “zero waste” contend that at least 80% of the typical MSW stream can be recycled or composted , and that reuse and waste prevention can reduce the remaining portion—if not all the way to zero, then close.“The primary ecological benefits associated with recycling are in using recovered materials in a production cycle to displace virgin materials,” says Darby Hoover, a solid waste specialist with the Natural Resources Defense Council (NRDC). “The associated savings of energy, water, and carbon associated with that substitution are where most of the environmental benefits occur. ... That’s the basis of the ‘closed-loop’ idea. Once you introduce a material into commerce, you should do all you can to keep it there.”Supporters of conversion technologies, meanwhile, contend that recycling and composting aren’t enough to sufficiently improve landfill-diversion rates, and that some sort of thermal processing of leftovers is necessary. They employ the newer term “zero-waste-to-landfill” to allow for conversion technologies and other WTE strategies as an additional and in some cases preferred form of recycling.“I strongly feel that the goal of zero-waste-to-landfill cannot be achieved without some additional technologies,” says James Stewart, chairman of the California-based industry group BioEnergy Producers Association. His home state has proposed a plan to improve its recycling rate, stuck at around 50% for the last six years,While there’s little overlap between these opposing perspectives, in practical terms it may be possible to find middle ground. For instance, some argue that WTE technologies could be used as a stopgap solution to keep high-value materials out of landfills while traditional recycling efforts continue to ramp up.“I really do have sympathy for folks who are saying, ‘It’s a shame that we’re landfilling this stuff, why can’t we take energy out of it until we can recycle more of it?’” Hoover says. “The problem is that interim solutions can interfere with the higher and better ecological pathway. We want to really make sure we’ve actually maximized recycling and composting before we get to the waste-to-energy facilities.” That said, Hoover believes there might be a role for some types of WTE technologies as a last-ditch effort to extract energy from materials that contain it before they go to a landfill.Shlomo Dowen, coordinator of the advocacy group United Kingdom Without Incineration Network, believes the traditional conception of zero waste remains within reach—and precludes conversion technologies entirely. “There is very little by way of ‘unrecyclable’ material that could not be addressed by redesign, better source separation, and better sorting technologies,” he says. “And much of what would remain would probably have little or no calorific value so would not be suitable for energy recovery.”Rod Bryden is among those convinced that conversion technologies deserve a place in solid-waste management. The prominent Ottawa businessman runs Plasco Energy Group, a company that hopes to recover power from trash via a proprietary plasma-based technology.,,These plans have suffered a number of setbacks, most notably in Plasco’s Canadian hometown early last year.But that wasn’t the end of it. Seven months after Plasco’s collapse, Bryden bought the company from its creditors for a dollar. Now he’s back at the helm of a restructured company planning its second act.Instead of using syngas to generate electricity on site for sale to a power company, the company now intends to produce and sell a cleaner fuel-grade syngas for blending with natural gas in third-party power plants. “We were never an expert in the power business, and we’re not in that business anymore,” Bryden explains.Tellingly, Plasco’s target market is no longer the United States or Canada, but places like the Chinese capital of Beijing, where Bryden says the price of natural gas is roughly three and a half times what it is in New York. If he can find the right location, he hopes to have a new plant under construction by the middle of next year.Industry consultant Jenkins remains skeptical about the expansion of conversion technologies in the United States. “[In many areas] we’ve got plenty of land, and nothing is driving the prices of landfills up,” he says. “We don’t have the economic drivers in the U.S. except in a few cities and counties.”Government subsidies, favorable regulations, and more social acceptance in Japan and parts of Europe have allowed these costly, capital-intensive facilities to advance even as they continue to flounder here. Over the last 40 years Japanese company JFE Engineering has built more than 160 incinerators and 10 gasification plants in its home country, says project development manager Kenny Miyagi.Harvey Gershman, another waste industry consultant familiar with the newer technologies, says he’s been surprised by their continued failure to gain traction in United States. “For the past ten years I’ve been saying ‘within the next four years.’ I was hoping we’d be able to turn the corner on these technologies a lot sooner than we’ve been able to.”A window of opportunity may already be closing on the technologies, suggests Wilson of GAIA. “There was a flood of proposals, and now there are only a few here and there, and they wither and die on their own. I think the interest overall has really waned over the past year, as people have gotten fed up after hearing so many promises.” But, she concedes, “there still are some really strong believers in it.”Mass-burn incinerationMass-burn combustion of MSW occurs in an oxygen-rich setting with minimal prior sorting or preparation. The resulting heat is used to produce steam and electricity.Municipal solid waste (MSW)MSW is the term for common mixed trash collected from homes, businesses, and institutions, including packaging, food waste, yard waste, and both durable and nondurable goods.Synthesis gas (syngas)Syngas, composed mainly of hydrogen and carbon monoxide, is produced by conversion technology processes. It can be used as fuel for electricity or converted into other salable products such as liquid fuels.Conversion technologiesThis blanket term encompasses noncombustion processes that convert solid waste into useful products. For the purposes of this article, the term refers specifically to gasification, plasma gasification, and pyrolysis, but other conversion technologies include depolymerization, anaerobic digestion, and fermentation.GasificationGasification is a process that converts any material containing carbon—such as coal, biomass, or MSW—into syngas. In the controlled presence of oxygen, temperatures of 900–3,000°F  break the feedstock molecules apart and recombine them into syngas.Plasma gasificationPlasma gasification uses a plasma torch to provide supplemental heat for the gasification process. Temperatures can reach 5,000–20,000°F .PyrolysisPyrolysis is a form of gasification that occurs at relatively low temperatures of 600–1,400°F (300–760°C) in the absence of oxygen.Waste-to-energy (WTE) technologiesThe full suite of WTE technologies includes thermal processes like mass-burn incineration and gasification as well as nonthermal processes like anaerobic digestion and landfill-gas recovery.Source: Stringfellow (2014)


Across affective behavior and narrative within stories of late procreative desire, dream journals and Word Association Tests of eight participants was the memory of a male sibling who had enjoyed primacy of place in the parental home over the daughter. The female body with a voice was missing in the one-sided perspectives of Analytical Psychology and Psychoanalysis on the subject of the feminine, until a whole view of psyche’s discontents in Feminist inspired Psychoanalytic theories from both schools on the female body were included. Freud and Jung’s views became evidence of patriarchy as background while extension of Feminist inspired psychoanalytical thinking, Queer theories and Creation Myth allowed new meanings of the embodied feminine to emerge through a recapitulation of a union of opposites as a union of epistemology and ethos. The essence of Jung’s mid-life theories, altered by modernity and eclipsed by female advancement, remains replicatable and paradigmatic outside of essentialist gender performance.While conducting doctoral research in social science on late motherhood, two analytical engagements with the feminine came to my attention as evidence of a patriarchal bias toward the realm of womanhood. Jung’s mythopoetic tension between symbolism and enactments with  Appearing in every culture, these motifs were intuitively drawn over millennia to signify psychic renewal, forecasting how dominant factors in the psyche undergo processes of decomposition and clarification by fire, out of which emerges the ‘new king’ or new consciousness . This al midlife . The eme midlife , para. 2 midlife . “Jung’s midlife  similarl midlife , pp. 215“Jung’s entire project, I am suggesting, is, in mythical terms an attempt to re-balance modernity that has been brought to crisis by an over-valuing of Logos at the expense of Eros-relating…by essentializing the creation myths, he is able to stabilize the masculine signifying he wants to retain it, while insisting upon its re-formation to include the feminine, which remains marginal”. .l life” Jung perhaps explains his gender biases best in describing his view of opposites in male and female terms followed by problems when the opposites are not in their ‘right order’. “…woman’s conscious is characterized more by the connective quality of Eros than by the discrimination and cognition associated by Logos. In men, Eros… is usually less developed than Logos. In women on the other hand, Eros is an expression of their true nature, while their Logos is often a regrettable accident”..he Lambs , p. 96).