Continuous quality improvement in a Maltese hospital using logical framework analysis

Purpose: The purpose of this paper is to present the application of logical framework analysis (LFA) for implementing continuous quality improvement (CQI) across multiple settings in a tertiary care hospital. Design/methodology/approach: This study adopts a multiple case study approach. LFA is implemented within three diverse settings, namely, intensive care unit, surgical ward, and acute in-patient psychiatric ward. First, problem trees are developed in order to determine the root causes of quality issues, specific to the three settings. Second, objective trees are formed suggesting solutions to the quality issues. Third, project plan template using logical framework (LOGFRAME) is created for each setting. Findings: This study shows substantial improvement in quality across the three settings. LFA proved to be effective to analyse quality issues and suggest improvement measures objectively. Research limitations/implications: This paper applies LFA in specific, albeit, diverse settings in one hospital. For validation purposes, it would be ideal to analyse in other settings within the same hospital, as well as in several hospitals. It also adopts a bottom-up approach when this can be triangulated with other sources of data. Practical implications: LFA enables top management to obtain an integrated view of performance. It also provides a basis for further quantitative research on quality management through the identification of key performance indicators and facilitates the development of a business case for improvement. Originality/value: LFA is a novel approach for the implementation of CQI programs. Although LFA has been used extensively for project development to source funds from development banks, its application in quality improvement within healthcare projects is scant.

The development of an algorithm to track blood pressure accurately based on the pulse transit time method

Oscillometric blood pressure (BP) monitors are currently used to diagnose hypertension both in home and clinical settings. These monitors take BP measurements once every 15 minutes over a 24 hour period and provide a reliable and accurate system that is minimally invasive. Although intermittent cuff measurements have proven to be a good indicator of BP, a continuous BP monitor is highly desirable for the diagnosis of hypertension and other cardiac diseases. However, no such devices currently exist. A novel algorithm has been developed based on the Pulse Transit Time (PTT) method, which would allow non-invasive and continuous BP measurement. PTT is defined as the time it takes the BP wave to propagate from the heart to a specified point on the body. After an initial BP measurement, PTT algorithms can track BP over short periods of time, known as calibration intervals. After this time has elapsed, a new BP measurement is required to recalibrate the algorithm. Using the PhysioNet database as a basis, the new algorithm was developed and tested using 15 patients, each tested 3 times over a period of 30 minutes. The predicted BP of the algorithm was compared to the arterial BP of each patient. It has been established that this new algorithm is capable of tracking BP over 12 minutes without the need for recalibration, using the BHS standard, a 100% improvement over what has been previously identified. The algorithm was incorporated into a new system based on its requirements and was tested using three volunteers. The results mirrored those previously observed, providing accurate BP measurements when a 12 minute calibration interval was used. This new system provides a significant improvement to the existing method allowing BP to be monitored continuously and non-invasively, on a beat-to-beat basis over 24 hours, adding major clinical and diagnostic value.

Teaching / learning process through the case method in the law degree

This project in teaching innovation and improvement aims to disseminate the case method as one of the most innovative educational instruments inteaching of Law in general, and specifically with regard to Family and Inheritance Law. The methodology used ensures learning through a legal conflict, which must be resolved by the students themselves from different viewpoints as legal agents. This is an activity in teaching innovation, in which students become the protagonists. Participation is voluntary, and the main aim is student motivation. The subject's aim is for students to learn public speaking skills fundamental to the profession while familiarising themselves with judicial practice. Theteacher sets up a legal conflict in order for students to resolve the dispute as legal agents with divergent viewpoints - in other words, as judges, attorneys, lawyers and so on. The project seeks alternatives to traditional teaching methods and is an innovative teaching method aimed at professionally training future lawyers as well as being a model that involves students more in their own learning.

