Ethics in Health Policy for Allergy : A Practical Approach for Decision-Makers

Comme à l’approche d’un tsunami, l’incidence grandissante des allergies affecte maintenant plus de 30% de la population des pays développés. Étant la cause de nombreuses morbidités et un risque significatif de mortalité, les allergies nécessitent des dépenses exorbitantes au système de santé et constituent une des plus importantes sources d’invalidité. Cette thèse a pour but de contribuer à faciliter la prise de décision éclairée dans le développement de politiques en santé en lien avec cette maladie immunitaire chronique en utilisant des principes d’éthique comme outils pour guider le développement de politiques en santé. Le premier chapitre démontre le présent déficit d’analyses des enjeux éthiques en allergologie et démontre de quelle façon les réflexions en éthique peuvent guider le développement de politiques et l’élaboration de stratégies appliquées aux allergies. Les chapitres qui suivront présentent des applications spécifiques des principes d’éthiques ciblant des contextes précis comme des méthodes qui fournissent des outils de réflexion et des cadres théoriques qui peuvent être appliqués par les décideurs pour guider des interventions en santé concernant les allergies et les conditions de co-morbidité reliées. Le second chapitre présente un cadre théorique pour l’évaluation et la priorisation d’interventions en santé publique par la diminution des allergènes présents dans l’environnement basées sur des théories de justice sociale. Les critères entourant les politiques d’évaluation se concentrent sur les enjeux éthiques référant aux populations vulnérables, sur une distribution plus égale des bénéfices pour la santé, et sur le devoir d’éviter la stigmatisation. Le troisième chapitre offre aux administrateurs et au personnel infirmier du réseau scolaire un cadre décisionnel pour guider le développement de politiques efficaces et éthiquement justifiables concernant les allergies alimentaires pour les écoles. Dans ce contexte, les principes de base d’éthique en santé publique et en bioéthique - par exemple, l’empowerment des populations vulnérables dans la prise en charge de leur santé et la protection de la confidentialité du dossier médical - servent d’outils pour évaluer les politiques. Le dernier chapitre emploie les principes de base de recherche en éthique comme méthode pour développer un argumentaire en faveur de la réforme des réglementations entourant la production de médicaments immunothérapeutiques. La nécessité éthique d’éviter les risques de méfait à l’endroit du sujet humain dans la recherche permettra de servir de guide pour structurer de futures politiques en santé publique en égard à la production d’immunothérapeutiques à l’échelle mondiale.

Limited sampling strategies for estimation of cyclosporine exposure in pediatric hematopoietic stem cell transplant recipients : methodological improvement and introduction of sampling time deviation analysis.

