Automatic indexing and retrieval of encounter-specific evidence for point-of-care support

Evidence-based medicine relies on repositories of empirical research evidence that can be used to support clinical decision making for improved patient care. However, retrieving evidence from such repositories at local sites presents many challenges. This paper describes a methodological framework for automatically indexing and retrieving empirical research evidence in the form of the systematic reviews and associated studies from The Cochrane Library, where retrieved documents are specific to a patient-physician encounter and thus can be used to support evidence-based decision making at the point of care. Such an encounter is defined by three pertinent groups of concepts - diagnosis, treatment, and patient, and the framework relies on these three groups to steer indexing and retrieval of reviews and associated studies. An evaluation of the indexing and retrieval components of the proposed framework was performed using documents relevant for the pediatric asthma domain. Precision and recall values for automatic indexing of systematic reviews and associated studies were 0.93 and 0.87, and 0.81 and 0.56, respectively. Moreover, precision and recall for the retrieval of relevant systematic reviews and associated studies were 0.89 and 0.81, and 0.92 and 0.89, respectively. With minor modifications, the proposed methodological framework can be customized for other evidence repositories. © 2010 Elsevier Inc.

Provision of pharmaceutical care by community pharmacists:a comparison across Europe

Objective To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. Methods A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). Results Response rates ranged from 10–71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. Conclusion The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

A comprehensive approach to quality management of intensive care services

Purpose – The purpose of this paper is to develop a comprehensive framework for improving intensive care unit performance. Design/methodology/approach – The study introduces a quality management framework by combining cause and effect diagram and logical framework. An intensive care unit was identified for the study on the basis of its performance. The reasons for not achieving the desired performance were identified using a cause and effect diagram with the stakeholder involvement. A logical framework was developed using information from the cause and effect diagram and a detailed project plan was developed. The improvement projects were implemented and evaluated. Findings – Stakeholders identified various intensive care unit issues. Managerial performance, organizational processes and insufficient staff were considered major issues. A logical framework was developed to plan an improvement project to resolve issues raised by clinicians and patients. Improved infrastructure, state-of-the-art equipment, well maintained facilities, IT-based communication, motivated doctors, nurses and support staff, improved patient care and improved drug availability were considered the main project outputs for improving performance. The proposed framework is currently being used as a continuous quality improvement tool, providing a planning, implementing, monitoring and evaluating framework for the quality improvement measures on a sustainable basis. Practical implications – The combined cause and effect diagram and logical framework analysis is a novel and effective approach to improving intensive care performance. Similar approaches could be adopted in any intensive care unit. Originality/value – The paper focuses on a uniform model that can be applied to most intensive care units.

What are tests for? The implications of stuttering steps along the patient pathway

This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense. © 2014 Elsevier Ltd.

A KM perspective on implementing an electronic patient record within an NHS hospital

The Electronic Patient Record (EPR) is being developed by many hospitals in the UK and across the globe. We class an EPR system as a type of Knowledge Management System (KMS), in that it is a technological tool developed to support the process of knowledge management (KM). Healthcare organisations aim to use these systems to provide a vehicle for more informed and improved clinical decision making thereby delivering reduced errors and risks, enhanced quality and consequently offering enhanced patient safety. Finding an effective way for a healthcare organisation to practically implement these systems is essential. In this study we use the concept of the business process approach to KM as a theoretical lens to analyse and explore how a large NHS teaching hospital developed, executed and practically implemented an EPR system. This theory advocates the importance of taking into account all organizational activities - the business processes - in considering any KM initiatives. Approaching KM through business processes allows for a more holistic view of the requirements across a process: emphasis is placed on how particular activities are performed, how they are structured and what knowledge demanded and not just supplied across each process. This falls in line with the increased emphasis in healthcare on patient-centred approaches to care delivery. We have found in previous research that hospitals are happy with the delivery of patient care being referred to as their 'business'. A qualitative study was conducted over a two and half year period with data collected from semi-structured interviews with eight members of the strategic management team, 12 clinical users and 20 patients in addition to non- participant observation of meetings and documentary data. We believe that the inclusion of patients within the study may well be the first time this has been done in examining the implementation of a KMS. The theoretical propositions strategy was used as the overarching approach for data analysis. Here Initial theoretical research themes and propositions were used to help shape and organise the case study analysis. This paper will present preliminary findings about the hospital's business strategy and its links to the KMS strategy and process.

