God and War: the Church of England and Armed Conflict in the Twentieth Century

Despite narratives of secularization, it appears that the British public persistently pay attention to clerical opinion and continually resort to popular expressions of religious faith, not least in time of war. From the throngs of men who gathered to hear the Bishop of London preach recruiting sermons during the First World War, to the attention paid to Archbishop Williams' words of conscience on Iraq, clerical rhetoric remains resonant. For the countless numbers who attended National Days of Prayer during the Second World War, and for the many who continue to find the Remembrance Day service a meaningful ritual, civil religious events provide a source of meaningful ceremony and a focus of national unity. War and religion have been linked throughout the twentieth century and this book explores these links: taking the perspective of the 'home front' rather than the battlefield. Exploring the views and accounts of Anglican clerics on the issue of warfare and international conflict across the century, the authors explore the church's stance on the causes, morality and conduct of warfare; issues of pacifism, obliteration bombing, nuclear possession and deterrence, retribution, forgiveness and reconciliation, and the spiritual opportunities presented by conflict. This book offers invaluable insights into how far the Church influenced public appraisal of war whilst illuminating the changing role of the Church across the twentieth century.

Books for asset management in hospitals in Seville.

Hospitals from ancient Seville had an important heritage for survival of the institution and its patients. In order to keep this heritage, the officialdom settled down several control mechanisms that would serve to manage a profitable management of their income and rights. For this purpose, they developed devising instruments able to preserve their possessions and put them into operation. This article attempts to identify the defining elements of these books, called “protocolos de bienes” (protocols goods), indicating their characteristics and evolution from archaic models until the final form. This final form was reached late sixteenth and early seventeenth century, at which time devoted use main codex of hospitality. To do this, we used the documentary collec-tions of Seville, preserved in different archives of the city, from where they have taken several significant examples showing the changes that occurred in both its internal structure and its mate-rials manufacturing, underlining the participation of official, booksellers, illuminators and calligraphers. Similarly, it has high-lighted the multifaceted and multifunctional character of this ins-titutions that became also a corporate identity. The multiplicity of hospitals in Sevilla had different types and features of protocols, which were modificated according to the different needs of each institution.

A cocaína e suas manifestações orofaciais

A cocaína é uma droga com ação estimulante no sistema nervoso central, extraída e refinada a partir da planta de coca (Erythroxylum coca). É característica por induzir o consumidor a um estado de hipervigilância reduzindo ao mesmo tempo, o cansaço e a fadiga. Este pó branco, cristalino, de sabor amargo, possui também um efeito anestésico local e vasoconstritor. As formas de apresentação mais comuns da droga são o cloridrato de cocaína e a cocaína crack. Esta droga destaca-se por ser o estimulante mais consumido na Europa com cerca de 3,4 milhões de consumidores estimados no ano de 2014. A prevalência do consumo desta droga em Portugal aumentou 0,3% de 2001, para 2012 na população geral (15-64 anos). Os estudos mais recentes em populações escolares (entre 2010 e 2011) evidenciaram, de um modo geral, o aumento da prevalência de consumo nesta população. Os efeitos adversos resultantes, tanto a nível físico como psíquico, são vários, sendo as manifestações orofaciais as que mais interferem na Qualidade de vida do toxicómano. As manifestações mais frequentes são as perfurações do septo nasal e palatino, bruxismo, gengivite, erosão dentária, xerostomia, cárie, lesões brancas atípicas e cefaleias em salva, tendo o Médico Dentista um papel importante no diagnóstico e tratamento destas lesões. A legislação, ao nível Europeu, sobre drogas procura uma uniformização das medidas aplicadas nos países membros, baseando-se no equilíbrio entre as sanções e o tratamento. Apesar das convenções das Nações Unidas sobre drogas limitarem o consumo de estupefacientes e substâncias psicotrópicas exclusivamente para fins médicos e científicos, cabe aos países signatários a liberdade de decisão das políticas a adoptar em matérias de infrações penais como a posse e o consumo ilegal.

