Across the dividing range - bridging the divides: Pharmacy opportunities across the hospital/community and inter-professional divides in rural and remote Australia

Rural and remote areas of Australia offer many opportunities for innovation in healthcare services. Some true healthcare 'network' models based around rural pharmacy can be established and evaluated. The lines between community and hospital pharmacy are often blurred and communication between health professionals enhanced. The blurring divide between hospital and community pharmacy in rural and remote areas has provided significant advances in practice. Projects have been set up to investigate the feasibility of community pharmacists integrating care for patients. These projects take advantage of the dual roles and the enhanced interaction between pharmacists and other health professionals in the bush. Opportunities for provision of clinical services beyond the traditional supply role have been taken in a number of remote communities

The price elasticity of the Euro to movements in foreign reserves through European Central Bank intevention

The Euro has been used as the largest weighting element in a basket of currencies for forex arrangements adopted by several Central European countries outside the European Union (EU). The paper uses a new time-series approach to examine the relationship between the Euro exchange rate and the level of foreign reserves. It employs Zero-no-zero (ZNZ) patterned vector error-correction (VECM) modelling to investigate Granger causal relations among foreign reserves, the European Monetary Union money supply and the Euro exchange rate. The findings confirm that foreign reserves may influence movements in the Euro's exchange rate. Further, ZNZ patterned VECM modelling with exogenous variables is used to estimate the amount of foreign reserves currently required in order to again achieve a targetted Euro exchange rate

The effect of a reduction in heroin supply on fatal and non-fatal drug overdoses in New South Wales, Australia

Objective: To examine the impact of a sudden and dramatic decrease in heroin availability, concomitant with increases in price and decreases in purity, on fatal and non-fatal drug overdoses in New South Wales, Australia. Design and setting: Time-series analysis was conducted where possible on data on overdoses collected from NSW hospital emergency departments, the NSW Ambulance Service, and all suspected drug-related deaths referred to the NSW Coroner's court. Main outcome measures: The number of suspected drug-related deaths where heroin and other drugs were mentioned; ambulance calls to suspected opioid overdoses; and emergency department admissions for overdoses on heroin and other drugs. Results: Both fatal and non-fatal heroin overdoses decreased significantly after heroin supply reduced; the reductions were greater among younger age groups than older age groups. There were no clear increases in non-fatal overdoses with cocaine, methamphetamines or benzodiazepines recorded at hospital emergency departments after the reduction in heroin supply. Data on drug-related deaths suggested that heroin use was the predominant driver of drug-related deaths in NSW, and that when heroin supply was reduced overdose deaths were more likely to involve a wider combination of drugs. Conclusion: A reduction in heroin supply reduced heroin-related deaths, and did not result in a concomitant increase, to the same degree, in deaths relating to other drugs. Younger people were more affected by the reduction in supply.

Archaeological Identification and Significance of ÉSAG (Agricultural Storage Pits) at Kaman-Kalehöyük, Central Anatolia

Evidence for the presence of storage pits described in Hittite texts by the Sumerogram "ÉSAG" is presented from Kaman-Kalehöyük, a multi-period tell site in central Turkey occupied during the second and first millennia BC. Small earthen pits matching the description of "ÉSAG" were part of the normal suite of domestic installations at the site throughout the period. Similar to pits seen across western Eurasia, they were probably used to store seed corn or seed for trade. Large earthen pits (>7m in diameter) were also present that matched the description of the "ÉSAG" form, and in some cases contained archaeological cereal remains. Evidence from Kaman shows "ÉSAG" were part of Anatolian life for at least 4,000 years and suggests that the term was generic for lined, earthen storage pits. The presence of so many small pits at Kaman-Kalehöyük showed that it was an agricultural production site for much of its existence. The appearance of the large pits, confined to the Hittite period, reflects centralised control of grain supply, probably by the Hittite Kingdom, and fits a pattern seen at other sites in the region during the second millennium BC. /// Hitit metinlerinde Sumerogram "ÉSAG" ile tanimlanan depo çukurlarinin varliğina dair kanit, Orta Anadolu'da M.Ö. İkinci ve Birinci binde iskan edilmiş çok dönemli bir yerleşim alani olan Kaman-Kalehöyük'ten taninmaktadir. Küçük toprak çukurlar "ÉSAG" in tanimlamasina uygun olarak bu dönem süresince normal ev düzeninin bir parçasi olarak karşimiza çikmiştir. Çukurlar, Bati Avrasya'daki benzer çukurlar gibi olasilikla ticaret maksadi ile misir tohumu ya da tohum muhafaza etmişlerdir. "ÉSAG" formunun tanimina uyan büyük toprak çukurlara (çapi 7m. den büyük) rağmen bunlarin tahil depolama ile ilgili bağlantilari tam olarak belirlenmemiştir. Kaman'daki delil, "ÉSAG" in en az 4,000 yildir Anadolu yaşaminin bir parçasi olduğunu ve bu sözcüğün sivanmiş toprak çukurlar için kullanildiğini işaret etmektedir. Kaman-Kalehöyük'te ele geçen birçok küçük çukur, yerleşimin varliğini sürdürdüǧü sürecin büyük bir bölümünde zirai üretim yapildiğini göstermektedir. Hitit Döneminde büyük çukurlarin ortaya çikmasi muhtemelen Hitit Kralliği tarafindan gerçekleştirilen tahil tedarikinin merkezi kontrolünü yansitmakta ve M.Ö. İkinci binde bu bölgedeki diğer yerleşim alanlarinda görülen şekle uymaktadir.