Le suivi thérapeutique est recommandé pour l’ajustement de la dose des agents immunosuppresseurs. La pertinence de l’utilisation de la surface sous la courbe (SSC) comme biomarqueur dans l’exercice du suivi thérapeutique de la cyclosporine (CsA) dans la transplantation des cellules souches hématopoïétiques est soutenue par un nombre croissant d’études. Cependant, pour des raisons intrinsèques à la méthode de calcul de la SSC, son utilisation en milieu clinique n’est pas pratique. Les stratégies d’échantillonnage limitées, basées sur des approches de régression (R-LSS) ou des approches Bayésiennes (B-LSS), représentent des alternatives pratiques pour une estimation satisfaisante de la SSC. Cependant, pour une application efficace de ces méthodologies, leur conception doit accommoder la réalité clinique, notamment en requérant un nombre minimal de concentrations échelonnées sur une courte durée d’échantillonnage. De plus, une attention particulière devrait être accordée à assurer leur développement et validation adéquates. Il est aussi important de mentionner que l’irrégularité dans le temps de la collecte des échantillons sanguins peut avoir un impact non-négligeable sur la performance prédictive des R-LSS. Or, à ce jour, cet impact n’a fait l’objet d’aucune étude. Cette thèse de doctorat se penche sur ces problématiques afin de permettre une estimation précise et pratique de la SSC. Ces études ont été effectuées dans le cadre de l’utilisation de la CsA chez des patients pédiatriques ayant subi une greffe de cellules souches hématopoïétiques. D’abord, des approches de régression multiple ainsi que d’analyse pharmacocinétique de population (Pop-PK) ont été utilisées de façon constructive afin de développer et de valider adéquatement des LSS. Ensuite, plusieurs modèles Pop-PK ont été évalués, tout en gardant à l’esprit leur utilisation prévue dans le contexte de l’estimation de la SSC. Aussi, la performance des B-LSS ciblant différentes versions de SSC a également été étudiée. Enfin, l’impact des écarts entre les temps d’échantillonnage sanguins réels et les temps nominaux planifiés, sur la performance de prédiction des R-LSS a été quantifié en utilisant une approche de simulation qui considère des scénarios diversifiés et réalistes représentant des erreurs potentielles dans la cédule des échantillons sanguins. Ainsi, cette étude a d’abord conduit au développement de R-LSS et B-LSS ayant une performance clinique satisfaisante, et qui sont pratiques puisqu’elles impliquent 4 points d’échantillonnage ou moins obtenus dans les 4 heures post-dose. Une fois l’analyse Pop-PK effectuée, un modèle structural à deux compartiments avec un temps de délai a été retenu. Cependant, le modèle final - notamment avec covariables - n’a pas amélioré la performance des B-LSS comparativement aux modèles structuraux (sans covariables). En outre, nous avons démontré que les B-LSS exhibent une meilleure performance pour la SSC dérivée des concentrations simulées qui excluent les erreurs résiduelles, que nous avons nommée « underlying AUC », comparée à la SSC observée qui est directement calculée à partir des concentrations mesurées. Enfin, nos résultats ont prouvé que l’irrégularité des temps de la collecte des échantillons sanguins a un impact important sur la performance prédictive des R-LSS; cet impact est en fonction du nombre des échantillons requis, mais encore davantage en fonction de la durée du processus d’échantillonnage impliqué. Nous avons aussi mis en évidence que les erreurs d’échantillonnage commises aux moments où la concentration change rapidement sont celles qui affectent le plus le pouvoir prédictif des R-LSS. Plus intéressant, nous avons mis en exergue que même si différentes R-LSS peuvent avoir des performances similaires lorsque basées sur des temps nominaux, leurs tolérances aux erreurs des temps d’échantillonnage peuvent largement différer. En fait, une considération adéquate de l'impact de ces erreurs peut conduire à une sélection et une utilisation plus fiables des R-LSS. Par une investigation approfondie de différents aspects sous-jacents aux stratégies d’échantillonnages limités, cette thèse a pu fournir des améliorations méthodologiques notables, et proposer de nouvelles voies pour assurer leur utilisation de façon fiable et informée, tout en favorisant leur adéquation à la pratique clinique.

What is reflection? A conceptual analysis of major definitions and a proposal of a five-component definition and model

La réflexion est considérée comme un élément significatif de la pédagogie et de la pratique médicales sans qu’il n’existe de consensus sur sa définition ou sur sa modélisation. Comme la réflexion prend concurremment plusieurs sens, elle est difficile à opérationnaliser. Une définition et un modèle standard sont requis afin d’améliorer le développement d’applications pratiques de la réflexion. Dans ce mémoire, nous identifions, explorons et analysons thématiquement les conceptualisations les plus influentes de la réflexion, et développons de nouveaux modèle et définition. La réflexion est définie comme le processus de s’engager (le « soi » (S)) dans des interactions attentives, critiques, exploratoires et itératives (ACEI) avec ses pensées et ses actions (PA), leurs cadres conceptuels sous-jacents (CC), en visant à les changer et en examinant le changement lui-même (VC). Notre modèle conceptuel comprend les cinq composantes internes de la réflexion et les éléments extrinsèques qui l’influencent.