Production Diseases in European Organic Dairy Farms – Current Status and Identification of Drivers for Improvement by Means of a Systemic Approach

The aims of this thesis were to determine the animal health status in organic dairy farms in Europe and to identify drivers for improving the current situation by means of a systemic approach. Prevalences of production diseases were determined in 192 herds in Germany, France, Spain, and Sweden (Paper I), and stakeholder consultations were performed to investigate potential drivers to improve animal health on the sector level (ibid.). Interactions between farm variables were assessed through impact analysis and evaluated to identify general system behaviour and classify components according to their outgoing and incoming impacts (Paper II-III). The mean values and variances of prevalences indicate that the common rules of organic dairy farming in Europe do not result in consistently low levels of production diseases. Stakeholders deemed it necessary to improve the current status and were generally in favour of establishing thresholds for the prevalence of production diseases in organic dairy herds as well as taking actions to improve farms below that threshold. In order to close the gap between the organic principle of health and the organic farming practice, there is the need to formulate a common objective of good animal health and to install instruments to ensure and prove that the aim is followed by all dairy farmers in Europe who sell their products under the organic label. Regular monitoring and evaluation of herd health performance based on reference values are considered preconditions for identifying farms not reaching the target and thus in need of improvement. Graph-based impact analysis was shown to be a suitable method for modeling and evaluating the manifold interactions between farm factors and for identifying the most influential components on the farm level taking into account direct and indirect impacts as well as impact strengths. Variables likely to affect the system as a whole, and the prevalence of production diseases in particular, varied largely between farms despite some general tendencies. This finding reflects the diversity of farm systems and underlines the importance of applying systemic approaches in health management. Reducing the complexity of farm systems and indicating farm-specific drivers, i.e. areas in a farm, where changes will have a large impact, the presented approach has the potential to complement and enrich current advisory practice and to support farmers’ decision-making in terms of animal health.

Un aporte a la comprensión de las estrategias emergentes en las organizaciones a través del concepto de improvisación y la metáfora musical

Este trabajo se inscribe en uno de los grandes campos de los estudios organizacionales: la estrategia. La perspectiva clásica en este campo promovió la idea de que proyectarse hacia el futuro implica diseñar un plan (una serie de acciones deliberadas). Avances posteriores mostraron que la estrategia podía ser comprendida de otras formas. Sin embargo, la evolución del campo privilegió en alguna medida la mirada clásica estableciendo, por ejemplo, múltiples modelos para ‘formular’ una estrategia, pero dejando en segundo lugar la manera en la que esta puede ‘emerger’. El propósito de esta investigación es, entonces, aportar al actual nivel de comprensión respecto a las estrategias emergentes en las organizaciones. Para hacerlo, se consideró un concepto opuesto —aunque complementario— al de ‘planeación’ y, de hecho, muy cercano en su naturaleza a ese tipo de estrategias: la improvisación. Dado que este se ha nutrido de valiosos aportes del mundo de la música, se acudió al saber propio de este dominio, recurriendo al uso de ‘la metáfora’ como recurso teórico para entenderlo y alcanzar el objetivo propuesto. Los resultados muestran que 1) las estrategias deliberadas y las emergentes coexisten y se complementan, 2) la improvisación está siempre presente en el contexto organizacional, 3) existe una mayor intensidad de la improvisación en el ‘como’ de la estrategia que en el ‘qué’ y, en oposición a la idea convencional al respecto, 4) se requiere cierta preparación para poder improvisar de manera adecuada.

Leaf water potential and sap flow as indicators of water stress in Crimson ‘seedless’ grapevines under different irrigation strategies

Vitis vinifera L. cv. Crimson Seedless is a late season red table grape developed in 1989, with a high market value and increasingly cultivated under protected environments to extend the availability of seedless table grapes into the late fall. The purpose of this work was to evaluate leaf water potential and sap flow as indicators of water stress in Crimson Seedless vines under standard and reduced irrigation strategy, consisting of 70 % of the standard irrigation depth. Additionally, two sub-treatments were applied, consisting of normal irrigation throughout the growing season and a short irrigation induced stress period between veraison and harvest. Leaf water potential measurements coherently signaled crop-available water variations caused by different irrigation treatments, suggesting that this plant-based method can be reliably used to identify water-stress conditions. The use of sap flow density data to establish a ratio based on a reference ‘well irrigated vine’ and less irrigated vines can potentially be used to signal differences in the transpiration rates, which may be suitable for improving irrigation management strategies while preventing undesirable levels of water stress. Although all four irrigation strategies resulted in the production of quality table grapes, significant differences (p ≤ 0.05) were found in both berry weight and sugar content between the standard irrigation and reduced irrigation treatments. Reduced irrigation increased slightly the average berry size as well as sugar content and technical maturity index. The 2-week irrigation stress period had a negative effect on these parameters.

