Quelle organisation des soins pour le patient polymorbide? [How should we organize health care for multimorbidity patients?].

Polymorbidity affects an increasing number of patients of all ages as demonstrated by a recent epidemiological study and represents a real challenge for the organization of health care. Appropriate management of polymorbid patients requires an interdisciplinary approach associating generalist and specialist physicians, but also nurses, other health professionals and social workers. An improvement in transition care between the community and the hospital is necessary in both directions. Prioritizing the treatment objectives is essential to allow patient adherence and avoid cumulative drug interactions and adverse effects. Those objectives are difficult to attain in the context of our present health care organization. This paper attempts to identify the difficulties involved in caring for polymorbid patients and propose ways to improve it.

From geriatric service to primary care: a retrospective pharmaceutical analysis of the medical prescription

Introduction The population of elderly persons is increasing andnegative outcomes due to polymedication are frequent. Discrepanciesin information about medication are frequent when older persons aretransitioning from hospital to home, increasing the risk of hospitalreadmission. The aims of this study were a) to determine discrepanciesin medical regimen indicated in two official discharge documents(DS = discharge summary, DP=discharge prescription); b) to characterizethe pharmacotherapy prescribed in older patients dischargedfrom a geriatric service.Materials & Methods Elderly patients (N=230) discharged from thegeriatric service (CHUV, Lausanne) over a 6-month period (January toJune 2009) were selected. Community pharmacists compared DS andDP to identify discrepancies including (a) drugs' name; (b) schedule ofadministration, dosage, frequency, prn prescription, treatment durationand galenic formulation. Beers' criteria were applied to identifypotentially inappropriate drugs and a descriptive analysis of drug costs,prescription profiles and generics were also performed.Results On average, patients were 82 ± 7 years old and stayed23.0 ± 11.6 days in the geriatric service. The delay between the datesof patient's discharge with the DP and the sending of the DS to hisgeneral physician averaged 14.0 ± 7.5 days (range 1-55). The DPhad an average of 10.0 ± 3.3 drugs (range 2-19). 77% of patients hadat least one discrepancy. A drug was missing on the DS in 57.8% ofpatients and 19.6% had a missing prn prescription. Among the 2312drugs prescribed, 3% belonged to Beers' list. They were prescribed to61 patients (26.5%), with 6 patients cumulating two Beers' potentiallyinappropriate drugs in their treatment. Analgesics (85% of thepatients), anticoagulants (80%), mineral supplements (77%), laxatives(52%) and antihypertensives (46%) were the drug classes most frequentlyprescribed. Mean costs of treatment as per DP was160.4 ± 179.4 Euros. Generic prescription represented more than 5%of the costs for 3 therapeutic classes (cholesterol-lowering agents(64%), antihypertensives (50%) and antidepressants (47%)).Discussion & Conclusion The high discrepancy rate between medicationlisted in the DP and the DS highlights a need for safetyimprovement. Potential benefits are expected from reinforced pharmacist-physician collaboration in transition from hospital to primarycare. In addition, even though Beers' criteria are questionable, thedrugs prescribed in this already fragile population, and the potentialopportunities of economical optimizations, are advocating thedevelopment and the scientific evaluation of a structured advancedcollaborative pharmacy practice service. This foresees improvedeffectiveness, safety and efficiency in the medication management ofelderly persons.

Juan Luis Vives and Richard Mulcaster: a humanist view of language

Humanist writers were multifaceted and thcir writings eclectic, delving into a wide range of fields of enquiry Many issues wcre raised and addressed, pursued ur abandoned, uftcn unsystematically. ‘[his hetcrogeneity has frequently lcd tu the neglect of specific facets of authurs who have gained renuwn in uthcr fzelds. ‘[his 1 believe tu be the case fur Richard Mulcaster and Juan Luis Vives, whuse contribution tu language Éhcory has been eclipsed by their rclatively mudem views un educatiun. ‘[heir views un language merit mure attention, if not fur their originality as such, at least fur te testimony they pruvide uf a periud in transition. ‘[he work uf these authors show 1mw views un language evolved thruughout te periud mié convey a sense uf its dynamic character. Profoundly cunservative attitudes coexist with progressive unes and, tliough ruoted in the past, thcy strain tuwards a new vision uf the nature and functioning uf language in human sucicty.