Development and Analysis of Compact AMicrostrip Antennas

The practical applications of microstrip antennas for mobile systems are in portable or pocket-size equipment and in vehicles. Antennas for VHFIUHF handheld portable equipment, such as pagers, portable telephones and transceivers, must naturally be small in size, light in weight and compact in structure. There is a growing tendency for portable equipment to be made smaller and smaller as the demand for personal communication rapidly increases, and the development of very compact hand-held units has become urgent.In this thesis work, main aim is to develop a more and more reduced sized microstrip patch antenna. It is well known that the smaller the antenna size, the lower the antenna efficiency. During the period of work, three different compact circular sided microstrip patches are developed and analysed, which have a significant size reduction compared to standard circular disk antenna (the most compact one of the basic microstrip patch configurations), without much deterioration of its properties like gain, bandwidth and efficiency. In addition to this the interesting results, dual port operation and circular polarization are also observed for some typical designs of these patches. These make the patches suitable for satellite and mobile communication systems.The theoretical investigations are carried out on these compact patches. The empirical relations are developed by modifying the standard equations of rectangular and circular disk microstrip patches, which helps to predict the resonant frequencies easily.

Modelling and Analysis of Recurrent Event Data with Multiple Causes

This thesis Entitled “modelling and analysis of recurrent event data with multiple causes.Survival data is a term used for describing data that measures the time to occurrence of an event.In survival studies, the time to occurrence of an event is generally referred to as lifetime.Recurrent event data are commonly encountered in longitudinal studies when individuals are followed to observe the repeated occurrences of certain events. In many practical situations, individuals under study are exposed to the failure due to more than one causes and the eventual failure can be attributed to exactly one of these causes.The proposed model was useful in real life situations to study the effect of covariates on recurrences of certain events due to different causes.In Chapter 3, an additive hazards model for gap time distributions of recurrent event data with multiple causes was introduced. The parameter estimation and asymptotic properties were discussed .In Chapter 4, a shared frailty model for the analysis of bivariate competing risks data was presented and the estimation procedures for shared gamma frailty model, without covariates and with covariates, using EM algorithm were discussed. In Chapter 6, two nonparametric estimators for bivariate survivor function of paired recurrent event data were developed. The asymptotic properties of the estimators were studied. The proposed estimators were applied to a real life data set. Simulation studies were carried out to find the efficiency of the proposed estimators.

Some concepts and models usefulninthe analysis of discrete life time data

This thesis entitled Reliability Modelling and Analysis in Discrete time Some Concepts and Models Useful in the Analysis of discrete life time data.The present study consists of five chapters. In Chapter II we take up the derivation of some general results useful in reliability modelling that involves two component mixtures. Expression for the failure rate, mean residual life and second moment of residual life of the mixture distributions in terms of the corresponding quantities in the component distributions are investigated. Some applications of these results are also pointed out. The role of the geometric,Waring and negative hypergeometric distributions as models of life lengths in the discrete time domain has been discussed already. While describing various reliability characteristics, it was found that they can be often considered as a class. The applicability of these models in single populations naturally extends to the case of populations composed of sub-populations making mixtures of these distributions worth investigating. Accordingly the general properties, various reliability characteristics and characterizations of these models are discussed in chapter III. Inference of parameters in mixture distribution is usually a difficult problem because the mass function of the mixture is a linear function of the component masses that makes manipulation of the likelihood equations, leastsquare function etc and the resulting computations.very difficult. We show that one of our characterizations help in inferring the parameters of the geometric mixture without involving computational hazards. As mentioned in the review of results in the previous sections, partial moments were not studied extensively in literature especially in the case of discrete distributions. Chapters IV and V deal with descending and ascending partial factorial moments. Apart from studying their properties, we prove characterizations of distributions by functional forms of partial moments and establish recurrence relations between successive moments for some well known families. It is further demonstrated that partial moments are equally efficient and convenient compared to many of the conventional tools to resolve practical problems in reliability modelling and analysis. The study concludes by indicating some new problems that surfaced during the course of the present investigation which could be the subject for a future work in this area.

Compositional data analysis: where we are and where should we be heading?

