The evolution and assessment of pharmaceutical care: Structure, processes, and outcomes

The evolution of pharmaceutical care is identified through a complete review of the literature published in the American Journal of Health-System Pharmacy, the sole comprehensive publication of institutional pharmacy practice. The evolution is categorized according to characteristics of structure (organizational structure, the role of the pharmacist), process (drug delivery systems, formulary management, acquiring drug products, methods to impact drug therapy decisions), and outcomes (cost of drug delivery, cost of drug acquisition and use, improved safety, improved health outcomes) recorded from the 1950s through the 1990s. While significant progress has been made in implementing basic drug distribution systems, levels of pharmacy involvement with direct patient care is still limited.^ A new practice framework suggests enhanced direct patient care involvement through increase in the efficiency and effectiveness of traditional pharmacy services. Recommendations advance internal and external organizational structure relationships that position pharmacists to fully use their unique skills and knowledge to impact drug therapy decisions and outcomes. Specific strategies facilitate expansion of the breadth and scope of each process component in order to expand the depth of integration of pharmacy and pharmaceutical care within the broad healthcare environment. Economic evaluation methods formally evaluate the impact of both operational and clinical interventions.^ Outcome measurements include specific recommendations and methods to increase efficiency of drug acquisition, emphasizing pharmacists' roles that impact physician prescribing decisions. Effectiveness measures include those that improve safety of drug distribution systems, decrease the potential of adverse drug therapy events, and demonstrate that pharmaceutical care can significantly contribute to improvement in overall health status.^ The implementation of the new framework is modeled on a case study at the M.D. Anderson Cancer Center. The implementation of several new drug distribution methods facilitated the redeployment of personnel from distributive functions to direct patient care activities with significant personnel and drug cost reduction. A cost-benefit analysis illustrates that framework process enhancements produced a benefit-to-cost ratio of 7.9. In addition, measures of effectiveness demonstrated significant levels of safety and enhanced drug therapy outcomes. ^

The Performance of Domestic and Foreign Banks: The Case of Korea and the Asian Financial Crisis

This paper considers the performance of banks, domestic and foreign, in Korea prior to, during, and immediately after the Asian financial crisis, examining how the profitability of those banks differed and identifying factors that explain why those differences existed. The performance of Korean banks deteriorated dramatically in 1998 with most banks recovering somewhat in 1999. Foreign banks did not experience the same negative effect on their returns on assets and equity as a rule. Several standard findings emerge. For example, equity to assets correlates positively with domestic, but not foreign, bank performance, as measured by the returns on assets and equity, even when the government recapitalized institutions that were performing quite badly. Also, foreign-currency deposits significantly and negatively correlate with domestic Korean bank performance, although only in the post-crisis period for regional banks. In sum, the domestic Korean banks suffered more severely from the Asian financial crisis than foreign banks.

The Effect of the Asian Financial Crisis on the Performance of Korean Nationwide Banks

The Asian financial crisis spread its effect quickly across a number of countries. Korea faced serious problems in her financial and corporate sectors. This paper considers the performance of Korean nationwide banks before, during, and immediately after the Asian financial crisis. The performance of Korean nationwide banks took a big hit in 1998. Most banks recovered somewhat in 1999 with the notable exception of the further deterioration of Seoul. Several factors possess strong correlations with bank performance. Among other standard findings, equity to assets correlates positively with bank performance, even when the government recapitalized a number of institutions that performed poorly. The Asian crisis did not affect the normal rules of good bank management. The government, however, directly intervened in the banking sector on a large scale to limit the scope of the crisis in the Korean economy.

Texas Department of Health organizational structure changes: A reflection of public health policy and agency expansion, September 1, 1946--June 30, 1994

The premise of this study is that changes in the agency's organizational structure reflect changes in government public health policy. Based on this premise, this study tracks the changes in the organizational structure and the overall expansion of the Texas Department of Health to understand the evolution of changing public health priorities in state policy from September 1, 1946 through June 30, 1994, a period of growth and new responsibilities. It includes thirty-seven observations of organizational structure as depicted by organizational charts of the agency and/or adapted from public documents. ^ The major questions answered are, what are the changes in the organizational structure, why did they occur and, what are the policy priorities reflected in these changes in and across the various time periods. ^ The analysis of the study included a thorough review of the organizational structure of the agency for the time-span of the study, the formulation of the criteria to be used in ascertaining the changes, the delineation of the changes in the organizational structure and comparison of the observations sequentially to characterize the change, the discovery of reasons for the structural changes (financial, statutory - federal and state, social and political factors), and the determination of policy priorities for each time period and their relation to the expansion and evolution of the agency. ^ The premise that the organizational structure of the agency and the changes over time reflect government public health policy and agency expansion was found to be true. ^