Teollisuusverkon stabiilisuus saarekekäyttöön siirryttäessä

Työn aluksi on käsitelty sähkövoimajärjestelmien stabiilisuutta yleisesti. Myös teollisuuden sähköverkkojen erityispiirteitä on tarkasteltu. Teollisuusverkkojen komponentteja koskevassa selvityksessä eri laitteet on käsitelty siten, että niiden tärkeimmät ominaisuudet verkon erilaisissa muutostilanteissa tulevat esille. Tahtigeneraattorit ja epätahtikoneet on käsitelty yksityiskohtaisesti. Tutkimuksessa on esitelty teollisuusverkon saarekekäyttöön johtavia syitä, saarekkeeseen siirtymisen kriteereitä ja saarekekäytön toteutustapoja. Tehonvajaussuojaukseen liittyen on tutustuttu kuormanpudotusjärjestelyihin. Myös höyryverkon kuormien tasausten mahdollisuuksiin on luotu katsaus. Verkostolaskentaa käsittelevässä luvussa on keskitytty sopivan laskentamallin luomiseen liittyviin menetelmiin ja rajoituksiin. Lisäksi on kerrottu työn käytännön osan laskentamallin luomisen keskeiset periaatteet. Työn lopuksi on suoritettu simulointeja, joissa on tutkittu erään teollisuusverkon stabiilisuutta saarekekäyttöön siirryttäessä Calpos-verkostolaskentaohjelmistolla.

Capital Controls with International Reserve Accumulation: Can this Be Optimal ?

Motivated by the Chinese experience, we analyze a semi-open economy where the central bank has access to international capital markets, but the private sector has not. This enables the central bank to choose an interest rate different from the international rate. We examine the optimal policy of the central bank by modelling it as a Ramsey planner who can choose the level of domestic public debt and of international reserves. The central bank can improve savings opportunities of credit-constrained consumers modelled as in Woodford (1990). We find that in a steady state it is optimal for the central bank to replicate the open economy, i.e., to issue debt financed by the accumulation of reserves so that the domestic interest rate equals the foreign rate. When the economy is in transition, however, a rapidly growing economy has a higher welfare without capital mobility and the optimal interest rate differs from the international rate. We argue that the domestic interest rate should be temporarily above the international rate. We also find that capital controls can still help reach the first best when the planner has more fiscal instruments.

Estereosseletividade em reações eletródicas

This review discusses the present state of the art of the stereochemistry of electrochemical reactions. The extent of asymmetric induction is progressing, but in general diastereoselectivities and enantioselectivities remain behind those from chemical synthesis. In recent years, new methodological developments have been successful. Effects that play important roles in homogeneous chemistry have been used with success. Lack of expressive enantiomeric excess (ee) could be related to the absence of tightly organized structures during the reaction of interest. The highest ee might be expected for redox reactions where conformational preference in transition state plays the important role or for the ones performed while adsorbed on the electrode, and where the chiral element is also at the surface, either adsorbed or chemically bound to the surface and interacting directly with the substrate. Electroenzymatic synthesis has a promising future.