Structural ambiguity of the Chinese version of the Hospital Anxiety and Depression Scale in patients with coronary heart disease

Background The Hospital Anxiety and Depression Scale (HADS) is a widely used screening tool designed as a case detector for clinically relevant anxiety and depression. Recent studies of the HADS in coronary heart disease (CHD) patients in European countries suggest it comprises three, rather than two, underlying sub-scale dimensions. The factor structure of the Chinese version of the HADS was evaluated in patients with CHD in mainland China. Methods Confirmatory factor analysis (CFA) was conducted on self-report HADS forms from 154 Chinese CHD patients. Results Little difference was observed in model fit between best performing three-factor and two-factor models. Conclusion The current observations are inconsistent with recent studies highlighting a dominant underlying tri-dimensional structure to the HADS in CHD patients. The Chinese version of the HADS may perform differently to European language versions of the instrument in patients with CHD.

Medicines management across the primary-hospital healthcare interface: a study of paediatric patients

A comparison of medicines management documents in use by NHS organisations in the West Midlands confirms that there are important differences between the primary care and hospital sectors in respect to medicines management interface issues. Of these, two aspects important to paediatric patients have been studied. These are the transfer of information as a patient is admitted to hospital, and access to long-term medicines for home-patients. National guidance provided by NICE requires medication reconciliation to be undertaken on admission to hospital for adults. A study of paediatric admissions, reported in this thesis, demonstrates that the clinical importance of this process is at least as important for children as for adults, and challenges current UK guidance. The transfer of essential medication information on hospital admission is central to the medication reconciliation process. Two surveys of PCTs in 2007 and again in 2009 demonstrate that very few PCTs provide guidance to GPs to support this process. Provision of guidance is increasing slowly but remains the exception. The provision of long-term medicines for children at home is hindered by this patient population often needing unlicensed drugs. Further studies demonstrate that primary care processes regularly fail to maintain access to essential drugs and patients and their carers frequently turn to hospitals for help. Surveys of hospital medical staff (single site) and hospital nurses (six UK sites) demonstrates the activity these healthcare workers perform to help children get the medicines they need. A similar survey of why carers turn to a hospital pharmacy department for urgent supplies (usually termed rescue-medicines) adds to the understanding of these problems and supports identifying service changes. A large survey of community pharmacies demonstrates the difficulties they have when dispensing hospital prescriptions and identifies practical solutions. This programme concludes by recommending service changes to support medication management for children.

Addressing the project implementation challenges in the Saudi Arabian power supply industry: an investigative approach towards improving project delivery

For many decades, the Kingdom of Saudi Arabia has been widely known for being a reliable oil exporter. This fact, however, has not exempted it from facing significant domestic energy challenges. One of the most pressing of these challenges involves bridging the widening electricity supply-demand gap where, currently, the demand is growing at a very fast rate. One crucial means to address this challenge is through delivering power supply projects with maximum efficiency. Project delivery delay, however, is not uncommon in this highly capital-intensive industry, indicating electricity supplies are not coping with the demand increases. To provide a deeper insight into the challenges of project implementation and efficient practice, this research adopts a pragmatic approach by triangulating literature, questionnaires and semi-structured interviews. The research was conducted in the Saudi Arabian power supply industry – Western Operating Area. A total of 105 usable questionnaires were collected, and 28 recorded, semi-structured interviews were conducted, analysed and synthesised to produce a conceptual model of what constitutes the project implementation challenges in the investigated industry. This was achieved by conducting a comprehensive ranking analysis applied to all 58 identified and surveyed factors which, according to project practitioners in the investigated industry, contribute to project delay. 28 of these project delay factors were selected as the "most important" ones. Factor Analysis was employed to structure these 28 most important project delay factors into the following meaningful set of 7 project implementation challenges: Saudi Electricity Company's contractual commitments, Saudi Electricity Company's communication and coordination effectiveness, contractors' project planning and project control effectiveness, consultant-related aspects, manpower challenges and material uncertainties, Saudi Electricity Company's tendering system, and lack of project requirements clarity. The study has implications for industry policy in that it provides a coherent assessment of the key project stakeholders' central problems. From this analysis, pragmatic recommendations are proposed that, if enacted, will minimise the significance of the identified problems on future project outcomes, thus helping to ensure the electricity supply-demand gap is diminished.