HEALTH MAINTENANCE ORGANIZATION ENVIRONMENT: AN EMPIRICAL STUDY OF THE RELATIONSHIP OF EXTERNAL CONTEXT AND PERFORMANCE

The research project is an extension of a series of administrative science and health care research projects evaluating the influence of external context, organizational strategy, and organizational structure upon organizational success or performance. The research will rely on the assumption that there is not one single best approach to the management of organizations (the contingency theory). As organizational effectiveness is dependent on an appropriate mix of factors, organizations may be equally effective based on differing combinations of factors. The external context of the organization is expected to influence internal organizational strategy and structure and in turn the internal measures affect performance (discriminant theory). The research considers the relationship of external context and organization performance.^ The unit of study for the research will be the health maintenance organization (HMO); an organization the accepts in exchange for a fixed, advance capitation payment, contractual responsibility to assure the delivery of a stated range of health sevices to a voluntary enrolled population. With the current Federal resurgence of interest in the Health Maintenance Organization (HMO) as a major component in the health care system, attention must be directed at maximizing development of HMOs from the limited resources available. Increased skills are needed in both Federal and private evaluation of HMO feasibility in order to prevent resource investment and in projects that will fail while concurrently identifying potentially successful projects that will not be considered using current standards.^ The research considers 192 factors measuring contextual milieu (social, educational, economic, legal, demographic, health and technological factors). Through intercorrelation and principle components data reduction techniques this was reduced to 12 variables. Two measures of HMO performance were identified, they are (1) HMO status (operational or defunct), and (2) a principle components factor score considering eight measures of performance. The relationship between HMO context and performance was analysed using correlation and stepwise multiple regression methods. In each case it has been concluded that the external contextual variables are not predictive of success or failure of study Health Maintenance Organizations. This suggests that performance of an HMO may rely on internal organizational factors. These findings have policy implications as contextual measures are used as a major determinant in HMO feasibility analysis, and as a factor in the allocation of limited Federal funds. ^

THE RELATIONSHIP BETWEEN ATTITUDE ASSESSMENT/ROLE PERCEPTION AND THE FINANCIAL PERFORMANCE OF HOSPITAL DEPARTMENT MANAGERS

Much of the current healthcare financial literature addresses the concern of government officials, the public, and healthcare providers regarding the need for control of health care costs. The literature suggests that attitudes of hospital department managers toward their role in financial management affects their ability to effect favorable financial results.^ There were several objectives of the dissertation: (1) To identify whether or not there exists a relationship between the attitude/role perception of hospital managers and the financial performance of their departments. (2) To compile a descriptive survey data base of key factors identified in the financial literature from individual hospitals. (3) To compile a brief descriptive survey of hospital managers' financial management background and training (both formal and informal). (4) To conduct an attitude assessment/role perception survey regarding the importance or relevance of a suggested financial management role set (i.e., issues discussed in the current literature) as viewed by the selected hospital managers and their matched administrators. (5) To propose plausible theoretical models and statistical tests of seven proposed hypotheses.^ The statistical results of a variety of methods generally suggested, for the sample population, that the null hypothesis should not be rejected concerning the relationships between a department manager's financial attitudes and role perceptions and the resultant financial performance.^ The fact that the results of this study did not suggest that there was a significant relationship which existed between role perception and financial performance does not necessarily indicate that the theories supporting such a relationship in literature are false, not that such a relationship does not exist. Several alternative theories were postulated to explain the apparent lack of statistical relationship, and suggestions for refinement and/or improvement of further research were discussed. ^

Escape performance of temperate king scallop, Pecten maximus under ocean warming and acidification

