A qualitative study of community pharmacists’ awareness of and involvement with intermediate care facilities

Rationale, aims and objectives: Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery and maximising independence. The introduction of IC has created a new interface between primary and secondary care. Older people are known to be at an increased risk of medication-related problems when transferring between healthcare settings and pharmacists are often not included as part of IC multidisciplinary teams. This study aimed to explore community pharmacists’ (CPs) awareness of IC services and to investigate their views of and attitudes towards the medicines management aspects of such services, including the transfer of medication information.

Method: Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with CPs practising in the vicinity of IC facilities in Northern Ireland, UK.

Results: Interviews were conducted with 16 CPs. Three themes were identified and named ‘left out of the loop’, ‘chasing things up’ and ‘closing the loop’. CPs felt that they were often ‘left out of the loop’ with regards to both their involvement with local IC services and communication across the healthcare interfaces. As a result, CPs resorted to ‘chasing things up’ as they had to proactively try to obtain information relating to patients’ medications. CPs viewed themselves as ideally placed to facilitate medicines management across the healthcare interfaces (i.e., ‘closing the loop’), but several barriers to potential services were identified.

Conclusion: CPs have limited involvement with IC services. There is a need for improvement of effective communication of patients’ medication information between secondary care, IC and community pharmacy. Increasing CP involvement may contribute to improving continuity of care across such healthcare interfaces, thereby increasing the person-centeredness of service provision.

Rocking behaviour of multi-block columns subjected to pulse-type ground motion accelerations

Ancient columns, made with a variety of materials such as marble, granite, stone or masonry are an important part of the
European cultural heritage. In particular columns of ancient temples in Greece and Sicily which support only the architrave are
characterized by small axial load values. This feature together with the slenderness typical of these structural members clearly
highlights as the evaluation of the rocking behaviour is a key aspect of their safety assessment and maintenance. It has to be noted
that the rocking response of rectangular cross-sectional columns modelled as monolithic rigid elements, has been widely investigated
since the first theoretical study carried out by Housner (1963). However, the assumption of monolithic member, although being
widely used and accepted for practical engineering applications, is not valid for more complex systems such as multi-block columns
made of stacked stone blocks, with or without mortar beds. In these cases, in fact, a correct analysis of the system should consider
rocking and sliding phenomena between the individual blocks of the structure. Due to the high non-linearity of the problem, the
evaluation of the dynamic behaviour of multi-block columns has been mostly studied in the literature using a numerical approach
such as the Discrete Element Method (DEM). This paper presents an introductory study about a proposed analytical-numerical
approach for analysing the rocking behaviour of multi-block columns subjected to a sine-pulse type ground motion. Based on the
approach proposed by Spanos (2001) for a system made of two rigid blocks, the Eulero-Lagrange method to obtain the motion
equations of the system is discussed and numerical applications are performed with case studies reported in the literature and with a
real acceleration record. The rocking response of single block and multi-block columns is compared and considerations are made
about the overturning conditions and on the effect of forcing function’s frequency.
.

A Wii Bit of Fun: A Novel Platform to Deliver Effective Balance Training to Older Adults

BACKGROUND: Falls and fall-related injuries are symptomatic of an aging population. This study aimed to design, develop, and deliver a novel method of balance training, using an interactive game-based system to promote engagement, with the inclusion of older adults at both high and low risk of experiencing a fall.

STUDY DESIGN: Eighty-two older adults (65 years of age and older) were recruited from sheltered accommodation and local activity groups. Forty volunteers were randomly selected and received 5 weeks of balance game training (5 males, 35 females; mean, 77.18 ± 6.59 years), whereas the remaining control participants recorded levels of physical activity (20 males, 22 females; mean, 76.62 ± 7.28 years). The effect of balance game training was measured on levels of functional balance and balance confidence in individuals with and without quantifiable balance impairments.

RESULTS: Balance game training had a significant effect on levels of functional balance and balance confidence (P < 0.05). This was further demonstrated in participants who were deemed at high risk of falls. The overall pattern of results suggests the training program is effective and suitable for individuals at all levels of ability and may therefore play a role in reducing the risk of falls.