Leaf water potential and sap flow as indicators of water stress in Crimson 'seedless' grapevines under different irrigation strategies

Abstract Vitis vinifera L. cv. Crimson Seedless is a late season red table grape developed in 1989, with a high market value and increasingly cultivated under protected environments to extend the availability of seedless table grapes into the late fall. The purpose of this work was to evaluate leaf water potential and sap flow as indicators of water stress in Crimson Seedless vines under standard and reduced irrigation strategy, consisting of 70 % of the standard irrigation depth. Additionally, two sub-treatments were applied, consisting of normal irrigation throughout the growing season and a short irrigation induced stress period between veraison and harvest. Leaf water potential measurements coherently signaled crop-available water variations caused by different irrigation treatments, suggesting that this plant-based method can be reliably used to identify water-stress conditions. The use of sap flow density data to establish a ratio based on a reference ‘well irrigated vine’ and less irrigated vines can potentially be used to signal differences in the transpiration rates, which may be suitable for improving irrigation management strategies while preventing undesirable levels of water stress. Although all four irrigation strategies resulted in the production of quality table grapes, significant differences (p ≤ 0.05) were found in both berry weight and sugar content between the standard irrigation and reduced irrigation treatments. Reduced irrigation increased slightly the average berry size as well as sugar content and technical maturity index. The 2-week irrigation stress period had a negative effect on these parameters.

Improvement of The Driver Simulator Control and Comparison Between Driver-Road-Vehicle Interaction in Real and Simulated Environment

The present doctoral thesis discusses the ways to improve the performance of driving simulator, provide objective measures for the road safety evaluation methodology based on driver’s behavior and response and investigates the drivers' adaptation to the driving assistant systems. The activities are divided into two macro areas; the driving simulation studies and on-road experiments. During the driving simulation experimentation, the classical motion cueing algorithm with logarithmic scale was implemented in the 2DOF motion cueing simulator and the motion cues were found desirable by the participants. In addition, it found out that motion stimuli could change the behaviour of the drivers in terms of depth/distance perception. During the on-road experimentations, The driver gaze behaviour was investigated to find the objective measures on the visibility of the road signs and reaction time of the drivers. The sensor infusion and the vehicle monitoring instruments were found useful for an objective assessment of the pavement condition and the drivers’ performance. In the last chapter of the thesis, the safety assessment during the use of level 1 automated driving “ACC” is discussed with the simulator and on-road experiment. The drivers’ visual behaviour was investigated in both studies with innovative classification method to find the epochs of the distraction of the drivers. The behavioural adaptation to ACC showed that drivers may divert their attention away from the driving task to engage in secondary, non-driving-related tasks.

Evaluation of deambulation in a protected environment and in the public green in limb amputated subjects treated through a new osteointegration method

The limb amputation is one of the oldest surgical procedures performed and it still represents an event that drastically changes the life of an individual. Despite the technological progress, the difficulties related to the realization and daily use of the socket remain very common. Among the different technologies adopted in the prosthetic field, this project focused on the osseointegration technique. This technique consists in implanting a stem within the medullary canal of the amputated skeletal segment that extends outside the amputation stump with a prosthesis, later connected to the metal extension. The objective of this PhD project is to treat and to evaluate selected patients with osseointegrated prosthetic implants for the treatment of lower limb amputations. Patients are recruited at the Rizzoli Orthopaedic Institute and at the Prosthesis - INAIL center of Vigorso (Budrio) during outpatient visits, while the surgical procedure is performed by the same expert surgeon in the II Orthopaedic and Traumatology Clinic of the Rizzoli Orthopaedic Institute. The project is still ongoing, to date three patients had completed both procedures, but due to various personal problems, just one of them is included in the analysis. This patient increased his percentage of prosthesis use and the level of mobility with an overall improvement of quality of live after the procedure. The osseointegration technique represents a promising alternative method of treatment for amputees who are not satisfied with their socket prosthesis. In the coming years it will continue the collection of clinical, radiographic and kinematic data of subjects undergoing this procedure in order to perform a long-term monitoring of both clinical outcomes and quality of life.