Le jeune adulte et la maturité vocationnelle

Plusieurs collèges compilent à chaque session les taux d'abandon, d'échec et de changement de programme de leurs étudiants. Bien que certains facteurs et causes d'échec, d'abandon ou de changement de programme aient pu être relevés, ces compilations statistiques ne s'avèrent guère utiles aux professionnels des services de consultation. Ces données permettent de constater les faits. Une analyse plus en détail nous permettant d'identifier les sources du problème serait beaucoup plus utile. En plus des étudiants qui échouent, abandonnent des cours ou changent de programme, que dire de ceux qui ont fixé trop rapidement ou de façon trop rigide leur choix vocationnel et de ceux qui se maintiennent dans un état d'indécision chronique au niveau de leur choix vocationnel ? Comment entreprendre des actions préventives à l'égard de ces phénomènes du cheminement scolaire des étudiants ? Nous identifions comme étant une des sources de ces phénomènes la maturité vocationnelle du jeune adulte, puisque c'est celle-ci qui influencera la qualité de ses choix et son adaptation professionnelle (Super; voir Laflamme et Petit, 1973). En effet, le jeune adulte doit être en mesure d'évaluer les motifs et les conséquences des gestes qu'il pose en fonction de la réalisation de son projet vocationnel, pour contrôler son cheminement scolaire. Or nous constatons, que même si les jeunes adultes semblent préoccupés par la question de leur orientation, bon nombre d'entre eux ne manifestent pas l'intérêt de prendre en charge leur démarche d'orientation. Plusieurs semblent s'occuper de cette question à la dernière minute, par exemple, juste avant les dates limites des demandes d'admission pour l'entrée au collège ou à l'université. D'autres semblent procéder par essais et erreurs sans nécessairement être conscients des valeurs, buts, ambitions qui les poussent à poser ces choix successifs (nouveaux programmes) parfois peu satisfaisants. Certains refuseront même de poser des choix reléguant au hasard ce qui arrivera d'eux. Tous ces faits et impressions tirés de notre expérience nous font penser que le jeune adulte ne semble pas s'impliquer personnellement dans les actes qu'il pose. Il ne semble pas croire qu'il a du pouvoir sur sa vie et qu'il peut prendre en charge les évènements qui l'entourent, particulièrement ici, son cheminement scolaire et sa démarche d'orientation. Il laisse plutôt l'environnement exercer un contrôle sur lui, ce qui a pour effet, croyons-nous, de le rendre passif quant à son cheminement scolaire et à sa démarche d'orientation. Il semble y avoir une contradiction: le jeune adulte est préoccupé par la question de son orientation mais ne semble pas motivé à investir beaucoup d'énergie pour son développement vocationnel. Il ne se prend pas en charge, il ne passe pas à l'action claire et manifeste. A l'observation de ces comportements, il nous apparaît alors que beaucoup de jeunes adultes ne sont pas réellement en possession de leur projet vocationnel. C'est là justement qu'il nous faut vérifier si le jeune adulte de niveau collégial a atteint une certaine maturité vocationnelle. Nous tenterons donc de voir comment se situe le jeune adulte du niveau collégial dans son développement vocationnel et ce, par rapport aux théories existantes et comment mesurer son niveau de maturité vocationnelle. Pour ce faire nous effectuerons, dans un premier temps, une revue de la littérature scientifique en ce qui a trait à la notion de maturité vocationnelle; puis nous effectuerons une revue et une critique des travaux antérieurs sur la mesure et l'évaluation de la maturité vocationnelle. Cette dernière étape vous permettra de déterminer quel instrument serait le plus adéquat pour mesurer la maturité vocationnelle du jeune adulte de niveau collégial.

Conversando com a tecnologia: contribuições de João Augusto Bastos para a educação tecnológica

For the reader of this book it is reserved a historical walk through the efforts realized in the field of education to settle the necessary basis for the formation of a participating citizen in the socio-technical process and the dialogic and communicative action with the technological world. There are ten articles that discuss about many aspects of the relationship between education and technology, experienced by the author, who at any moment forgot thinkers with whom he spoke as Jürgen Habermas, Karl Marx, Karl Popper, Theodor Adorno, Max Horkheimer and Ruy Gama. You can dream and run away from the instrumental knowledge to incorporate the woven continuous experience in the practice and experience with people. In this atmosphere of concepts, characteristics and perspectives is the technological education, which runs through dialogue with technology, possession of knowledge and interdisciplinary. Talking to the technology, the subject interacts with society so that the demands are part of projects in this field of this champ of knowledge and the other sciences. It also means to explore knowledge and practices of professionals and educators working in this field full of normative and formative values.