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRiST

Aim: To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care. Background: Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients' care pathways, within general practice and IAPT services. Methods: Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis. Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems. Conclusions: A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.

Giving whistleblowers greater protection:improving quality of care

This year, an independent review of whisleblowing in the NHS made recommendations as to how whistleblowers could be given greater protection. The review, chaired by Sir Robert Francis, intended to improve the quality of patient care and safety in the health service. But with many practitioners remaining unregulated, there are unanswered questions as to how reports of mistakes can be properly investigated and the necessary action taken against incompetent or negligent practitioners. Amanda Casey, Chair of the Registration Council for Clinical Physiologists, makes the case for regulation of professionals whose work poses potential risks to patients and can place healthcare managers in an invidious position.

Adósság, pénz és szabadság = Taxation, money and freedom

A tanulmány a Déltengeri Társasággal foglalkozó tanulmány folytatása (Madarász [2011]). A 18. századi brit államadósság szerepéről és kezeléséről szóló modern gazdaságtörténeti értékelések áttekintése után a tanulmány részletesen bemutatja Davenant, Defoe, Bolingbroke, Hume, Wallace, Pinto, Steuart és Smith érvelését a \"közhitel\" lehetséges és szükségszerű gazdasági és politikai hatásairól, a háborús kiadások fedezésének módjairól. Részletesebben tárgyalja Hume és Smith álláspontját a papírpénz és a bankok szerepéről, a pénzmennyiség változásának következményeiről és a skóciai \"szabad\" bankrendszer jellemzőiről. A vita egyik oldalán a közhitelt szükséges, ám veszélyes eszköznek tekintették, amely válságba sodorhatja az országot, és aláássa a politikai szabadságot, a másik vélemény szerint a kereskedő állam adóssága szükséges és előnyös, ösztönzi a gazdaság fejlődését, és kifejezi a polgárok bizalmát a kormányzat iránt. / === / The study, following on from the author s previous work on the history of South Sea Company, focuses on the issue of public debt in 18th-century British economic writings. The first part reviews recent debates among economic historians: how to explain the growing credibility of British governments after 1689. The next details the arguments of some important protagonists in the early modern age - Davenant, Defoe, Bolingbroke, Hume, Wallace, Pinto, Steuart and Smith - on the expected economic and political consequences of an increasing public debt and on the methods of financing wars. This is followed by discussion of the monetary theories of Hume and Smith, notably their views on banks, credit, paper money, the effects of increasing money supply, and the features of free\" Scottish banking system. Two main lines of argument were advanced in the controversies on public debt. Several writers regarded it as a necessary but dangerous instrument that undermines political liberty and can lead the state into financial bankruptcy. Others described it as not only necessary, but advantageous to a commercial nation, by stimulating trade and development and symbolizing the public s confidence in their government.

Formal professional relationships between general practitioners and specialists: possible associations with patient health and pharmacy costs

This article investigates whether the strength of formal professional relationships between general practitioners (GPs) and specialists (SPs) affects either the health status of patients or their pharmacy costs. To this end, it measures the strength of formal professional relationships between GPs and SPs through the number of shared patients and proxies the patient health status by the number of comorbidities diagnosed and treated. In strong GP–SP relationships, the patient health status is expected to be high, due to efficient care coordination, and the pharmacy costs low, due to effective use of resources. To test these hypotheses and compare the characteristics of the strongest GP–SP connections with those of the weakest, this article concentrates on diabetes—a chronic condition where patient care coordination is likely important. Diabetes generates the largest shared patient cohort in Hungary, with the highest traffic of specialist medication prescriptions. This article finds that stronger ties result in lower pharmacy costs, but not in higher patient health statuses. Key points for decision makers • The number of shared patients may be used to measure the strength of formal professional relationships between general practitioners and specialists. • A large number of shared patients indicates a strong, collaborative tie between general practitioners and specialists, whereas a low number indicates a weak, fragmented tie. • Tie strength does not affect patient health—strong, collaborative ties between general practitioners and specialists do not involve better patient health than weak, fragmented ties. • Tie strength does affect pharmacy costs—strong, collaborative ties between general practitioners and specialists involve significantly lower pharmacy costs than weak, fragmented ties. • Pharmacy costs may be reduced by lowering patient care fragmentation through channelling a general practitioner’s patients to a small number of specialists and increasing collaboration between general practitioner and specialists. • Limited patient choice is financially more beneficial than complete freedom of choice, and no more detrimental to patient health.