Innovative microbiome-based system for the improvement of productivity, safety and sustainability of mussels farming

Northwestern Adriatic Sea Mediterranean mussels are exposed to fluctuating environmental parameters and to natural and anthropogenic stressors. Today is well known that mussels can be defined as holobiont, even if remains a lot to elucidate about how an organism and its microbial component response to environmental stress. This PhD dissertation aims to investigate microbiome possible adaptive patters exploiting the organism physiology response to stress, using the NGS sequencing method. The experimental approach consisted of two phases to first determine (i) the microbiome at a tissue scale level, (ii) the microbiome and physiological response to natural and anthropogenic stress environment and the chemical assessment of the microecosystem the Northwestern Adriatic Sea Mediterranean Mussel lives in. Results revealed firstly a robust microbiome well differentiated from seawater microecosystem, with compositional variations at the organ level. Thanks to those findings, digestive gland, the organ in which digestive and detoxification processes allow animal to tolerate and accumulate xenobiotics of natural and anthropogenic origin, was the selected tissue for the second phase of the project. The second phase of the project evaluated the putative physiological variations and the compositional changes in microbiome of digestive gland. I then manage to assess microbiome region trends across the north Adriatic, with each sampling site well differentiated from the others. Finally, a chemical method able to a powerful tool for the analytical detection of the major pollutants in mussels were validated. These first results may provide baseline information for future studies approaches of seasonal and region trends of microbiota profiles and physiological responses in terms of metabolism.

RNA interference technology as a potential control method for fruit and horticultural crops pathogens Botrytis cinerea and Plasmopara viticola

Chapter 1, a general introduction on Botrytis cinerea and its threat to crop production is presented. What Botrytis looks like, its life cycle, why it is a threat to agricultural production, its worldwide pest status, and its current state of management is further elaborated on. Chapter 2, a general introduction on Plasmopara viticola, its threat to grape production and management strategies presented. Chapter 3, titled " RNA Interference Strategies for Future Management of Plant Pathogenic Fungi: Prospects and Challenges ", presents the rapid improvement and extensive implementation of RNA interference (RNAi) technology for the management of fungal pathogens. In this chapter, we describe the application of exogenous RNAi involved in plant pathogenic fungi and discuss dsRNA production, formulation, and RNAi delivery methods. Chapter 4, titled " Exogenous dsRNAs against chitin synthase and glucan synthase genes suppress the growth of the pathogenic fungus Botrytis cinerea " addresses two important questions: Is RNAi technology functional for B. cinerea control ? And which target genes can be exploited for RNAi-based B.cinerea disease control ? Upon target genes selections, an exogenous RNAi protocol was set up and we could effectively deliver a known dose of bacterially produced double stranded RNA (dsRNA) to induce RNAi in B. cinerea. Chapter 5, titled " Double-Stranded RNA Targeting Dicer-Like Genes Compromises the Pathogenicity of Plasmopara viticola on Grapevine “, which deals mainly on RNAi induction against Plasmopara viticola. This chapter addresses two main questions: Is RNAi technology functional in contrasting Plasmopara viticola? And which target genes can be exploited for RNAi-based disease control in Plasmopara viticola?. In the last Chapter (Chapter 6) titled “General discussions and perspectives for future research”, the major research findings from this thesis are discussed together with perspectives for future research.

Evaluation of the sustainability level of a dairy and poultry farm: The Response-Inducing Sustainability Evaluation (RISE) method

Within this master thesis, various aspects related to the issue of sustainability in the food sector were addressed, focusing on the greenhouse gas emissions derived from livestock production. The increment in population number and wealth is directly related to the growing demand for meat products, which is, in turn, related to an increase in greenhouse gas emissions. Consumers are becoming more and more aware of these environmental issues and, therefore, sustainability factors are becoming even more relevant also from the environmental point of view. A very useful tool in this field is Response-Inducing Sustainability Evaluation (RISE), a software that allows you to determine the sustainability of a farm under many aspects, like energy consumption, livestock management and soil use. The RISE software processes the information obtained through a questionnaire submitted by the farmer, in which 10 different areas of sustainability in the farm are covered. For each theme, the results are expressed clearly with a score that goes from 0 to 100. The experimentation discussed in this work included two different projects, one regarding a dairy farm and the other regarding a poultry farm. The first one was conducted on a dairy farm in Germany and the results allowed to highlight the weakest areas of the farm on which recommendations were given for ecological improvement. The second project was conducted on a chicken broiler farm in Italy, on an experimental basis since it was the first time that the software was applied to poultry. The results pointed out the aspects that can be improved in the RISE software in order to make it more suitable for future poultry studies.