Educação ambiental no curso de técnico de edificações - ifsul campus Pelotas : desafios e possibilidades da educação emancipatória nos cursos técnicos

O presente trabalho de dissertação de mestrado visa a descortinar as contradições que estão presentes nas representações de docentes e discentes da disciplina de práticas construtivas do Curso Técnico de Edificações, do Instituto Federal Sul-Rio-Grandese (IFSul), campus Pelotas, em suas relações sócioeducativas, encontrando nesse desvelamento alternativas para o desenvolvimento destas atividades práticas de forma a contribuir na sustentabilidade do curso, e por conseguinte na sustentabilidade das relações entre homens, natureza e meio ambiente. A partir dessas representações sociais e contradições, esse trabalho possibilitou, através de um estudo de caso de natureza qualitativa dialética, de posse das categorias do Materialismo Dialético e Histórico e da economia política, uma compreensão dialética de como o modo de produção capitalista interfere nas ações em geral, inclusive nas relações de educação. A opção por esse assunto foi principalmente devido a constatações próprias, como professor de práticas construtivas, da necessidade de continuidade das atividades práticas no curso, mas de uma maneira mais coerente com as leis da natureza, por um processo educativo emancipador de educadores e educandos, socializando os saberes libertadores da educação ambiental. O estudo mostrou-se coerente e revelador materializando-se em possibilidades, projetos e ações imediatas de transformações dentro do curso de maneira a interferir nas relações de todos entre si e com a natureza, com uma forma possível de utilizar as matériasprimas necessárias sem o desperdício, com o máximo de aproveitamento e reciclagem, com a possibilidade de levar essas aulas práticas para fora dos muros da escola, em atividades necessárias para entidades assistenciais, minimizando a geração de resíduos sólidos a serem descartados na natureza, contribuindo dessa maneira com o perfeito relacionamento homem-homem, homem-natureza, na busca da sustentabilidade e na conservação da vida no Planeta.

Monseigneur Antoine Racine et les communautés de religieuses enseignantes dans le diocèse de Sherbrooke de 1874 à 1893

Le diocèse de Sherbrooke fut érigé par le Pape Pie IX. La bulle d'érection, datée de Rome le 28 août 1874, confirmait ainsi le voeu de l'épiscopat de la province ecclésiastique de Québec, émis au cinquième concile provincial du 23 mai 1873. Le nouveau diocèse comprenait un démembrement des diocèses de Québec, de St-Hyacinthe et des Trois-Rivières; Québec cédait trois cantons plus une paroisse; St-Hyacinthe, dix-huit cantons; et Trois-Rivières, vingt-quatre. Moins de la moitié de la population de ce territoire était catholique, soit seulement 30,255 sur une population totale de 68,283 habitants, d'après le recensement de 1870. Par une bulle romaine du premier septembre 1874, Antoine Racine, prêtre desservant de l'église Saint-Jean-Baptiste de Québec, était nommé premier évêque du nouveau diocèse. L'évêque élu avait été prévenu quelques jours auparavant par une lettre de Rome. Consacré à Québec, le 18 octobre 1874, des mains de Mgr Elzéar Alexandre Taschereau, archevêque de Québec, Mgr Antoine Racine prit possession du siège de Sherbrooke le 20 du même mois. Pendant dix-neuf ans, soit jusqu'à sa mort survenue le 17 juillet 1893, l'évêque de Sherbrooke conduisit son diocèse avec prudence, le dotant d'institutions stables. Ses nécrologistes et ses biographes le considèrent comme un des principaux artisans de la pénétration catholique et française dans les Cantons de l'Est. […]

L’association Duterimbere et la promotion du crédit aux femmes rwandaises : cas de la préfecture de la ville de Kigali