A gyógyszerkiadás és a betegek egészségi állapota a háziorvosi és szakorvosi kapcsolatok függvényében = Formal professional relations between general practitioners and specialists. Possible links with patient health and pharmacy cost

Arra a kérdésre keressük a választ, hogy a szoros háziorvosi-szakorvosi szakmai kapcsolatoknak van-e hatásuk a betegek gyógyszerkiadására, illetve egészségi állapotára. Az orvosok közötti szakmai kapcsolatok szorosságát a közösen gondozott betegek száma alapján határoztuk meg, míg a betegek egészségügyi állapotát a diagnosztizált és kezelt társbetegségek számával mértük. Hipotézisünk egyrészt az volt, hogy a hatékonyabb koordinációnak köszönhetően a szoros kapcsolatban kezelt betegek jobb egészségi állapotúak, másrészt kezelésük az erőforrások hatékonyabb felhasználása miatt kisebb gyógyszerköltséggel jár. E két hipotézist a cukorbetegekre teszteltük. Azért esett erre a krónikus betegségre a választásunk, mert itt a háziorvosok és a szakorvosok együttműködése elsődleges fontosságú. Magyarországon a cukorbetegek esetében a legnagyobb a közösen kezelt betegek populációja, valamint itt a legmagasabb a szakorvosi javaslatra felírt háziorvosi receptek száma. Azt az eredményt kaptuk, hogy a szoros kapcsolatban kezelt betegek nem rendelkeznek sem jobb, sem rosszabb egészségi állapottal, miközben a kapcsolódó gyógyszerkiadásuk szignifikánsan alacsonyabb. ____ The article considers whether strong formal professional relations between GPs and specialists in shared care affect either the health of patients or the pharmacy costs they incur. The strength of such relations is measured by the number of shared patients; patient health is proxied by number of co-morbidities diagnosed and treated. The first hypothesis is that patients treated amid strong GP-specialist relations have better health status than those treated amid weak ones, due to enhanced efficiency of care coordination. The second is that patients treated in such strong relations incur lower pharmacy costs high numbers of shared patients are assumed to promote appropriate, effective use of resources. The article tests these hypotheses and compares the outcomes of the strongest and weakest GP-specialist relations through the example of diabetes, a chronic condition where patient-care coordination is important. Diabetes generates the largest shared patient cohort in Hungary, with the highest number of specialist medication prescriptions. This article finds that stronger ties result in significantly lower pharmacy costs, but not a higher patient health status.