CONCLUSIONS: Commercial hardware can be modified to deliver engaging methods of effective balance assessment and training for the older population.

Conceptions of subject analysis: a metatheoretical investigation

Thesis (Ph. D.)--University of Washington, 2005.

Validating A knowledge transfer framework in health services

The study of knowledge transfer (KT) has been proceeding in parallel but independently in health services and in business, presenting an opportunity for synergy and sharing. This paper uses a survey of 32 empirical KT studies with their 96 uniquely named determinants of KT success to identify ten unique determinants for horizontal knowledge transfer success. These determinants, the outcome measure of Knowledge Use, and separate explicit and tacit transfer flows constitute the KT Framework, extending the work of previous KT framework authors. Our Framework was validated through a case study of the transfer of clinical practice guideline knowledge between the cardiac teams of selected Ontario hospitals, using a survey of senders and receivers developed from the KT literature. The study findings were: 8 of 10 determinants were supported by the Successful Transfer Hospitals; and 4 of 10 determinants were found to a higher degree in the Successful than non-Successful transfer hospitals. Taken together, the results show substantive support for the KT Framework determinants, indicating aggregate support of 9 of these determinants, but not the 10th - Knowledge Complexity. The transfer of tacit knowledge was found to be related to the transfer of the explicit knowledge and expressed as the transfer or recreation of resource profile and internal process tacit knowledge, where this tacit transfer did not require interactions between Sender and Receiver. This study provides managers with the building blocks to assess and improve the success rates of their knowledge transfers.

On international cost-sharing of pharmaceutical R&D

Ramsey pricing has been proposed in the pharmaceutical industry as a principle to price discriminate among markets while allowing to recover the (fixed) R&D cost. However, such analyses neglect the presence of insurance or the fund raising costs for most of drug reimbursement. By incorporating these new elements, we aim at providing some building blocks towards an economic theory incorporating Ramsey pricing and insurance coverage. We show how coinsurance affects the optimal prices to pay for the R&D investment. We also show that under certain conditions, there is no strategic incentive by governments to set coinsurance rates in order to shift the financial burden of R&D. This will have important implications to the application of Ramsey pricing principles to pharmaceutical products across countries.

Synthesis of molecular biomimetics

Biomimetics has paved the way toward new materials and technologies inspired in Nature. Biomolecules and their supramolecular organization have today a leading role in biomimetics, benefiting from the recent advances in nanotechnology. The production of biomimetic materials may be however a difficult task, because Nature does it very well. The use of several building blocks assembled in bottom-up arrangement is without doubt at the core of this process. Such building blocks include different molecules or molecular arrangements, of synthetic or natural origin, such as amino acids, lipids, carbohydrates, nucleic acids, carbon allotropes, dendrimers, or organosilanes, among others. The most common approaches to produce synthetic biomimetic materials are reported herein, with special emphasis to building blocks and their supramolecular arrangement.

Modeling and optimization of extracellular polysaccharides production by Enterobacter A47