Depuis longtemps, les femmes du monde entier en général et rwandaises en particulier sont restées et restent encore, sauf quelques rares exceptions, en marge des activités de développement économique ou s'y sont intéressées tardivement. Dépourvues de propriété et de biens, les femmes n'ont que le droit de l'usufruit sur le patrimoine familial dont seuls les garçons sont héritiers. Retenues par les travaux domestiques et agricoles non rémunérateurs, les femmes ne disposent pas d'argent, à part de petites sommes qui leur sont remises par leur mari, destinées à défrayer les dépenses courantes (achat de sel, pétrole, savon etc.). Depuis un certain temps, la terre arable se fait plus rare et de plus en plus improductive. Les femmes deviennent chefs de famille suite au veuvage, à l'abandon du toit conjugal par les hommes, à la tolérance des enfants illégitimes. Pour ces raisons certaines femmes abandonnent les activités agricoles ou les associent au petit commerce, à l'artisanat et aux divers métiers non structurés apportant un revenu monétaire immédiat pour faire vivre leurs familles. Cependant l'accès aux ressources de production n'est pas facile. Malgré la possession d'une capacité de travail admirable, les femmes se heurtent à l'acquisition des ressources naturelles et du capital de risque qui constitue une base importante pour la réussite de ce genre d'activité d'appoint. La majorité des femmes n'ayant pas de revenu salarial ou autres revenus permanents, l'accès au crédit se présente comme un tabou. Cela est dû à plusieurs facteurs dont les plus fréquents se résument par le manque de garantie, l'absence ou l'insuffisance d'information et de formation en matière de crédit, la sous-estimation par les banquiers des femmes dans les affaires, etc. Pour faire face à cette situation, les organisations non gouvernementales (ONG) extérieures ayant des projets de développement dans le pays octroyaient de temps en temps des crédits aux femmes ou les avalisaient auprès des banques. Mais une fois que le projet en question arrive à terme, cette activité d'appui aux femmes s'arrête sans laisser aucune structure de continuité. Le Centre de formation et de recherche coopératives et le ministère de la Jeunesse et du Mouvement associatif prennent la relève en avalisant les coopératives et les groupements (y compris ceux des femmes) auprès des banques populaires. Toutefois leur soutien reste encore insignifiant face au problème. C'est dans cette optique qu'en mai 1987, pour tenter de briser ce mythe à l'égard des femmes en matière d'accès au crédit, l'association «Duterimbere» («Allons de l'avant») fut créée par un groupe de femmes intellectuelles, en tant qu'organisation locale sans but lucratif. Celle-ci vient se joindre à d'autres intervenants qui déploient des efforts pour relever le défi d'inaccessibilité des femmes au crédit. Préoccupée par ce problème, nous partirons de l'analyse des services de l'association Duterimbere à l'égard des femmes pour pouvoir apprécier en quoi Duterimbere se distingue d'autres ONG ou structures d'appui aux femmes. Le projet de création d'un service d'épargne et de crédit que nous nous proposons d'intégrer parmi les services de Duterimbere serait, à notre avis, d'un apport non négligeable et viendrait parachever le soutien de Duterimbere aux femmes, au moins en ce qui concerne les petits crédits.

Detection of virulence-associated genes in pathogenic and commensal avian Escherichia coli isolates

Poultry colibacillosis due to Avian Pathogenic Escherichia coli (APEC) is responsible for several extra-intestinal pathological conditions, leading to serious economic damage in poultry production. The most commonly associated pathologies are airsacculitis, colisepticemia, and cellulitis in broiler chickens, and salpingitis and peritonitis in broiler breeders. In this work a total of 66 strains isolated from dead broiler breeders affected with colibacillosis and 61 strains from healthy broilers were studied. Strains from broiler breeders were typified with serogroups O2, O18, and O78, which are mainly associated with disease. The serogroup O78 was the most prevalent (58%). All the strains were checked for the presence of 11 virulence genes: 1) arginine succinyltransferase A (astA); ii) E. coli hemeutilization protein A (chuA); iii) colicin V A/B (cvaA/B); iv) fimbriae mannose-binding type 1 (fimC); v) ferric yersiniabactin uptake A (fyuA); vi) iron-repressible high-molecular-weight proteins 2 (irp2); vii) increased serum survival (iss); viii) iron-uptake systems of E. coli D (iucD); ix) pielonefritis associated to pili C (papC); x) temperature sensitive haemaglutinin (tsh), and xi) vacuolating autotransporter toxin (vat), by Multiplex-PCR. The results showed that all genes are present in both commensal and pathogenic E. coli strains. The iron uptake-related genes and the serum survival gene were more prevalent among APEC. The adhesin genes, except tsh, and the toxin genes, except astA, were also more prevalent among APEC isolates. Except for astA and tsh, APEC strains harbored the majority of the virulence-associated genes studied and fimC was the most prevalent gene, detected in 96.97 and 88.52% of APEC and AFEC strains, respectively. Possession of more than one iron transport system seems to play an important role on APEC survival.