Osaamisen johtaminen Suomen kunnissa

Kunnissa eletään muutosten aikaa, ja osaamisen johtamisella pyritään vastaamaan kehityksen mukanaan tuomiin haasteisiin. Osaamisen johtamista pidetäänkin tärkeänä asiana kuntien kehittämisessä. Viime vuosina osaamisen johtaminen on ollut voimakkaasti esillä myös yksityisellä sektorilla, jossa se on nähty tärkeänä elementtinä kilpailukyvyn kehittämisessä. Osaamisen johtaminen on toimintaa, jolla kehitetään yksilöiden ja organisaation osaamista sekä organisaation yhteistyövalmiutta. Osaamisen johtamisessa huomioidaan myös organisaatiolle asetetut strategiset tavoitteet. Tässä tutkimuksessa osaamisen johtaminen ankkuroidaan tietojohtamisen, henkilöstövoimavarojen johtamisen (HRM:n) ja oppivan organisaation viitekehyksiin. Tutkimusotteeksi on valittu kvantitatiivinen tutkimusote. Kvantitatiivinen tutkimusote mahdollistaa osaamisen johtamisen rakenteellisen analyysin ja kuvaamisen. Tutkimuksen kohderyhmänä ovat kaikki Suomen 444 kuntaa vuonna 2004. Tutkimuksen tiedonkeruu suoritettiin lomakekyselyn avulla, ja tutkimus kohdistettiin kuntien henkilöstöasioiden asiantuntijoille. Tutkimuksen keskeisenä tavoitteena oli mallintaa ja kuvata osaamisen johtamista Suomen kunnissa. Tutkimusongelma liittyy kuntien osaamisen johtamisen nykytilaan ja tavoitteisiin sekä siihen, missä vaiheissa kunnat ovat osaamisen johtamisessaan. Kyselyn avulla tutkittiin myös kuntien halukkuutta kehittää osaamisen johtamistaan. Vastausten pohjalta analysoitiin lisäksi, mitkä asiat kunnissa vaikuttavat osaamisen johtamiseen. Tutkimuksen tuloksissa tulevat esille neljä erilaista kunnissa vallitsevaa osaamisen johtamisen orientaatiota: Strategiaohjattu yhteisöllinen orientaatio, Innovatiivinen orientaatio, Teknologinen orientaatio ja Strategialähtöinen järjestelmäorientaatio. Nämä neljä orientaatiota ovat tunnistettavissa myös taustakirjallisuudessa. Kunnat ryhmiteltiin orientaatioiden perusteella neljään ryhmään, jotka nimettiin seuraavasti: Innostuneet aloittelijat, Tekniset aloittelijat, Edistyneet ja Kehittyvät. Innostuneiden aloittelijoiden ryhmässä korostuu innovatiivinen orientaatio, mutta muut osaamisen johtamisen orientaatiot tulevat esille heikosti. Teknisten aloittelijoiden ryhmässä korostuu teknologinen orientaatio, mutta muut osaamisen johtamisen orientaatiot tulevat esille heikosti. Edistyneiden ryhmässä kaikki osaamisen johtamisen orientaatiot tulevat hyvin esille. Kehittyvien ryhmässä korostuvat sekä innovatiivinen että teknologinen orientaatio. Kuntien osaamisen johtamisen nykytilanne on murroksessa. Osaamisen johtaminen on suuressa osassa kunnista hyvässä vauhdissa, mutta kehitettävääkin on. Tietotekniset välineet osaamisen johtamisessa ovat hyvät useimmissa kunnissa. Tulevaisuuden osaamistarpeina pidetään erityisesti vuorovaikutustaitoja ja oman ammattialan osaamista. Kunnissa on myös huomioitu ainakin tavoitteiden tasolla tulevaisuus ja sen tuomat haasteet.

Late effects of cancer at a young age: Registry-based studies of the health of cancer patients and their off-spring