Among bivalves, scallops are exceptional due to their capacity to escape from predators by swimming which is provided by rapid and strong claps that are produced by the phasic muscle interspersed with tonic muscle contractions. Based on the concept of oxygen and capacity-limited thermal tolerance, the following hypothesis was tested: ocean warming and acidification (OWA) would induce disturbances in aerobic metabolic scope and extracellular acid-case status and impair swimming performance in temperate scallops. Following long-term incubation under near-future OWA scenarios [20 vs. 10 °C (control) and 0.112 kPa CO2 (hypercapnia) vs. 0.040 kPa CO2 (normocapnic control)], the clapping performance and metabolic rates (MR) were measured in resting (RMR) and fatigued (maximum MR) king scallops, Pecten maximus, from Roscoff, France. Exposure to OA, either alone or combined with warming, left MR and swimming parameters such as the total number of claps and clapping forces virtually unchanged. Only the duration of the escape response was affected by OA which caused earlier exhaustion in hyper- than in normocapnic scallops at 10 °C. While maximum MR was unaffected, warm exposure increased RMR in both normocapnic and hypercapnic P. maximus resulting in similar Q 10 values of ~2.2. The increased costs of maintenance and the observation of strongly reduced haemolymph PO2 levels indicate that at 20 °C scallops have reached the upper thermal pejus range with unbalanced capacities for aerobic energy metabolism. As a consequence, warming to 20 °C decreased mean phasic force during escape performance until fatigue. The observed prolonged recovery time in warm incubated scallops might be a consequence of elevated metabolic costs at reduced oxygen availability in the warmth.

Seawater carbonate chemistry and aerobic performance of coral reef fishes during experiments, 2009

Concerns about the impacts of ocean acidification on marine life have mostly focused on how reduced carbonate saturation affects calcifying organisms. Here, we show that levels of CO2-induced acidification that may be attained by 2100 could also have significant effects on marine organisms by reducing their aerobic capacity. The effects of temperature and acidification on oxygen consumption were tested in 2 species of coral reef fishes, Ostorhinchus doederleini and O. cyanosoma, from the Great Barrier Reef, Australia. The capacity for aerobic activity (aerobic scope) declined at temperatures above the summer average (29°C) and in CO2-acidified water (pH 7.8 and ~1000 ppm CO2) compared to control water (pH 8.15). Aerobic scope declined by 36 and 32% for O. doederleini and O. cyanosoma at temperatures between 29 to 32°C, whereas it declined by 33 and 47% for O. doederleini and O. cyanosoma in acidified water compared to control water. Thus, the declines in aerobic scope in acidified water were similar to those caused by a 3°C increase in water temperature. Minimum aerobic scope values of ~200 mg O2 kg-1 h-1 were attained for both species in acidified water at 32°C, compared with over 600 mg O2 kg-1 h-1 in control water at 29°C. Mortality rate increased sharply at 33°C, indicating that this temperature is close to the lethal thermal limit for both species. Acidification further increased the mortality rate of O. doederleini, but not of O. cyanosoma. These results show that coral reef fishes are sensitive to both higher temperatures and increased levels of dissolved CO2, and that the aerobic performance of some reef fishes could be significantly reduced if climate change continues unabated.