Caraterização dos padrões de jogo ofensivos após recuperação de posse bola a partir de desarme ou interceção: análise comparativa da equipa principal e equipa B do Sporting Club de Portugal

O jogo de futebol, e simultaneamente o seu processo ofensivo, tem sido, nos últimos anos, alvo de diversos trabalhos de investigação. Tendo como objetivo a sua análise e caracterização, o especial interesse por parte dos investigadores tem estado focado predominantemente no processo ofensivo no seu todo, desde a recuperação de posse de bola, o desenvolvimento do processo em si e a sua finalização. O presente estudo teve como principal objetivo a caraterização do processo ofensivo da equipa principal e equipa B do Sporting Clube de Portugal após recuperação de posse de bola por desarme ou interceção. Foram registadas as sequências ofensivas de 16 jogos (8 por equipa), da equipa principal e da sua equipa B, da época 2014/15, na condição de visitado, com recurso ao software Videobserver (Afra, 2013). As sequências ofensivas foram observadas e registadas a partir da recuperação de posse de bola de forma dinâmica, ou seja, através de desarme ou interceção. Para a análise estatística descritiva e sequencial foi utilizado o software SDIS GSEQ 5.1 (Bakeman & Quera, 1996). Os resultados permitiram concluir que i) as equipas observadas recuperaram a posse de bola maioritariamente no setor médio defensivo e numa relação de igualdade ou superioridade relativa; ii) as equipas observadas, desenvolvem o processo ofensivo de forma semelhante, recorrendo ao passe curto ou médio, para a frente, ou diagonal frente e rasteiro como comportamento mais vezes verificado após a recuperação de posse de bola; iii) O método de jogo ofensivo mais utilizado pelas equipas observadas é o ataque rápido. A equipa principal do SCP, ao contrário da equipa B, não é influenciada pela forma como o adversário reage à perda de posse de bola para optar pelo seu método de jogo ofensivo; iv) no caso da equipa principal, o método de jogo ofensivo que potencia mais situações de finalização com sucesso é o ataque rápido, enquanto na equipa B é o contra-ataque; v) ambas as equipas optam pelo método de jogo ofensivo contra-ataque, quando a recuperação de posse de bola acontece no setor defensivo e setor médio defensivo, sendo substituído pelo ataque rápido nos setores mais adiantados.

Caraterização dos padrões de jogo ofensivos após recuperação de posse bola a partir de desarme ou interceção: análise comparativa da equipa principal e equipa B do Sporting Club de Portugal

O jogo de futebol, e simultaneamente o seu processo ofensivo, tem sido, nos últimos anos, alvo de diversos trabalhos de investigação. Tendo como objetivo a sua análise e caracterização, o especial interesse por parte dos investigadores tem estado focado predominantemente no processo ofensivo no seu todo, desde a recuperação de posse de bola, o desenvolvimento do processo em si e a sua finalização. O presente estudo teve como principal objetivo a caraterização do processo ofensivo da equipa principal e equipa B do Sporting Clube de Portugal após recuperação de posse de bola por desarme ou interceção. Foram registadas as sequências ofensivas de 16 jogos (8 por equipa), da equipa principal e da sua equipa B, da época 2014/15, na condição de visitado, com recurso ao software Videobserver (Afra, 2013). As sequências ofensivas foram observadas e registadas a partir da recuperação de posse de bola de forma dinâmica, ou seja, através de desarme ou interceção. Para a análise estatística descritiva e sequencial foi utilizado o software SDIS GSEQ 5.1 (Bakeman & Quera, 1996). Os resultados permitiram concluir que i) as equipas observadas recuperaram a posse de bola maioritariamente no setor médio defensivo e numa relação de igualdade ou superioridade relativa; ii) as equipas observadas, desenvolvem o processo ofensivo de forma semelhante, recorrendo ao passe curto ou médio, para a frente, ou diagonal frente e rasteiro como comportamento mais vezes verificado após a recuperação de posse de bola; iii) O método de jogo ofensivo mais utilizado pelas equipas observadas é o ataque rápido. A equipa principal do SCP, ao contrário da equipa B, não é influenciada pela forma como o adversário reage à perda de posse de bola para optar pelo seu método de jogo ofensivo; iv) no caso da equipa principal, o método de jogo ofensivo que potencia mais situações de finalização com sucesso é o ataque rápido, enquanto na equipa B é o contra-ataque; v) ambas as equipas optam pelo método de jogo ofensivo contra-ataque, quando a recuperação de posse de bola acontece no setor defensivo e setor médio defensivo, sendo substituído pelo ataque rápido nos setores mais adiantados.