Modern cancer therapy has resulted in increased survival among patients diagnosed with cancer at a young age. These improvements have led to the investigation of late morbidity and mortality associated with cancer and its treatments. The aim of this study was to evaluate late effects of cancer treated at a young age on the health of patients and their offspring. Utilising the nationwide population-based registries in Finland, we evaluated the risk of hypothyroidism and the probability of parenthood in cancer survivors as well as preterm birth, neonatal outcomes, and the risk of cancer among offspring of patients. The survivor cohort, identified from the Finnish Cancer Registry, consisted of 25,784 cancer patients diag-nosed between ages 0 and 34 in 1953–2004. By linkage to the population register, siblings of these patients were identified for comparison. The prevalence of hypothyroidism was higher among former childhood cancer (aged 0–16) patients than in the general population. The probability of parenthood following early onset cancer was overall significantly reduced compared to siblings. Offspring of female cancer survivors were at an increased risk of preterm birth, this risk being highest among patients diagnosed in childhood and early adulthood (aged 20–34 years). The offspring were not, however, at a significantly increased risk of neonatal death or stillbirth, though they were more likely to need monitoring or intensive care in the neonatal period. The risk of sporadic cancer among offspring of male and female cancer survivors was not elevated in comparison to the general population. The study showed that former cancer patients are at risk of certain adverse endocrine and reproductive health outcomes and should be followed for timely intervention. The offspring of cancer survivors do not appear to be at risk for adverse health outcomes.

Siirtymätalouksien tutkimuslaitoksen (BOFIT) kokoelma

Suomen Pankin kirjastolla on erilliskokoelma Siirtymätalouksien tutkimuslaitoksessa, BOFITissa. Kokoelma on painottunut siirtymätalouksia käsittelevään tieteelliseen kirjallisuuteen, tilasto- ja kausijulkaisuihin. Kokoelmaa on kartutettu 1980-luvulta lähtien ja siihen sisältyy merkittävä määrä nimekkeitä, joita ei ole hankittu muihin suomalaisiin kirjastoihin. Kokoelmaa on rajattu sekä aihepiireiltään että maantieteellisesti kulloistenkin tutkimuspainopisteiden mukaisesti. Kokoelman keskeinen aihealue on makrotalous ja erityisinä painopisteinä ovat rahatalous, talouspolitiikka ja talousuudistukset. Paljon kirjallisuutta löytyy myös raha- ja valuuttapolitiikasta, pankkitoiminnasta ja kansainvälisistä taloussuhteista. Maantieteellisinä painopisteinä ovat tällä hetkellä erityisesti Venäjä ja Kiina. Vanhempaa aineistoa löytyy myös Baltian sekä Itä-Euroopan maista, Neuvostoliitosta sekä Suomen idänkaupasta. Kirjakokoelma sisältää n. 5300 nimekettä, lehtikokoelma n. 150 nimekettä. Artikkeliviitteitä löytyy n. 2300 vuodesta 1990 lähtien. Kokoelma sisältää tiedot myös kaikesta BOFITin omasta julkaisutuotannosta. Suurin osa kokoelmasta on englanninkielistä.