The Chef In Society: Origins And Development

In his discourse - The Chef In Society: Origins And Development - Marcel R. Escoffier, Graduate Student, School of Hospitality Management at Florida International University, initially offers: “The role of the modern professional chef has its origins in ancient Greece. The author traces that history and looks at the evolution of the executive chef as a manager and administrator.” “Chefs, as tradespersons, can trace their origins to ancient Greece,” the author offers with citation. “Most were slaves…” he also informs you. Even at that low estate in life, the chef was master of the slaves and servants who were at close hand in the environment in which they worked. “In Athens, a cook was the master of all the household slaves…” says Escoffier. As Athenian influence wanes and Roman civilization picks-up the torch, chefs maintain and increase their status as important tradesmen in society. “Here the first professional societies of cooks were formed, almost a hierarchy,” Escoffier again cites the information. “It was in Rome that cooks established their first academy: Colleqium Coquorum,” he further reports. Chefs, again, increase their significance during the following Italian Renaissance as the scope of their influence widens. “…it is an historical fact that the marriage of Henry IV and Catherine de Medici introduced France to the culinary wonders of the Italian Renaissance,” Escoffier enlightens you. “Certainly the professional chef in France became more sophisticated and more highly regarded by society after the introduction of the Italian cooking concepts.” The author wants you to know that by this time cookbooks are already making important inroads and contributing to the history of cooking above and beyond their obvious informational status. Outside of the apparent European influences in cooking, Escoffier also ephemerally mentions the development of Chinese and Indian chefs. “It is interesting to note that the Chinese, held by at least one theory as the progenitors of most of the culinary heritage, never developed a high esteem for the position of chef,” Escoffier maintains the historical tack. “It was not until the middle 18th Century that the first professional chef went public. Until that time, only the great houses of the nobility could afford to maintain a chef,” Escoffier notes. This private-to-public transition, in conjunction with culinary writing are benchmarks for the profession. Chefs now establish authority and eminence. The remainder of the article devotes itself to the development of the professional chef; especially the melding of two seminal figures in the culinary arts, Cesar Ritz and August Escoffier. The works of Frederick Taylor are also highlighted.

La respuesta liberal de Edmund Burke a la crisis de legitimidad política del siglo XVIII

Edmund Burke is both the greatest and the most underrated political thinker of the last three hundred years. We could not agree more with this assertion of Jesse Norman. Very few political-statesmen have attainted the enormous repercussion both in politics and in history that Burke had deployed over the last centuries. Nevertheless, Burke remains unfairly unknown for a wider public. And what it is more, the vast majority tend to think of him as a conservative, if not a liberal-conservative. A prior precision has to be made before continuing regarding the term liberal for the sake of accuracy. Burke was a prominent Whig, what in Spanish language we describe as a liberal, in the sense that both Hayek and Milton Friedman uttered, far from the meaning “kidnapped” of the word liberal by the Anglo-Saxon left. The object of this thesis is to investigate the non-solved controversy on Burke`s figure and the liberal answer he provided with to the political crisis of legitimacy of the 18th century. There is an existing shared opinion by the academia that prior to the Reflections on the Revolution of France, his masterpiece, he was an outstanding and prominent Whig. Champion of liberty, justice and good governance, guardian of liberal virtues and the authentic developer of the efficient policy put in place by the Marquis of Rockingham in order to curb the corruption and influence emanating from the court of George the Third and his double cabinet.

Commandeering Aesop’s Bamboo Canon: A 19th Century Confederacy of Creole Fugitive Fables

In my thesis, “Commandeering Aesop’s Bamboo Canon: A 19th Century Confederacy of Creole Fugitive Fables,” I ask and answer the ‘Who? What? Where? When? Why?” of Creole Literature using the 19th century production of Aesopian fables as clues to resolve a set of linguistic, historical, literary, and geographical enigmas pertaining the ‘birth-place(s)’ of Creolophone Literatures in the Caribbean Sea, North and South America, as well as the Indian Ocean. Focusing on the fables in Martinique (1846), Reunion Island (1826), and Mauritius (1822), my thesis should read be as an attempt capture the links between these islands through the creation of a particular archive defined as a cartulary-chronicle, a diplomatic codex, or simply a map in which I chart and trace the flight of the founding documents relating to the lives of the individual authors, editors, and printers in order to illustrate the articulation of a formal and informal confederation that enabled the global and local institutional promotion of Creole Literature. While I integrate various genres and multi-polar networks between the authors of this 19th century canon comprised of sacred and secular texts such as proclamations, catechisms, and proverbs, the principle literary genre charted in my thesis are collections of fables inspired by French 17th century French Classical fabulist, Jean de la Fontaine. Often described as the ‘matrix’ of Creolophone Literature, these blues and fables constitute the base of the canon, and are usually described as either ‘translated,’ ‘adapted,’ and even ‘cross-dressed’ into Creole in all of the French Creolophone spaces. My documentation of their transnational sprouting offers proof of an opaque canonical formation of Creole popular literature. By constituting this archive, I emphasize the fact that despite 200 years of critical reception and major developments and discoveries on behalf of Creole language pedagogues, literary scholars, linguists, historians, librarians, archivist, and museum curators, up until now not only have none have curated this literature as a formal canon. I also offer new empirical evidence in order to try and solve the enigma of “How?” the fables materially circulated between the islands, and seek to come to terms with the anonymous nature of the texts, some of which were published under pseudonyms. I argue that part of the confusion on the part of scholars has been the result of being willfully taken by surprise or defrauded by the authors, or ‘bamboozled’ as I put it. The major paradigmatic shift in my thesis is that while I acknowledge La Fontaine as the base of this literary canon, I ultimately bypass him to trace the ancient literary genealogy of fables to the infamous Aesop the Phrygian, whose biography – the first of a slave in the history of the world – and subsequent use of fables reflects a ‘hidden transcript’ of ‘masked political critique’ between ‘master and slave classes’ in the 4th Century B.C.E. Greece.