Ticonderoga & its dependencies, August 1776.

Scale ca. 1:18,000.

Evangelical young women, contemporary Christianity, and an empowering self- understanding: a study into how contemporary women of faith understand themselves and God in relation to Dei, Holy Scripture and Christian mission

This thesis combines historical reflection with qualitative research to examine how Christian young women from Evangelical traditions are developing religious self- understanding in empowering ways. It seeks to establish connections between the ways in which historians and feminist theologians have responded to forces of restriction and limitation in Christian women’s past, and the strategies of self-empowerment adopted by Evangelical young women today. This study approaches Christian history and the present condition of female self-understanding through three central questions: How do young women understand themselves in relation to the imago Dei? How do young women understand themselves in relation to the Bible? How do young women understand themselves in relation to Christian mission? The first chapter addresses the ways in which young women are responding to historic denials of woman as the imago Dei and concepts of female inferiority or especial guilt by reclaiming possession of the divine image. The next section discusses how young women are relating to the Bible in empowering ways, both by adopting similar strategies to those utilised throughout Christianity’s past, and through the development of their own patterns of interpretation. Finally, this thesis draws attention to Christian mission as a space of empowerment, examining how young women develop life-enriching knowledge of God and self through involvement with mission. This thesis proposes that as young women continue to develop strategies that enable them to understand themselves and their faith in empowering ways, knowledge of their innate dignity and potential will inspire them — and those who come after them — to witness to God freely and fully in all contexts.

Studies of antihypertensive drug persistence and adherence in the Glasgow Blood Pressure Clinic