Virikkeinen käsikirja

Kirjallisuusarvostelu

Tilannekuvaa liikkuvasta maalista

Kirjallisuusarvostelu

Investigations into the determinations of hydride-forming elements

Analytical methods for the determination of trace amounts of germanium, tin and arsenic were established using hydride generation coupled with direct current plasma atomic emission spectrometry. A continuous gas flowing batch system for the hydride generation was investigated and was applied to the determination of germanium(Ge), tin(Sn), antimony(Sb) and lead(Pb) (Preliminary results suggest that it is also applicable to arsenic)As) ). With this system, the reproducibility of signals was improved and the determination was speeded up, compared with the conventional batch type hydride generation system. Each determination was complete within one minute. Interferences from a number of transition metal ions, especially from Pd(II), Pt(IV), Ni(II), Cu(II), Co(II), and Fe(II, III), have proven to be very serious under normal conditions, in the determination of germanium, tin, and arsenic. These interference effects were eliminated or significantly reduced in the presence of L-cystine or L-cysteine. Thus, a 10-1000 fold excess of Ni(II), Cu(II), Co(II), Fe(II), Pt(IV), Pd(II), etc. can be tolerated without interference, In the presence of L-cystine or L-cysteine, compared with absence of interference reducing agent. The methods for the determination of Ge, Sn, and As were examined by the analyses of standard reference materials. Interference effects from the sample matrix, for example, in transition metal-rich samples, copper, iron and steel, were eliminated by L-cystine (for As and Sn) and by LI cysteine (for Ge). The analysis of a number of standard reference materials gave excellent results of As and Sn contents in agreement with the certified values, showing there was no systematic interference. The detection limits for both germanium and tin were 20 pg ml- I . Preliminary studies were carried out for the determination of antimony and lead. Antimony was found to react with NaBH4, remaInIng from the previous determinations, giving an analytical signal. A reversed injection manner, i.e., injection of the NaBH4 solution prior to the analyte solution was used to avoid uncertainty caused by residual NaBH4 present and to ensure that an excess of NaB H4 was available. A solution of 0.4% L-cysteine was found to reduce the interference from selected transition metal ions, Co(II), Cu(II), Ni(II) and Pt(IV). Hydrochloric acid - hydrogen peroxide, nitric acid - ammonium persulphate, and potassium dichromate malic acid reaction systems for lead hydride generation were compared. The potassium dichromate - malic acid reaction medium proved to be the best with respect to reproducibility and minimal interference. Cu(II), Ni(II), and Fe(II) caused strong interference In lead determinations, which was not reduced by L-cysteine or Lcystine. Sodium citrate, ascorbic acid, dithizone, thiosemicarbazide and penicillamine reduced interferences to some extent. Further interference reduction studies were carried out uSIng a number of amino acids, glycine, alanine, valine, leucine and histidine, as possible interference reducing agents in the determination of germanium. From glycine, alanine, valine to leucine, the interference reduction effect in germanium determinations decreased. Histidine II was found to be very promising In the reduction of interference. In fact, histidine proved more efficient than L-cystine and L-cysteine In the reduction of interference from Ni(II) in the determination of germanium. Signal enhancement by easily ionized elements (EIEs), usually regarded as an interference effect in analysis by DCP-AES, was studied and successfully applied to advantage in improving the sensitivity and detection limit in the determination of As, Ge, Sn, Sb, and Pb. The effect of alkali and alkaline-earth elements on the determination of the above five hydride forming elements was studied. With the appropriate EIE, a signal enhancement of 40-115% was achieved. Linear calibration and good reproducibility were also obtained in the presence of EIEs. III

Stereoselective synthesis of substituted hexahydro-3a,4a-diazacyclopentaphenanthren-4-ones and aminoferrocenes

This thesis explored the development of several methodologies for the stereoselective construction of ligand frameworks and some of their applications. The first segment concerns the application of an enantioselective lithiation at an Sp3_ hybridized position adjacent to nitrogen by means of the widely used and typically highly effective enantioselective lithiation with ( -)-sparteine. This investigation was intended to develop a method to install chirality into a system that would be converted into a family of diaminoylidenes for use as phosphine mimics in transition metal catalysis or as nucleophilic reagents. Molecular modeling of the system revealed some key interactions between the substrate and (-)-sparteine that provided general insight into the diamine's mode of action and should lend some predictive value to its future applications. The second portion focuses on the development of methods to access 1,2- disubstituted aminoferrocenes, an underexplored class of metallocenes possessing planar chirality. Two routes were examined involving a diastereoselective and an enantioselective pathway, where the latter method made use of the first BF3-mediated lithiation-substitution to install planar chirality. Key derivatives such as 1,2- aminophosphines, made readily accessible by the new route, were evaluated as ligands for Pd(II), Pt(II) and Ir(I). These complexes show activity in a number of transformations with both achiral and prochiral substrates. Optimization experiments were conducted to prepare enantiomerically enriched 2-substituted-I-aminoferrocenes by direct asymmetric lithiation of BF3-coordinated tertiary aminoferrocenes. A predictive computational model describing the transition state of this reaction was developed in collaboration with Professor Travis Dudding's group (Department of Chemistry, Brock University). The predicted stereochemistry of the process was confirmed by single-crystal X-ray analysis of a 2-phosphino-l-dimethylaminoferrocene derivative. Enantiomerically pure samples of the aminophosphine ligands derived from this new process have given promising preliminary results in the enantioselective hydrogenation of prochiral alkenes and warrant further stUdy in metal-mediated catalysis.