A Highly Improved Method For Sensitive Determination Of Amitriptyline In Pharmaceutical Formulations Using An Unmodified Carbon Nanotube Electrode In The Presence Of Sulfuric Acid.

The present paper describes a novel, simple and reliable differential pulse voltammetric method for determining amitriptyline (AMT) in pharmaceutical formulations. It has been described for many authors that this antidepressant is electrochemically inactive at carbon electrodes. However, the procedure proposed herein consisted in electrochemically oxidizing AMT at an unmodified carbon nanotube paste electrode in the presence of 0.1 mol L(-1) sulfuric acid used as electrolyte. At such concentration, the acid facilitated the AMT electroxidation through one-electron transfer at 1.33 V vs. Ag/AgCl, as observed by the augmentation of peak current. Concerning optimized conditions (modulation time 5 ms, scan rate 90 mV s(-1), and pulse amplitude 120 mV) a linear calibration curve was constructed in the range of 0.0-30.0 μmol L(-1), with a correlation coefficient of 0.9991 and a limit of detection of 1.61 μmol L(-1). The procedure was successfully validated for intra- and inter-day precision and accuracy. Moreover, its feasibility was assessed through analysis of commercial pharmaceutical formulations and it has been compared to the UV-vis spectrophotometric method used as standard analytical technique recommended by the Brazilian Pharmacopoeia.

Low-density Three-dimensional Foam Using Self-reinforced Hybrid Two-dimensional Atomic Layers.

Low-density nanostructured foams are often limited in applications due to their low mechanical and thermal stabilities. Here we report an approach of building the structural units of three-dimensional (3D) foams using hybrid two-dimensional (2D) atomic layers made of stacked graphene oxide layers reinforced with conformal hexagonal boron nitride (h-BN) platelets. The ultra-low density (1/400 times density of graphite) 3D porous structures are scalably synthesized using solution processing method. A layered 3D foam structure forms due to presence of h-BN and significant improvements in the mechanical properties are observed for the hybrid foam structures, over a range of temperatures, compared with pristine graphene oxide or reduced graphene oxide foams. It is found that domains of h-BN layers on the graphene oxide framework help to reinforce the 2D structural units, providing the observed improvement in mechanical integrity of the 3D foam structure.

Biochemical, Anthropometric And Body Composition Indicators As Predictors Of Hepatic Steatosis In Obese Adolescents.

To describe the prevalence of hepatic steatosis and to assess the performance of biochemical, anthropometric and body composition indicators for hepatic steatosis in obese teenagers. Cross-sectional study including 79 adolecents aged from ten to 18 years old. Hepatic steatosis was diagnosed by abdominal ultrasound in case of moderate or intense hepatorenal contrast and/or a difference in the histogram ≥7 on the right kidney cortex. The insulin resistance was determined by the Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) index for values >3.16. Anthropometric and body composition indicators consisted of body mass index, body fat percentage, abdominal circumference and subcutaneous fat. Fasting glycemia and insulin, lipid profile and hepatic enzymes, such as aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase and alkaline phosphatase, were also evaluated. In order to assess the performance of these indicators in the diagnosis of hepatic steatosis in teenagers, a ROC curve analysis was applied. Hepatic steatosis was found in 20% of the patients and insulin resistance, in 29%. Gamma-glutamyltransferase and HOMA-IR were good indicators for predicting hepatic steatosis, with a cutoff of 1.06 times above the reference value for gamma-glutamyltransferase and 3.28 times for the HOMA-IR. The anthropometric indicators, the body fat percentage, the lipid profile, the glycemia and the aspartate aminotransferase did not present significant associations. Patients with high gamma-glutamyltransferase level and/or HOMA-IR should be submitted to abdominal ultrasound examination due to the increased chance of having hepatic steatosis.