We take stock of the present position of compositional data analysis, of what has been achieved in the last 20 years, and then make suggestions as to what may be sensible avenues of future research. We take an uncompromisingly applied mathematical view, that the challenge of solving practical problems should motivate our theoretical research; and that any new theory should be thoroughly investigated to see if it may provide answers to previously abandoned practical considerations. Indeed a main theme of this lecture will be to demonstrate this applied mathematical approach by a number of challenging examples

Multivariate ARIMA Compositional Time Series Analysis

A compositional time series is obtained when a compositional data vector is observed at different points in time. Inherently, then, a compositional time series is a multivariate time series with important constraints on the variables observed at any instance in time. Although this type of data frequently occurs in situations of real practical interest, a trawl through the statistical literature reveals that research in the field is very much in its infancy and that many theoretical and empirical issues still remain to be addressed. Any appropriate statistical methodology for the analysis of compositional time series must take into account the constraints which are not allowed for by the usual statistical techniques available for analysing multivariate time series. One general approach to analyzing compositional time series consists in the application of an initial transform to break the positive and unit sum constraints, followed by the analysis of the transformed time series using multivariate ARIMA models. In this paper we discuss the use of the additive log-ratio, centred log-ratio and isometric log-ratio transforms. We also present results from an empirical study designed to explore how the selection of the initial transform affects subsequent multivariate ARIMA modelling as well as the quality of the forecasts

e-Research Methods Theme 7 Data Analysis

In this theme you will work through a series of texts and activities and reflect on your view of research and the process of analysis of data and information. Most activities are supported by textual or audio material and are there to stimulate your thinking in a given area. The purpose of this theme is to help you gain a general overview of the main approaches to research design. Although the theme comprises two main sections, one on quantitative research and the other on qualitative research, this is purely to guide your study. The two approaches may be viewed as being part of a continuum with many research studies now incorporating elements of both styles. Eventually you will need to choose a research approach or methodology that will be practical, relevant, appropriate, ethical, of good quality and effective for the research idea or question that you have in mind.

La sabiduría como competencia gerencial

Aunque el concepto de sabiduría ha sido ampliamente estudiado por expertos de áreas como la filosofía, la religión y la psicología, aún enfrenta limitaciones en cuanto a su definición y evaluación. Por esto, el presente trabajo tiene como objetivo, formular una definición del concepto de sabiduría que permita realizar una propuesta de evaluación del concepto como competencia en los gerentes. Para esto, se realizó un análisis documental de tipo cualitativo. De esta manera, se analizaron diversos textos sobre la historia, las definiciones y las metodologías para evaluar tanto la sabiduría como las competencias; diferenciando la sabiduría de otros constructos y analizando la diferencia entre las competencias generales y las gerenciales para posteriormente, definir la sabiduría como una competencia gerencial. Como resultado de este análisis se generó un prototipo de prueba denominado SAPIENS-O, a través del cuál se busca evaluar la sabiduría como competencia gerencial. Como alcances del instrumento se pueden identificar la posibilidad de medir la sabiduría como competencia en los gerentes, la posibilidad de dar un nuevo panorama a las dificultades teóricas y empíricas sobre la sabiduría y la posibilidad de facilitar el estudio de la sabiduría en ambientes reales, más específicamente en ambientes organizacionales.

De la literatura y la estadística a la apropiación territorial: análisis de la narración geográfica sobre las provincias del norte neogranadinas en la segunda mitad del siglo XIX

Las obras geográficas de Manuel Ancízar y Felipe Pérez dan cuenta de la manera en la que la élite intelectual neogranadina se apropió y representó el aspecto físico y humano de la nación al inicio y final de la Comisión Corográfica (1850-1859). Un análisis comparativo de las obras mostrará la manera en la que la narración literaria y la geográfica influyen en la elaboración de imaginarios territoriales para unificar la nación y consolidar la identidad nacional a partir de la apropiación territorial en la segunda mitad del siglo XIX