This archive draws on, connects and critiques the methodologies of several disciplinary fields. I use post-colonial literary studies to map the literary genealogies Aesop; use a comparative historical approach to the abolitions of slavery in both the 19th century Caribbean and the Indian Ocean; and chart the early appearance of folk music in early colonial societies through Musicology and Performance Studies. Through the use of Sociolinguistics and theories of language revival, ecology, and change, I develop an approach of ‘reflexive Creolistics’ that I ultimately hope will offer new educational opportunities to Creole speakers. While it is my desire that this archive serves linguists, book collectors, and historians for further scientific inquiry into the innate international nature of Creole language, I also hope that this innovative material defense and illustration of Creole Literature will transform the consciousness of Creolophones (native and non-native) who too remain ‘bamboozled’ by the archive. My goal is to erase the ‘unthinkability’ of the existence of this ancient maritime creole literary canon from the collective cultural imaginary of readers around the globe.

L’espace comme matériau : l’architecture moderne et le complexe du Bauhaus à Dessau

Pour respecter les droits d’auteur, la version électronique de ce mémoire a été dépouillée de certains documents visuels. La version intégrale du mémoire a été déposée à la Division de la gestion des documents et des archives.

L'évolution des voix/voies de femmes dans leurs écrits sur l'Église aux XVIIe et XVIIIe siècles

Feminist movements have allowed many female authors to become decisive and influential figures in literary history by studying their experiences, voices and forms of resistance. This thesis, however, focuses specifically on religious women, those seeking divine comfort outside the confines of institutional laws, or those who, out of protest, are caught in the middle. Founded on historical and feminist perspectives, this study examines the heterodox resistance of six French women living within or outside of Church boundaries during the 17th and 18th centuries: two eras that are particularly significant for women’s progress and modernity. This work strives to demonstrate how these women, doubly subjected to Church discourse and that of society, managed to live out their vocation (female and Christian) and make social, cultural and religious statements that contributed to changing the place of women in society. It aims to grasp the similarities and differences between the actions and ideas of women belonging to both the religious and secular spheres. Regardless of the century, the space and their background, women resist to masculine, patriarchal, ecclesial, political and social mediation and institutions. In locating examples of how they oppose the practices, rules and constraints that are imposed upon them, as well as of their exclusion from the socio-political space, this thesis also seeks to identify epistemological changes that mark the transition from the 17th to the 18th century. This thesis firstly outlines the necessary feminist theory upon which the project is based before identifying the evolution of women’s positions within the socio-ideological and political framework in which they lived. The questions of confession and spiritual direction are of particular interest since they serve as prime examples of masculine mediation and its issues and consequences – most notably the control of the female body and mind. The illustration of bodily metamorphoses bear testament to ideological changes, cultural awareness and female subjectivity, just as the scriptural inscriptions of unorthodox ideas and writing. The female body, both object and subject of the quest for individual and collective liberties, attests, in this way, to the movement towards Enlightenment values of freedom and justice.