“Not only do they fear men’s attacks on their bodies but also they face denigrating social systems that reinforce a second-class status and devalue what it means to live through a feminine point of view”. These dangers, horrors and defilements have been described and examined by both Kristeva  and DougThe Woman’s Encyclopedia of Myth and Secrets, Alexander Stewart “Students in mythology find that when the feminine principle is subjected to sustained attack, it often quietly submerges. Under the water (where organic life began) it swims through the subconscious of the dominant male society, occasionally bobbing to the surface to offer a glimpse of the rejected harmony”. , regarding what women really want: sovereignty over their own life. Here then lies the ethical methodological junction, where Feminist inspired Psychoanalytic and Feminist leaning Analytical Psychology join up to write an ethos for the use of intra-psychic and inter-subjectivity in research with female participants. The tension we are considering is when the body matters and when it does not.The feminine hero may be different from the heroine in my observations. The heroine comes up in life believing it is safe to be female because her nurturing early environment made it so. Throughout her development she does not cower at real life challenges, even those threatening her with domination and sublimation rituals . Whereasis delayed motherhood a revolt against domination of the biological imperative to reproduce in uncertain relationship to patriarchy? This is an ethical question to do with non-normative sexual behavior, the place where Queer theory began its linguistic life before moving into gay and lesbian caucuses, Feminist politics upward to academic institutions, in parallel to rising awareness of AIDS [“A complex… results from the blend of an archetypal core… and human experience particularly in the early years of life” .  of AIDS  before t of AIDS , p. 29).can’t be made) to signify monolithically” .ically” . pposites , somethipposites  describepposites , p. 107)pposites , p. 28).pposites , p. 291)g agency ,77 as itg agency , p. 87).midlife pregnant pause [primal material, rather than constructing pathologies for non-participation in essentialist notions of feminine performance. Unconscious processes of the embodied feminine achieving late motherhood in mid-life emerged as a Feminist issue of power, control, defense, separation and repair. From this, a new union of epistemology and ethos has become impossible to ignore, in part because what is emerging in late motherhood is a different kind of mothering, on which rests the future of a different relationship to patriarchy.I did not enter into the research topic of a nt pause  leading


Objective. The aim of this study was to provide a definition of big data in healthcare. Methods. A systematic search of PubMed literature published until May 9, 2014, was conducted. We noted the number of statistical individuals (n) and the number of variables (p) for all papers describing a dataset. These papers were classified into fields of study. Characteristics attributed to big data by authors were also considered. Based on this analysis, a definition of big data was proposed. Results. A total of 196 papers were included. Big data can be defined as datasets with Log(n∗p) ≥ 7. Properties of big data are its great variety and high velocity. Big data raises challenges on veracity, on all aspects of the workflow, on extracting meaningful information, and on sharing information. Big data requires new computational methods that optimize data management. Related concepts are data reuse, false knowledge discovery, and privacy issues. Conclusion. Big data is defined by volume. Big data should not be confused with data reuse: data can be big without being reused for another purpose, for example, in omics. Inversely, data can be reused without being necessarily big, for example, secondary use of Electronic Medical Records (EMR) data. The 21st century is an era of big data involving all aspects of human life, including biology and medicine . As a reTo date, however, the term “big data” does not have a proper definition in the MeSH  database yet. A precise, well-formed, and unambiguous definition is a requirement for a shared understanding of the term big data. The objective of this work is to provide a definition of big data in healthcare through a review of the literature.(big data[Title/Abstract]) AND (“1900/01/01”[Date - Publication]: “2014/05/09”[Date - Publication]).For this literature review, we conducted a systematic search of the PubMed database for all papers published until May 9, 2014, using the keywords “big data.” To be fully inclusive, we did not define a start date. We used the following PubMed query:Titles and abstracts were reviewed by a human for eligibility. Papers were excluded if they were not directly related to healthcare or if big data was not found to be the topic of the paper.We then attempted to retrieve the full-text papers. We used online search facilities , resources, and services of the Lille University library and tried to directly contact the first or corresponding author. Full-text papers were then read.Each of the remaining papers was included in the analysis and classified either as a paper describing a dataset, a dissertation, or a review of the literature.n) and the number of variables (p). It should be noted that the number of statistical individuals n is not necessarily physical persons but can also be, for example, gene sequences. The number of variables p could be, for example, the number of physicochemical properties used to classify amino acids ). It is followed by medical specialties : 15 papers  and public health , epidemiology, pharmacovigilance, and public health): 10 papers .Among the 48 papers describing a dataset, three main categories of studies were identified: omics, medical specialties, and public health. The term “omics” refers to