Hypertension (HTN) is a major risk factor for cardiovascular diseases including stroke, coronary heart disease (CHD), chronic renal failure, peripheral vascular disease, myocardial infarction, congestive heart failure and premature death. The prevalence of HTN in Scotland is very high and although a high proportion of the patients receive antihypertensive medications, blood pressure (BP) control is very low. Recommendations for starting a specific antihypertensive class have been debated between various guidelines over the years. Some guidelines and HTN studies have preferred to start with a combination of an antihypertensive class instead of using a single therapy, and they have found greater BP reductions with combination therapies than with monotherapy. However, it has been shown in several clinical trials that 20% to 35% of hypertensive patients could not achieve the target BP, even though they received more than three antihypertensive medications. Several factors were found to affect BP control. Adherence and persistence were considered as the factors contributing the most to uncontrolled hypertension. Other factors such as age, sex, body mass index (BMI), alcohol intake, baseline systolic BP (SBP), and the communication between physicians and patients have been shown to be associated with uncontrolled BP and resistant hypertension. Persistence, adherence and compliance are interchangeable terms and have been used in the literature to describe a patient’s behaviour with their antihypertensive drugs and prescriptions. The methods used to determine persistence and adherence, as well as the inclusion and exclusion criteria, vary between persistence and adherence studies. The prevalence of persistence and adherence have varied between these studies, and were determined to be high in some studies and low in others. The initiation of a specific antihypertensive class has frequently been associated with an increase or decrease in adherence and persistence. The tolerability and efficacy of the initial antihypertensive class have been the most common methods of explaining this association. There are also many factors that suggest a relationship with adherence and persistence. Some factors in previous studies, such as age, were frequently associated with adherence and persistence. On the other hand, relationships with certain factors have varied between the studies. The associations of age, sex, alcohol use, smoking, baseline systolic blood pressure (SBP) and diastolic BP (DBP), the presence of comorbidities, an increase in the number of pills and the relationship between patients and physicians with adherence and persistence have been the most commonly investigated factors. Most studies have defined persistence in terms of a patient still taking medication after a period of time. A medication possession ratio (MPR) ≥ 80 has been used to define compliance. Either of these terminologies, or both, have been used to estimate adherence. In this study, I used the same definition for persistence to identify patients who have continued with their initial treatment, and used persistence and MPR to define patients who adhered to their initial treatment. The aim of this study was to estimate the prevalence of persistence and adherence in Scotland. Also, factors that could have had an effect on persistence and adherence were studied. The number of antihypertensive drugs taken by patients during the study and factors that led to an increase in patients being on a combination therapy were also evaluated. The prevalence of resistance and BP control were determined by taking the BP after the last drug had been taken by persistent patients during five follow-up studies. The relationship of factors such as age, sex, BMI, alcohol use, smoking, estimated glomerular filtration rate (eGFR), and albumin levels with BP reductions for each antihypertensive class were determined. Information Services Division (ISD) data, which includes all antihypertensive drugs, were collected from pharmacies in Scotland and linked to the Glasgow Blood Pressure Clinic (GBPC) database. This database also includes demographic characteristics, BP readings and clinical results for all patients attending the GBPC. The case notes for patients who attended the GBPC were reviewed and all new antihypertensive drugs that were prescribed between visits, BP before and after taking drugs, and any changes in the hypertensive drugs were recorded. A total of 4,232 hypertensive patients were included in the first study. The first study showed that angiotensin converting enzyme inhibitor (ACEI) and beta-blockers (BB) were the most prescribed antihypertensive classes between 2004 and 2013. Calcium channel blockers (CCB), thiazide diuretics and angiotensin receptor blockers (ARB) followed ACEI and BB as the most prescribed drugs during the same period. The prescription trend of the antihypertensive class has changed over the years with an increase in prescriptions for ACEI and ARB and a decrease in prescriptions for BB and diuretics. I observed a difference in antihypertensive class prescriptions by age, sex, SBP and BMI. For example, CCB, thiazide diuretics and alpha-blockers were more likely to be prescribed to older patients, while ACEI, ARB or BB were more commonly prescribed for younger patients. In a second study, 4,232 and 3,149 hypertensive patients were included to investigate the prevalence of persistence in the Scottish population in 1- and 5-year studies, respectively. The prevalence of persistence in the 1-year study was 72.9%, while it was only 62.8% in the 5-year study. Those patients taking ARB and ACEI showed high rates of persistence and those taking diuretics and alpha blockers had low rates of persistence. The association of persistence with clinical characteristics was also investigated. Younger patients were more likely to totally stop their treatment before restarting their treatment with other antihypertensive drugs. Furthermore, patients who had high SBP tended to be non-persistent. In a third study, 3,085 and 1,979 patients who persisted with their treatment were included. In the first part of the study, MPR was calculated, and patients with an MPR ≥ 80 were considered as adherent. Adherence rates were 29.9% and 23.4% in the 1- and 5-year studies, respectively. Patients who initiated the study with ACEI were more likely to adhere to their treatments. However, patients who initiated the study with thiazide diuretics were less likely to adhere to their treatments. Sex, age and BMI were different between the adherence and non-adherence groups. Age was an independent factor affecting adherence rates during both the 1- and 5-year studies with older patients being more likely to be adherent. In the second part of the study, pharmacy databases were checked with patients' case notes to compare antihypertensive drugs that were collected from the pharmacy with the antihypertensive prescription given during the patient’s clinical visit. While 78.6% of the antihypertensive drugs were collected between clinical visits, 21.4% were not collected. Patients who had more days to see the doctor in the subsequent visit were more likely to not collect their prescriptions. In a fourth study, 3,085 and 1,979 persistent patients were included to calculate the number of antihypertensive classes that were added to the initial drug during the 1-year and 5-year studies, respectively. Patients who continued with treatment as a monotherapy and who needed a combination therapy were investigated during the 1- and 5-year studies. In all, 55.8% used antihypertensive drugs as a monotherapy and 44.2% used them as a combination therapy during the 1-year study. While 28.2% of patients continued with treatment without the required additional therapy, 71.8% of the patients needed additional therapy. In all, 20.8% and 46.5% of patients required three different antihypertensive classes or more during the 1-year and 5-year studies, respectively. Patients who started with ACEI, ARB and BB were more likely to continue as monotherapy and less likely to need two more antihypertensive drugs compared with those who started with alpha-blockers, non-thiazide diuretics and CCB. Older ages, high BMI levels, high SBP and high alcohol intake were independent factors that led to an increase in the probability of patients taking combination therapies. In the first part of the final study, BPs were recorded after the last drug had been taken during the 5 year study. There were 815 persistent patients who were assigned for this purpose. Of these, 39% had taken one, two or three antihypertensive classes and had controlled BP (controlled hypertension [HTN]), 29% of them took one or two antihypertensive classes and had uncontrolled BP (uncontrolled HTN), and 32% of the patients took three antihypertensive classes or more and had uncontrolled BP (resistant HTN). The initiation of an antihypertensive drug and the factors affecting BP pressure were compared between the resistant and controlled HTN groups. Patients who initiated the study with ACEI were less likely to be resistant compared with those who started with alpha blockers and non-thiazide diuretics. Older patients, and high BMI tended to result in resistant HTN. In the second part of study, BP responses for patients who initiated the study with ACEI, ARB, BB, CCB and thiazide diuretics were compared. After adjusting for risk factors, patients who initiated the study with ACEI and ARB were more respondent than those who took CCB and thiazide diuretics. In the last part of this study, the association between BP reductions and factors affecting BP were tested for each antihypertensive drug. Older patients responded better to alpha blockers. Younger patients responded better to ACEI and ARB. An increase in BMI led to a decreased reduction in patients on ACEI and diuretics (thiazide and non-thiazide). An increase in albumin levels and a decrease in eGFR led to decreases in BP reductions in patients on thiazide diuretics. An increase in eGFR decreased the BP response with ACEI. In conclusion, although a high percentage of hypertensive patients in Scotland persisted with their initial drug prescription, low adherence rates were found with these patients. Approximately half of these patients required three different antihypertensive classes during the 5 years, and 32% of them had resistant HTN. Although this study was observational in nature, the large sample size in this study represented a real HTN population, and the large pharmacy data represented a real antihypertensive population, which were collected through the support of prescription data from the GBPC database. My findings suggest that ACEI, ARB and BB are less likely to require additional therapy. However, ACEI and ARB were better tolerated than BB in that they were more likely to be persistent than BB. In addition, users of ACEI, and ARB have good BP response and low resistant HTN. Linkage patients who participated in these studies with their morbidity and mortality will provide valuable information concerning the effect of adherence on morbidity and mortality and the potential benefits of using ACEI or ARB over other drugs.