Polysaccharides are gaining increasing attention as potential environmental friendly and sustainable building blocks in many fields of the (bio)chemical industry. The microbial production of polysaccharides is envisioned as a promising path, since higher biomass growth rates are possible and therefore higher productivities may be achieved compared to vegetable or animal polysaccharides sources. This Ph.D. thesis focuses on the modeling and optimization of a particular microbial polysaccharide, namely the production of extracellular polysaccharides (EPS) by the bacterial strain Enterobacter A47. Enterobacter A47 was found to be a metabolically versatile organism in terms of its adaptability to complex media, notably capable of achieving high growth rates in media containing glycerol byproduct from the biodiesel industry. However, the industrial implementation of this production process is still hampered due to a largely unoptimized process. Kinetic rates from the bioreactor operation are heavily dependent on operational parameters such as temperature, pH, stirring and aeration rate. The increase of culture broth viscosity is a common feature of this culture and has a major impact on the overall performance. This fact complicates the mathematical modeling of the process, limiting the possibility to understand, control and optimize productivity. In order to tackle this difficulty, data-driven mathematical methodologies such as Artificial Neural Networks can be employed to incorporate additional process data to complement the known mathematical description of the fermentation kinetics. In this Ph.D. thesis, we have adopted such an hybrid modeling framework that enabled the incorporation of temperature, pH and viscosity effects on the fermentation kinetics in order to improve the dynamical modeling and optimization of the process. A model-based optimization method was implemented that enabled to design bioreactor optimal control strategies in the sense of EPS productivity maximization. It is also critical to understand EPS synthesis at the level of the bacterial metabolism, since the production of EPS is a tightly regulated process. Methods of pathway analysis provide a means to unravel the fundamental pathways and their controls in bioprocesses. In the present Ph.D. thesis, a novel methodology called Principal Elementary Mode Analysis (PEMA) was developed and implemented that enabled to identify which cellular fluxes are activated under different conditions of temperature and pH. It is shown that differences in these two parameters affect the chemical composition of EPS, hence they are critical for the regulation of the product synthesis. In future studies, the knowledge provided by PEMA could foster the development of metabolically meaningful control strategies that target the EPS sugar content and oder product quality parameters.

The role of trust and its evolution in distributed teams in a multinational organisation

Tutkimuksen päätavoitteena on ollut selvittää miten kansallinen ja organisaatiokulttuuri, niihin liittyvät normit ja arvot edesauttavat tai vaikeuttavat luottamuksen kehittymistä monikulttuurisissa tiimeissä maailmanlaajuisessa organisaatiossa. Tutkimuksen avulla haluttiin myös selvittää miten luottamus kehittyy hajautetuissa monikansallisissa tiimeissä WorldCom Internationalissa. Empiirinen tutkimusmenetelmä perustuu kvalitatiivisiin teemahaastatteluihin, jotka tehtiin WorldComin työntekijöille. Tutkimuksessa havaittiin, ettei yhteisten sosiaalisten normien merkitys luottamuksen syntymiselle ole niin merkittävä, koska WorldComin yhtenäiset toimintatavat sekä hallitseva amerikkalaisen emoyhtiön "kotikulttuuri" muodostavat yhtenäiset toimintalinjat tiimeissä. Tietokonevälitteisen kommunikoinnin jatkuva käyttö on edesauttanut työntekijöiden ns. sosiaalisen älyn kehittymistä, sillä henkilökohtaisen tapaamisen puuttuminen kehittää vastaavasti taitoja aistia ja tulkita sähköpostien tai puhelinneuvotteluiden aikana välittyviä vastapuolen "näkymättömiä" vihjeitä.

Synthetic studies on prostaglandins: "synthesis of a new thia-PGEI analog"

A PGE1 analog, namely (±)-trans-2-(6'-carbomethoxyhexyl)-3- (E-3"-thia-1 "-octene)-4-hydroxycyclopentanone 71, has been prepared for the first time. Towards the synthesis of this compound, several synthetic approaches aimed at the preparation of the required acetylenic and E-halovinylic sulfides as building blocks were investigated. Among all the methods examined, it appeared evident that the best route to ethynyl n.pentyl sulfide 81 is via a double dehydrohalogenation of the corresponding 1,2-dibromoethyl sulfide with sodium amide in liquid ammonia. In addition, the isomerically pure E-2-iodoethenyl n.pentyl sulfide 85 is conveniently prepared in high yield and stereoselectivity by hydrozirconation-iodination of the terminal ethynyl sulfide 81. The classical hydroalumination and hydroboration reactions for the preparation of vinyl halides from alkynes gave only small yields when applied as methods towards the synthesis of 85 . The building block 2-(6'-carbomethoxyhexyl)-4-hydroxy-2- cyclopentenone (±)-1 carrying the upper side-chain of prostaglandin E 1 was prepared by a step-wise synthesis involving transformations of compounds possessing the required carbocyclic framework (see scheme 27). The synthesis proved to be convenient and gave a good overall yield of (±)-1 which was protected as the TH P-derivative 37 or the siloxy derivative 38. With the required building blocks 81 and 37 in hand, the target 1S-thia-PGE1 analog (±)-71 was prepared via the in situ higher cuprate formation-conjugate addition reaction. This method proved to be convenient and stereospecific. The standard cuprate method, involving an organocuprate reagent generated from an isolated vinyl iodide, did not work well in our case and gave a complicated mixture of products. The target compound will be submitted for assessment of bio log ical activity.