Roles in construction projects: analysis and terminology

Standard form contracts are typically developed through a negotiated consensus, unless they are proffered by one specific interest group. Previously published plans of work and other descriptions of the processes in construction projects tend to focus on operational issues, or they tend to be prepared from the point of view of one or other of the dominant interest groups. Legal practice in the UK permits those who draft contracts to define their terms as they choose. There are no definitive rulings from the courts that give an indication as to the detailed responsibilities of project participants. The science of terminology offers useful guidance for discovering and describing terms and their meanings in their practical context, but has never been used for defining terms for responsibilities of participants in the construction project management process. Organizational analysis enables the management task to be deconstructed into its elemental parts in order that effective organizational structures can be developed. Organizational mapping offers a useful technique for reducing text-based descriptions of project management roles and responsibilities to a comparable basis. Research was carried out by means of a desk study, detailed analysis of nine plans of work and focus groups representing all aspects of the construction industry. No published plan of work offers definitive guidance. There is an enormous amount of variety in the way that terms are used for identifying responsibilities of project participants. A catalogue of concepts and terms (a “Terminology”) has been compiled and indexed to enable those who draft contracts to choose the most appropriate titles for project participants. The purpose of this terminology is to enable the selection and justification of appropriate terms in order to help define roles. The terminology brings an unprecedented clarity to the description of roles and responsibilities in construction projects and, as such, will be helpful for anyone seeking to assemble a team and specify roles for project participants.

A lightweight technique for assessing risks in requirements analysis

A simple and practical technique for assessing the risks, that is, the potential for error, and consequent loss, in software system development, acquired during a requirements engineering phase is described. The technique uses a goal-based requirements analysis as a framework to identify and rate a set of key issues in order to arrive at estimates of the feasibility and adequacy of the requirements. The technique is illustrated and how it has been applied to a real systems development project is shown. How problems in this project could have been identified earlier is shown, thereby avoiding costly additional work and unhappy users.

The 'direct costs' of livestock disease: The development of a system of models for the analysis of 30 endemic livestock diseases in Great Britain

The 'direct costs' attributable to 30 different endemic diseases of farm animals in Great Britain are estimated using a standardised method to construct a simple model for each disease that includes consideration of disease prevention and treatment costs. The models so far developed provide a basis for further analyses including cost-benefit analyses for the economic assessment of disease control options. The approach used reflects the inherent livestock disease information constraints, which limit the application of other economic analytical methods. It is a practical and transparent approach that is relatively easily communicated to veterinary scientists and policy makers. The next step is to develop the approach by incorporating wider economic considerations into the analyses in a way that will demonstrate to policy makers and others the importance of an economic perspective to livestock disease issues.

Predicting feed quality - chemical analysis and in vitro evaluation

As the ideal method of assessing the nutritive value of a feedstuff, namely offering it to the appropriate class of animal and recording the production response obtained, is neither practical nor cost effective a range of feed evaluation techniques have been developed. Each of these balances some degree of compromise with the practical situation against data generation. However, due to the impact of animal-feed interactions over and above that of feed composition, the target animal remains the ultimate arbitrator of nutritional value. In this review current in vitro feed evaluation techniques are examined according to the degree of animal-feed interaction. Chemical analysis provides absolute values and therefore differs from the majority of in vitro methods that simply rank feeds. However, with no host animal involvement, estimates of nutritional value are inferred by statistical association. In addition given the costs involved, the practical value of many analyses conducted should be reviewed. The in sacco technique has made a substantial contribution to both understanding rumen microbial degradative processes and the rapid evaluation of feeds, especially in developing countries. However, the numerous shortfalls of the technique, common to many in vitro methods, the desire to eliminate the use of surgically modified animals for routine feed evaluation, paralleled with improvements in in vitro techniques, will see this technique increasingly replaced. The majority of in vitro systems use substrate disappearance to assess degradation, however, this provides no information regarding the quantity of derived end-products available to the host animal. As measurement of volatile fatty acids or microbial biomass production greatly increases analytical costs, fermentation gas release, a simple and non-destructive measurement, has been used as an alternative. However, as gas release alone is of little use, gas-based systems, where both degradation and fermentation gas release are measured simultaneously, are attracting considerable interest. Alternative microbial inocula are being considered, as is the potential of using multi-enzyme systems to examine degradation dynamics. It is concluded that while chemical analysis will continue to form an indispensable part of feed evaluation, enhanced use will be made of increasingly complex in vitro systems. It is vital, however, the function and limitations of each methodology are fully understood and that the temptation to over-interpret the data is avoided so as to draw the appropriate conclusions. With careful selection and correct application in vitro systems offer powerful research tools with which to evaluate feedstuffs. (C) 2003 Elsevier B.V. All rights reserved.