Curing, defects and mechanical performance of fiber-reinforced composites

Tradicionalmente, la fabricación de materiales compuestos de altas prestaciones se lleva a cabo en autoclave mediante la consolidación de preimpregnados a través de la aplicación simultánea de altas presiones y temperatura. Las elevadas presiones empleadas en autoclave reducen la porosidad de los componentes garantizando unas buenas propiedades mecánicas. Sin embargo, este sistema de fabricación conlleva tiempos de producción largos y grandes inversiones en equipamiento lo que restringe su aplicación a otros sectores alejados del sector aeronáutico. Este hecho ha generado una creciente demanda de sistemas de fabricación alternativos al autoclave. Aunque estos sistemas son capaces de reducir los tiempos de producción y el gasto energético, por lo general, dan lugar a materiales con menores prestaciones mecánicas debido a que se reduce la compactación del material al aplicar presiones mas bajas y, por tanto, la fracción volumétrica de fibras, y disminuye el control de la porosidad durante el proceso. Los modelos numéricos existentes permiten conocer los fundamentos de los mecanismos de crecimiento de poros durante la fabricación de materiales compuestos de matriz polimérica mediante autoclave. Dichos modelos analizan el comportamiento de pequeños poros esféricos embebidos en una resina viscosa. Su validez no ha sido probada, sin embargo, para la morfología típica observada en materiales compuestos fabricados fuera de autoclave, consistente en poros cilíndricos y alargados embebidos en resina y rodeados de fibras continuas. Por otro lado, aunque existe una clara evidencia experimental del efecto pernicioso de la porosidad en las prestaciones mecánicas de los materiales compuestos, no existe información detallada sobre la influencia de las condiciones de procesado en la forma, fracción volumétrica y distribución espacial de los poros en los materiales compuestos. Las técnicas de análisis convencionales para la caracterización microestructural de los materiales compuestos proporcionan información en dos dimensiones (2D) (microscopía óptica y electrónica, radiografía de rayos X, ultrasonidos, emisión acústica) y sólo algunas son adecuadas para el análisis de la porosidad. En esta tesis, se ha analizado el efecto de ciclo de curado en el desarrollo de los poros durante la consolidación de preimpregnados Hexply AS4/8552 a bajas presiones mediante moldeo por compresión, en paneles unidireccionales y multiaxiales utilizando tres ciclos de curado diferentes. Dichos ciclos fueron cuidadosamente diseñados de acuerdo a la caracterización térmica y reológica de los preimpregnados. La fracción volumétrica de poros, su forma y distribución espacial se analizaron en detalle mediante tomografía de rayos X. Esta técnica no destructiva ha demostrado su capacidad para analizar la microestructura de materiales compuestos. Se observó, que la porosidad depende en gran medida de la evolución de la viscosidad dinámica a lo largo del ciclo y que la mayoría de la porosidad inicial procedía del aire atrapado durante el apilamiento de las láminas de preimpregnado. En el caso de los laminados multiaxiales, la porosidad también se vio afectada por la secuencia de apilamiento. En general, los poros tenían forma cilíndrica y se estaban orientados en la dirección de las fibras. Además, la proyección de la población de poros a lo largo de la dirección de la fibra reveló la existencia de una estructura celular de un diámetro aproximado de 1 mm. Las paredes de las celdas correspondían con regiones con mayor densidad de fibra mientras que los poros se concentraban en el interior de las celdas. Esta distribución de la porosidad es el resultado de una consolidación no homogenea. Toda esta información es crítica a la hora de optimizar las condiciones de procesado y proporcionar datos de partida para desarrollar herramientas de simulación de los procesos de fabricación de materiales compuestos fuera de autoclave. Adicionalmente, se determinaron ciertas propiedades mecánicas dependientes de la matriz termoestable con objeto de establecer la relación entre condiciones de procesado y las prestaciones mecánicas. En el caso de los laminados unidireccionales, la resistencia interlaminar depende de la porosidad para fracciones volumétricas de poros superiores 1%. Las mismas tendencias se observaron en el caso de GIIc mientras GIc no se vio afectada por la porosidad. En el caso de los laminados multiaxiales se evaluó la influencia de la porosidad en la resistencia a compresión, la resistencia a impacto a baja velocidad y la resistencia a copresión después de impacto. La resistencia a compresión se redujo con el contenido en poros, pero éste no influyó significativamente en la resistencia a compresión despues de impacto ya que quedó enmascarada por otros factores como la secuencia de apilamiento o la magnitud del daño generado tras el impacto. Finalmente, el efecto de las condiciones de fabricación en el proceso de compactación mediante moldeo por compresión en laminados unidireccionales fue simulado mediante el método de los elementos finitos en una primera aproximación para simular la fabricación de materiales compuestos fuera de autoclave. Los parámetros del modelo se obtuvieron mediante experimentos térmicos y reológicos del preimpregnado Hexply AS4/8552. Los resultados obtenidos en la predicción de la reducción de espesor durante el proceso de consolidación concordaron razonablemente con los resultados experimentales. Manufacturing of high performance polymer-matrix composites is normally carried out by means of autoclave using prepreg tapes stacked and consolidated under the simultaneous application of pressure and temperature. High autoclave pressures reduce the porosity in the laminate and ensure excellent mechanical properties. However, this manufacturing route is expensive in terms of capital investment and processing time, hindering its application in many industrial sectors. This fact has driven the demand of alternative out-of-autoclave processing routes. These techniques claim to produce composite parts faster and at lower cost but the mechanical performance is also reduced due to the lower fiber content and to the higher porosity. Corrient numerical models are able to simulate the mechanisms of void growth in polymer-matrix composites processed in autoclave. However these models are restricted to small spherical voids surrounded by a viscous resin. Their validity is not proved for long cylindrical voids in a viscous matrix surrounded by aligned fibers, the standard morphology observed in out-of-autoclave composites. In addition, there is an experimental evidence of the detrimental effect of voids on the mechanical performance of composites but, there is detailed information regarding the influence of curing conditions on the actual volume fraction, shape and spatial distribution of voids within the laminate. The standard techniques of microstructural characterization of composites (optical or electron microscopy, X-ray radiography, ultrasonics) provide information in two dimensions and are not always suitable to determine the porosity or void population. Moreover, they can not provide 3D information. The effect of curing cycle on the development of voids during consolidation of AS4/8552 prepregs at low pressure by compression molding was studied in unidirectional and multiaxial panels. They were manufactured using three different curing cycles carefully designed following the rheological and thermal analysis of the raw prepregs. The void volume fraction, shape and spatial distribution were analyzed in detail by means of X-ray computed microtomography, which has demonstrated its potential for analyzing the microstructural features of composites. It was demonstrated that the final void volume fraction depended on the evolution of the dynamic viscosity throughout the cycle. Most of the initial voids were the result of air entrapment and wrinkles created during lay-up. Differences in the final void volume fraction depended on the processing conditions for unidirectional and multiaxial panels. Voids were rod-like shaped and were oriented parallel to the fibers and concentrated in channels along the fiber orientation. X-ray computer tomography analysis of voids along the fiber direction showed a cellular structure with an approximate cell diameter of 1 mm. The cell walls were fiber-rich regions and porosity was localized at the center of the cells. This porosity distribution within the laminate was the result of inhomogeneous consolidation. This information is critical to optimize processing parameters and to provide inputs for virtual testing and virtual processing tools. In addition, the matrix-controlled mechanical properties of the panels were measured in order to establish the relationship between processing conditions and mechanical performance. The interlaminar shear strength (ILSS) and the interlaminar toughness (GIc and GIIc) were selected to evaluate the effect of porosity on the mechanical performance of unidirectional panels. The ILSS was strongly affected by the porosity when the void contents was higher than 1%. The same trends were observed in the case of GIIc while GIc was insensitive to the void volume fraction. Additionally, the mechanical performance of multiaxial panels in compression, low velocity impact and compression after impact (CAI) was measured to address the effect of processing conditions. The compressive strength decreased with porosity and ply-clustering. However, the porosity did not influence the impact resistance and the coompression after impact strength because the effect of porosity was masked by other factors as the damage due to impact or the laminate lay-up. Finally, the effect of the processing conditions on the compaction behavior of unidirectional AS4/8552 panels manufactured by compression moulding was simulated using the finite element method, as a first approximation to more complex and accurate models for out-of autoclave curing and consolidation of composite laminates. The model parameters were obtained from rheological and thermo-mechanical experiments carried out in raw prepreg samples. The predictions of the thickness change during consolidation were in reasonable agreement with the experimental results.