biology fields of study ending in -omics, such as genomics, metabolomics, or proteomics. The main area represented is omics: 23 papers ) for each year of publication of the papers that describe a dataset. We observe a nonsignificant increase of 0.43 per year .n), Log(p), and Log(n∗p), respectively, for omics, medical specialties, public health, and all papers. It can be pointed out that Log(n∗p) is inferior to 7 in 23 studies out of 48 .Figures p) as a function of Log(n) for omics, medical specialties, and public health. This figure suggests the following differences between omics, medical specialties, and public health categories:n, high p;big data in omics concern massive data collected on a limited number of individuals: small n, small p;public health studies concern an important number of individuals and a low number of variables: high n, high p.medical specialties are characterized by an important number of individuals and variables: high The main characteristic about big data found in the papers is its massive size and complexity , 9–17. B12 bytes), petabytes (1015 bytes) or exabytes (1018 bytes)” [17)” [Volume is the main characteristic mentioned by authors , 30, 31. bytes)” . “Volume bytes)” . Some au bytes)” , 32: “Ho)” [17)” . Data seVariety is another important characteristic of big data , 33–35. Moreover, big data can be “volatile, that is, changing, and available only for a limited amount of time” .Accelerated increase of data is another attribute of big data , 31, 42.Veracity comes next: big data can be difficult to validate , 26–28. Big data raises challenges on all aspects of the workflow: from amassing , capturiFinding new statistical and computational methods is another challenge raised by big data , 61, 62.Several authors emphasize the fact that it is necessary to derive useful information of these data , 63, 64 Many authors highlight the necessity of identifying ways to facilitate information access and sharing , 65–67. Some authors mention the fact that the number of available human experts who have both clinical and analytic knowledge is not sufficient yet , 68: “thSome authors mention the fact that big data can be data that are commonly collected without an immediate use: “Massive amounts of data are commonly collected without an immediate business case, but simply because it is affordable. This data, so it is hoped, will later answer questions, most of which yet have to arise” . They puSome authors highlight the fact that deriving knowledge from big data can lead to false results and to conclusions that are wrong –75: “ExpOne concern mentioned by several authors is privacy issues: “the increasing ease with which data may be used and reused has increased concerns about privacy and informed consent” . The abin∗p) is superior or equal to 7.A definition of big data was established on the basis of findings from the literature review. We consider that big data should exclusively be defined by volume, and we propose that a dataset could be qualified as “big dataset” only if Log inferior to 7, even when the analysis is performed with a simple spreadsheet instead of statistical software calling for high computational capacities. However, this proposal suggests that half of the studies describing a dataset in this literature review wrongly call their dataset big data. As everyone talks about the challenges of computing and data processing, considering what we know today in practice about software and computers, it would have been difficult to admit a threshold of Log(n∗p) superior or equal to 6 , because we know that, nowadays, such size of data is easy to deal with.Nevertheless, as there is no definition of big data, the literature can itself be wrong. It is a limitation of this inductive approach: we use observations to build a definition. The problem of defining a threshold illustrates this difficulty: the threshold of 10It should also be pointed out that there is an undeniable current trend of big data, which leads to the fact that the term “big data” is now used to qualify datasets that, in the past, would not have been called this way. Moreover, we can consider that the size of datasets that qualify as big data may keep on increasing due to the main property of big data, which is the challenge on data processing and the fact that computational infrastructure that is required to process these large-scale datasets may progress with time.Data reuse has been defined as a related concept of big data because we think that there might be some confusion between these two terms: data reuse is the fact of using for decisional purposes data that were collected routinely for transactional purposes, whereas big data is related to the size of the data collection. Indeed, data can be big without being reused for another purpose: this is the case of omics, for example. Inversely, data can be reused without being necessarily big, such as secondary use of data from Electronic Medical Records (EMR).Big data presents many opportunities for translational studies, and informatics will be the key for successful translational research . As ShahInformatics is needed to fully harness the potential of health data and new tools are emerging to translate health data into knowledge for improved healthcare.