(A) Optimization of solid body phase synthesis of RNA using the Cpep chemistry. (B) Synthesis of BODIPY labeled oligonucleotides

(A) Solid phase synthesis of oligonucleotides are well documented and are extensively studied as the demands continue to rise with the development of antisense, anti-gene, RNA interference, and aptamers. Although synthesis of RNA sequences faces many challenges, most notably the choice of the 2' -hydroxy protecting group, modified 2' -O-Cpep protected ribonucleotides were synthesized as alternitive building blocks. Altering phosphitylation procedures to incorporate 3' -N,N-diethyl phosphoramidites enhanced the overall reactivity, thus, increased the coupling efficiency without loss of integrety. Furthermore, technical optimizations of solid phase synthesis cycles were carried out to allow for successful synthesis of a homo UIO sequences with a stepwise coupling efficiency reaching 99% and a final yield of 91 %. (B) Over the past few decades, dipyrrometheneboron difluoride (BODIPY) has gained recognition as one of the most versatile fluorophores. Currently, BODIPY labeling of oligonucleotides are carried out post-synthetically and to date, there lacks a method that allows for direct incorporation of BODIPY into oligonucleotides during solid phase synthesis. Therefore, synthesis of BODIPY derived phosphoramidites will provide an alternative method in obtaining fluorescently labelled oligonucleotides. A method for the synthesis and incorporation of the BODIPY analogues into oligonucleotides by phosphoramidite chemistry-based solid phase DNA synthesis is reported here. Using this approach, BODIPY-labeled TlO homopolymer and ISIS 5132 were successfully synthesized.

Tetrathiafulvalene and 2,2'-Bipyridine: Bridging both Worlds in the Pursuit of Novel Molecular Materials

The preparation and characterization of two families of building blocks for molecule-based magnetic and conducting materials are described in three projects. In the first project the synthesis and characterization of three bis-imine ligands LI - L3 is reported. Coordination of LI to a series of metal salts afforded the five novel coordination complexes Sn(L4)C4 (I), [Mn(L4)(u-CI)(CI)(EtOH)h (II), [CU(L4)(u-sal) h(CI04)2 (sal = salicylaldehyde anion) (III), [Fe(Ls)2]CI (IV) and [Fe(LI)h(u-O) (V). All complexes have been structurally and magnetically characterized. X-ray diffraction studies revealed that, upon coordination to Lewis acidic metal salts, the imine bonds of LI are susceptible to nucleophilic attack. As a consequence, the coordination complexes (I) - (IV) contain either the cyclised ligand L4 or hydrolysed ligand Ls. In contrast, the dimeric Fe3+ complex (V) comprises two intact ligand LI molecules. In. this complex, the ligand chelates two Fe(III) centres in a bis-bidentate manner through the lone pairs of a phenoxy oxygen and an imine nitrogen atom. Magnetic studies of complexes (II-V) indicate that the dominant interactions between neighbouring metal centres in all of the complexes are antiferromagnetic. In the second project the synthesis and characterization two families of TTF donors, namely the cyano aryl compounds (VI) - (XI) and the his-aryl TTF derivatives (XII) - (XIV) are reported. The crystal structures of compounds (VI), (VII), (IX) and (XII) exhibit regular stacks comprising of neutral donors. The UV -Vis spectra of compounds (VI) - (XIV) present an leT band, indicative of the transfer of electron density from the TTF donors to the aryl acceptor molecules. Chemical oxidation of donors (VI), (VII), (IX) and (XII) with iodine afforded a series of CT salts that where possible have been characterized by single crystal X -ray diffraction. Structural studies showed that the radical cations in these salts are organized in stacks comprising of dimers of oxidized TTF donors. All four salts behave as semiconductors, displaying room temperature conductivities ranging from 1.852 x 10-7 to 9.620 X 10-3 Scm-I. A second series of CT salts were successfully prepared via the technique of electrocrystallization. Following this methodology, single crystals of two CT salts were obtained. The single crystal X-ray structures of both salts are isostructural, displaying stacks formed by trimers of oxidized donors. Variable temperature conductivity measurements carried out on this series of CT salts reveal they also are semiconductors with conductivities ranging from 2.94 x 10-7 to 1.960 X 10-3 S em-I at room temperature. In the third project the synthesis and characterization of a series of MII(hfac)2 coordination complexes of donor ligand (XII) where M2+ = Co2+, Cu2+, Ni2+ and Zn2+ are reported. These complexes crystallize in a head-to-tail arrangement of TTF donor and bipyridine moieties, placing the metal centres and hfac ligands are located outside the stacks. Magnetic studies of the complexes (XV) - (XVIII) indicate that the bulky hfac ligands prevent neighbouring metal centres from assembling in close proximity, and thus they are magnetically isolated.