The source, cost and prevention of central venous catheter-related infection

Central venous catheters have become an integral part of patient management however they are associated with many complications including infection. Despite efforts being made to reduce the incidence of such infect ions the problem continues to increase and has resource implications for the Health Service. Studies relating to the source of microorganisms causing CVC-associated infection, the cost of such infections and the efficacy of an antimicrobial catheter have been undertaken. Thirty patients who required a CVC as part of their medical management and underwent cardiac surgery had the distal tips of their catheters sampled whilst in situ. Sampling took place within 1 h of catheter placement. Bacteria were isolated from 16% of the catheter distal tips sampled in situ. The guidewires used to insert the devices were also contaminated (50%). When CVC were inserted via a protective sheath, avoiding contact with the skin. the incidence of microbial contamination was reduced. These findings suggest that despite rigorous skin disinfection and strict aseptic technique, viable microorganisms are impacted onto the distal tip of CVC during the insertion procedure. Needleless intravascular access devices have been introduced in order to reduce the incidence of need1estick injury. However, it was unclear whether such connectors would act as a portal of entry for microorganisms to CVC. The efficacy of these devices was investigated. Within the controlled laboratory environment it was demonstrated that needleless devices, when challenged with microorganisms, did not allow the passage of microbes when flu id was injected. This therefore suggested that the devices should not increase the risk of catheter colonisation. When used in clinical practice however microbial contamination of the needleless connectors was 55 % in comparison to the routinely used luer connectors (23%). The cost of infections associated with CVC was determined. Twenty patients catheterised with a CVC designed for long term use who were admitted to hospital with a presumptive diagnosis of catheter-related infection were studied. The treatment given specifically for this infection was costed. The mean cost of such an infection was £ 1781.81. Throughout the UK this may amount to £1.565.906 per annum. The cost of infections associated with CVC designed for short term use was estimated to be between 5 and 7 million pounds per annum in the UK. In an attempt to reduce both the incidence and cost of catheter- related infection antimicrobial CVC have been developed. The efficacy of a novel polyurethane CVC impregnated on both the internal and external catheter surface with the quaternary ammonium compound benzalkonium chloride was investigated. Eighty eight patients received an antimicrobial catheter and 78 patients a conventional polyurethane CVC. The anti-microbial CVC resulted in a reduction in microbial colonisation of the external and internal polymer surfaces as compared to the control device. The observed reduction in microbial colonisation with the anti-microbial CVC may decrease the likelihood of subsequent infection offering a useful approach to the prevention of catheter-related infections.

Towards a unified definition of supply chain management:the four fundamentals

A wide range of definitions of supply chain management (SCM) have been developed over the last three decades. The philosophy of SCM is based firmly on a recognition that it is only by working in a more integrated manner that competitive advantage can be maximised. However, for this to become a reality the development of common definitions and understandings between supply chain partners is a critical success factor. The corollary of this is that a lack of definitional consistency and a common understanding is an inhibitor to the successful adoption of SCM thinking in practice. This paper reviews a number of definitions of SCM, as well as discussions and analyses of such definitions. This leads to the central point posited in the paper – the need for a ‘unified definition’. Such a definitional construct, labelled the Four Fundamentals of SCM, is proposed with the core of the paper providing a narrative description of this construct based on a wide range of literature.

Outsourced services and 'imbalanced' supply markets

In the UK public sector, procurement decisions for outsourced services are usually taken at a local level, for example by a hospital trust or a local government authority. Cumulatively, these fragmented decisions can lead to ‘imbalanced’ supply markets (too few or too many suppliers), to the detriment of both suppliers and purchasers. This paper considers what can be done to manage imbalanced supply markets resulting from the fragmented procurement of outsourced services across a sector, using the case of the English National Health Service. The types and levels of action available within the health sector are explored.