Synthetic scope and DFT analysis of the chiral binap-gold (I) complex-catalyzed 1,3-dipolar cycloaddition of azlactones with alkenes

The 1,3-dipolar cycloaddition between glycine-derived azlactones with maleimides is efficiently catalyzed by the dimeric chiral complex [(Sa)-Binap·AuTFA]2. The alanine-derived oxazolone only reacts with tert-butyl acrylate giving anomalous regiochemistry, which is explained and supported by Natural Resonance Theory and Nucleus Independent Chemical Shifts calculations. The origin of the high enantiodiscrimination observed with maleimides and tert-butyl acrylate is analyzed using DFT computed at M06/Lanl2dz//ONIOM(b3lyp/Lanl2dz:UFF) level. Several applications of these cycloadducts in the synthesis of new proline derivatives with a 2,5-trans-arrangement and in the preparation of complex fused polycyclic molecules are described.

Aviation English: Structure and Importance of an International Airborne Language

In today’s globalized world, air travel is one of the fastest growing markets. Millions of aircrafts take off and then touch down all around the world each day. This well-synchronized symphony, however, is much more complex than it seems, and communication – language - plays a crucial role during a plane’s journey. Misunderstandings and miscommunications can have disastrous effects, so the adoption of a standard phraseology to be used during flight is a means to overcome language barriers, avoid ambiguous expressions and guarantee a safe and effective operation of an aircraft. Little is known about the interaction that goes on between pilots and air traffic controllers (ATCOs), and even though the language of aviation is English, cockpit communication can be hard to understand for people who are not familiar with this specific language. The scope of this thesis is to examine the origins of this uncommon language, the characteristics and peculiarities of air communication and to shed a little light on this mystery called Aviation English.

Whole of Government Approach for Institutional and Policy Coherence

The comprehensive structure of cooperation at domestic level reflects on bilateral, regional and global level.

Federal centralization; a study and criticism of the expanding scope of congressional legislation,

Mode of access: Internet.

Federal centralization; a study and criticism of the expanding scope of congressional legislation,

Mode of access: Internet.

The status of the nation's highways and bridges: conditions and performance. 1991. Report.

Mode of access: Internet.