(A) Photoregulation of DNA Functions by Cyclic Azobenzene-tethered Oligonucleotides (B) Site-specific Fluorescent Labeling of DNA using Inverse Electron Demand Diels-Alder Reaction between trans-Cyclooctene Derivatives and BODIPY-Tetrazine Adducts

(A) Most azobenzene-based photoswitches require UV light for photoisomerization, which limit their applications in biological systems due to possible photodamage. Cyclic azobenzene derivatives, on the other hand, can undergo cis-trans isomerization when exposed to visible light. A shortened synthetic scheme was developed for the preparation of a building block containing cyclic azobenzene and D-threoninol (cAB-Thr). trans-Cyclic azobenzene was found to thermally isomerize back to the cis-form in a temperature-dependent manner. cAB-Thr was transformed into the corresponding phosphoramidite and subsequently incorporated into oligonucleotides by solid phase synthesis. Melting temperature measurement suggested that incorporation of cis-cAB into oligonucleotides destabilizes DNA duplexes, these findings corroborate with circular dichroism measurement. Finally, Fluorescent Energy Resonance Transfer experiments indicated that trans-cAB can be accommodated in DNA duplexes. (B) Inverse Electron Demand Diels-Alder reactions (IEDDA) between trans-olefins and tetrazines provide a powerful alternative to existing ligation chemistries due to its fast reaction rate, bioorthogonality and mutual orthogonality with other click reactions. In this project, an attempt was pursued to synthesize trans-cyclooctene building blocks for oligonucleotide labeling by reacting with BODIPY-tetrazine. Rel-(1R-4E-pR)-cyclooct-4-enol and rel-(1R,8S,9S,4E)-Bicyclo[6.1.0]non-4-ene-9-ylmethanol were synthesized and then transformed into the corresponding propargyl ether. Subsequent Sonogashira reactions between these propargylated compounds with DMT-protected 5-iododeoxyuridine failed to give the desired products. Finally a methodology was pursued for the synthesis of BODIPY-tetrazine conjugates that will be used in future IEDDA reactions with trans-cyclooctene modified oligonucleotides.

L’agrément : un agent moteur de développement des capacités, d’apprentissage collectif et de socialisation. Une étude de cas en profondeur dans un hôpital privé saoudien