Wealth shocks, credit-supply shocks, and asset allocation:evidence from household and firm portfolios

We use a unique dataset with bank clients’ security holdings for all German banks to examine how macroeconomic shocks affect asset allocation preferences of households and non-financial firms. Our analysis focuses on two alternative mechanisms which can influence portfolio choice: wealth shocks, which are represented by the sovereign debt crisis in the Euro area, and credit-supply shocks which arise from reductions in borrowing abilities during bank distress. While households with large holdings of securities from stressed Euro area countries (Greece, Ireland, Italy, Portugal, and Spain) de-crease the degree of concentration in their security portfolio as a result of the Euro area crisis, non-financial firms with similar levels of holdings from stressed Euro area countries do not. Credit-supply shocks at the bank level result in lower concentration, for both households and non-financial corporations. Only shocks to corporate credit bear ramifications on bank clients’ portfolio concentration. Our results are robust to falsification tests, and instrumental variables estimation.

Reporting and managing risk:a look at current practice at Tesco, RBS, local and central government

These case studies from CIMA highlight the need to embed risk management within more easily understood behaviours, consistent with the overall organisational culture. In each case, some form of internal audit team provides either an oversight function or acts as an expert link in that feedback loop. Frontline staff, managers and specialists should be completely aligned on risk, in part just to ensure that there is a consistency of approach. They should understand instinctively that good performance includes good risk management. Tesco has continued to thrive during the recession and remains a robust and efficient group of businesses despite the emergence of potential threats around consumer spending and the supply chain. RBS, by contrast, has suffered catastrophic and very public failures of risk management despite a large in-house function and stiff regulation of risk controls. Birmingham City Council, like all local authorities, is adapting to more commercial modes of operation and is facing diverse threats and opportunities emerging as a result of social change. And DCMS, like many other public sector organisations, has to handle an incredibly complex network of delivery partners within the context of a relatively recent overhaul of central government risk management processes. Key Findings: •Risk management is no longer solely a financial discipline, nor is it simply a concern for the internal control function. •Where organisations retain a discrete risk management cadre – often specialists at monitoring and evaluating a range of risks – their success is dependent on embedding risk awareness in the wider culture of the enterprise. •Risk management is most successful when it is explicitly linked to operational performance. •Clear leadership, specific goals, excellent influencing skills and open-mindedness to potential threats and opportunities are essential for effective risk management. •Bureaucratic processes and systems can hamper good risk management – either as a result of a ‘box-ticking mentality’ or because managers and staff believe they do not need to consider risk themselves.

Exploring the digital supply chain:implications and models for online software distribution

As a discipline, supply chain management (SCM) has traditionally been primarily concerned with the procurement, processing, movement and sale of physical goods. However an important class of products has emerged - digital products - which cannot be described as physical as they do not obey commonly understood physical laws. They do not possess mass or volume, and they require no energy in their manufacture or distribution. With the Internet, they can be distributed at speeds unimaginable in the physical world, and every copy produced is a 100% perfect duplicate of the original version. Furthermore, the ease with which digital products can be replicated has few analogues in the physical world. This paper assesses the effect of non-physicality on one such product – software – in relation to the practice of SCM. It explores the challenges that arise when managing the software supply chain and how practitioners are addressing these challenges. Using a two-pronged exploratory approach that examines the literature around software management as well as direct interviews with software distribution practitioners, a number of key challenges associated with software supply chains are uncovered, along with responses to these challenges. This paper proposes a new model for software supply chains that takes into account the non-physicality of the product being delivered. Central to this model is the replacement of physical flows with flows of intellectual property, the growing importance of innovation over duplication and the increased centrality of the customer in the entire process. Hybrid physical / digital supply chains are discussed and a framework for practitioners concerned with software supply chains is presented.

Consuming linked data in supply chains:enabling data visibility via linked pedigrees

The performance of a supply chain depends critically on the coordinating actions and decisions undertaken by the trading partners. The sharing of product and process information plays a central role in the coordination and is a key driver for the success of the supply chain. In this paper we propose the concept of "Linked pedigrees" - linked datasets, that enable the sharing of traceability information of products as they move along the supply chain. We present a distributed and decentralised, linked data driven architecture that consumes real time supply chain linked data to generate linked pedigrees. We then present a communication protocol to enable the exchange of linked pedigrees among trading partners. We exemplify the utility of linked pedigrees by illustrating examples from the perishable goods logistics supply chain.