Model BOT partnerstwa publiczno-prywatnego w realizacji inwestycji infrastrukturalnych

Partnerstwo publiczno-prywatne zyskuje coraz większą popularność w realizacji zadań publicznych, szczególnie w obszarze inwestycji infrastrukturalnych. W toku upowszechniania wykorzystania kapitału i wiedzy pochodzącej z sektora prywatnego do realizacji inwestycji, które dotychczas były domeną sektora publicznego wykształciły się różne modele partnerstwa. Jednym z najpowszechniejszych z nich jest model BOT, czyli build, operate and transfer, co w przekładzie na język polski oznacza buduj, eksploatuj i przekaż. Już samo rozwinięcie tego skrótu, wystarcza do opisania w sposób ogólny tej koncepcji. Polega ona na wykorzystaniu potencjału gospodarczego i organizacyjnego partnera prywatnego do budowy określonego obiektu użyteczności publicznej, następnie podmiot ten odzyskuje poniesione koszty i zapewnia sobie odpowiednią stopę zysku dzięki eksploatacji tego obiektu na podstawie udzielonej mu koncesji. Po wygaśnięciu koncesji prawa do eksploatacji obiektu wracają w posiadanie podmiotu publicznego. Niniejszy artykuł ma charakter poglądowy. Autor na wstępie przybliża podstawy prawne partnerstwa oraz status prawny jego uczestników. Następnie w oparciu o regulacje prawne przedstawiony zostaje proces realizacji przedsięwzięcia BOT, po czym określane są potencjalne korzyści i koszty płynące z zastosowania tego modelu.