Cette thèse vise à comprendre comment et dans quelle mesure l’agrément des établissements de santé est-il efficace pour développer les capacités des acteurs, nécessaires pour améliorer la qualité des soins et des services. Au cours des dix dernières années, il y a eu une croissance rapide, à l'échelle mondiale de la mise en œuvre de programmes d'agrément en santé pour l’amélioration de la qualité. L'expérience de la dernière décennie prouve que l'agrément est une technique valable pour l'amélioration de la qualité dans beaucoup d’organismes de santé. Il est également utilisé pour soutenir les réformes en santé. Malgré cela, les outils de gestion comme l’agrément sont souvent critiqués, car elles sont adoptées avec enthousiasme négligeant fréquemment une implantation favorisant la mise en place de comportements durables et la démonstration de meilleurs résultats. Le développement des capacités (DC) est un processus délibéré, multidimensionnel, dynamique dont le but est d’améliorer la performance des individus, des équipes, de l’organisation et d’un système. Le DC constitue une des trois assises de l’implantation d’une démarche institutionnalisée de la qualité, au même niveau que la communication et la reconnaissance. Cette recherche c’est déroulée dans un organisme d’Arabie Saoudite dans le cadre de leur première démarche avec le Conseil canadien d’agrément (CCASS) des services de santé. Une étude de cas unique d’implantation de l’agrément a été menée utilisant une approche mixte. Quatre niveaux d’analyse ont été étudiés en détail (individu, équipe, organisation et système) afin de mesurer 28 effets escomptés du DC puisés dans la littérature. Des entretiens semi-structurés, des groupes de discussion, une revue de la documentation ont été réalisés. Dans le but de mesurer trois des effets escomptés, un questionnaire sur le niveau d’implantation de la qualité (NIQ) a été administré pour la première fois en Arabie Saoudite dans cinq organismes. La performance du cas a été évaluée en relation avec les autres et en fonction de son positionnement dans le cycle d’agrément. Des analyses qualitatives et quantitatives utilisant la technique de polissage par la médiane ont été exécutées. Au niveau des individus, l’agrément a motivé la participation à de nouvelles formations. L’auto-évaluation est l’étape qui encourage l’apprentissage par l’autocritique. Le sentiment de fierté est le changement affectif le plus souvent répertorié. Les équipes ont amélioré leur communication par l’implantation d’une « chaîne de commandement ». Elle a introduit des notions de respect et de clarté des rôles telles qu’exigées par les normes. Au moyen de la mesure du NIQ, nous avons constaté que la majorité des organismes saoudiens se positionnent au niveau minimal d’implantation (assurance qualité). Le plus expérimenté avec l’agrément démontre les meilleurs résultats tout près du second niveau. Enfin, plus les organismes progressent dans la démarche d’agrément, plus les écarts de perception entre les 8 domaines mesurés par le questionnaire du NIQ et entre les différentes catégories d’emploi s’amincissent. En conclusion, l’agrément a démontré de l’efficacité à développer de nouvelles capacités par l’intégration des transformations des individus et par l’impact de l’acquisition des nouvelles capacités sur le changement des pratiques, majoritairement au niveau des individus, des équipes et de l’organisation. Le processus d’agrément a également fait preuve d’importants pouvoirs de convergence au niveau de l’adoption des pratiques édictées par les normes d’agrément qui contribuent positivement à l’amélioration de la qualité.

Synthesis and characterization of main-chain bile acid-based degradable polymers

Les acides biliaires sont des composés naturels existants dans le corps humain. Leur biocompatibilité, leur caractère amphiphile et la rigidité de leur noyau stéroïdien, ainsi que l’excellent contrôle de leurs modifications chimiques, en font de remarquables candidats pour la préparation de matériaux biodégradables pour le relargage de médicaments et l'ingénierie tissulaire. Nous avons préparé une variété de polymères à base d’acides biliaires ayant de hautes masses molaires. Des monomères macrocycliques ont été synthétisés à partir de diènes composés de chaînes alkyles flexibles attachées à un noyau d'acide biliaire via des liens esters ou amides. Ces synthèses ont été réalisées par la fermeture de cycle par métathèse, utilisant le catalyseur de Grubbs de première génération. Les macrocycles obtenus ont ensuite été polymérisés par ouverture de cycle, entropiquement induite le catalyseur de Grubbs de seconde génération. Des copolymères ont également été préparés à partir de monolactones d'acide ricinoléique et de monomères cycliques de triester d’acide cholique via la même méthode. Les propriétés thermiques et mécaniques et la dégradabilité de ces polymères ont été étudiées. Elles peuvent être modulées en modifiant les différents groupes fonctionnels décorant l’acide biliaire et en ayant recours à la copolymérisation. La variation des caractéristiques physiques de ces polymères biocompatibles permet de moduler d’autres propriétés utiles, tel que l’effet de mémoire de forme qui est important pour des applications biomédicales.