Strategies to prevent potentially inappropriate prescribing and adverse drug reactions in older patients

INTRODUCTION: Potentially inappropriate prescribing (PIP) is a major contributor to adverse drug reactions and overall increased healthcare costs. The aim of this thesis was to identify, develop and implement strategies with the potential to prevent PIP and ADRs in older patients. METHODS: A systematic review of the qualitative literature (Meta-synthesis); A qualitative study in Irish hospitals; A randomised controlled trial (RCT) to assess the impact of an online educational module on doctors’ prescribing knowledge and confidence; Exploration of the potential for a frailty index score to enable doctors identify patients at increased risk of PIP and ADRs; Exploration of the potential for the SHiM tool to enable doctors to optimise prescribing for older patients. RESULTS: The meta-synthesis identified four key concepts: (i) Desire to please the patient; (ii) Feeling of being forced to prescribe; (iii) Tension between experience and guidelines; (iv) Prescriber fear. Similar themes also emerged from the qualitative study. In the RCT, the online educational module resulted in a highly significant 22% difference in test scores between intervention and control groups. The studies exploring the frailty index score showed a significant positive relationship between a patient’s frailty status and their likelihood of experiencing PIP/ADRs. Patients above a frailty threshold of 0.16 were at least twice as likely to experience PIP/ADRs. SHiM was found to be a useful tool in terms of reconciling patients’ medications. However, the evidence for it being capable of preventing clinically relevant adverse events was poor. CONCLUSION:Qualitative research in this thesis has proposed novel theories relating to the causative factors of PIP in older patients. In doing so, it has identified several areas for intervention and laid down a road map for future research.

The role of transformative thinking and practice in a property entrepreneur's response to the funding crisis since 2008

This portfolio of exploration explores the role of transformative thinking and practice in a property entrepreneur’s response to the financial crisis which swept over Ireland from 2008. The complexity of this challenge and the mental capacity to meet its demands is at the core of the exploration. This inquiry emerged from the challenges the financial crisis presented to my values, beliefs, assumptions, and theories, i.e. the interpretive lens through which I make meaning of my experiences. Given the issue identified, this inquiry is grounded in aspects of theories of constructive developmental psychology, applied developmental science, and philosophy. Integrating and linking these elements to business practice is the applied element of the Portfolio. As the 2008 crisis unfolded I realised I was at the limits of my way of knowing. I came to understand that the underlying structure of a way of knowing is the ‘subject-object relationship’ i.e. what a way of knowing can reflect upon, look at, have perspective on, in other words, make object, as against what is it embedded in, attached to, identified within, or subject to. My goal became enhancing my awareness of how I made meaning and how new insights, which would transform a way of knowing, are created. The focus was on enhancing my practice. This Portfolio is structured into three essays. Essay One reported on my self-reflection and external evaluation out of which emerged my developmental goals. In Essay Two I undertake a reading for change programme in which different meaning making systems were confronted in order to challenge me as a meaning maker. Essay Three reported on my experiment which concerned the question whether it was possible for me as a property entrepreneur, and for others alike, to retain bank finance in the face of the overwhelming objective of the bank to deleverage their balance sheet of property loans. The output of my research can be grouped into General Developmental and Specific Business Implications. Firstly I address those who are interested in a transformational-based response to the challenges of operating in the property sector in Ireland during a crisis. I outline the apparatus of thought that I used to create insight, and thus transform how I thought, these are Awareness, Subject-object separation, Exploring other’s perspectives from the position of incompleteness, Dialectical thinking and Collingwood’s Questioning activity. Secondly I set out my learnings from the crisis and their impact on entrepreneurial behaviour and the business of property development. I identify ten key insights that have emerged from leading a property company through the crisis. Many of these are grounded in common sense, however, in my experience these were, to borrow Shakespeare’s words, “More honor'd in the breach than the observance” in pre Crisis Ireland. Finally I set out a four-step approach for forging a strategy. This requires my peer practitioners to identify (i) what they are subject to, (ii) Assess the Opportunity or challenge in a Systemic Context, (iii) Explore Multiple Perspectives on the opportunity or Challenge with an Orientation to change how you know and (iv) Using the Questioning Activity to create Knowledge. Based on my experience I conclude that transformative thinking and practice is a key enabler for a property entrepreneur, in responding to a major collapse of traditional (bank debt) funding.

A qualitative analysis of parental coping with an early diagnosis of hearing loss in Ireland

The recent implementation of Universal Neonatal Hearing Screening (UNHS) in all 19 maternity hospitals across Ireland has precipitated early identification of paediatric hearing loss in an Irish context. This qualitative, grounded theory study centres on the issue of parental coping as families receive and respond to (what is typically) an unexpected diagnosis of hearing loss in their newborn baby. Parental wellbeing is of particular concern as the diagnosis occurs in the context of recovery from birth and at a time when the parent-child relationship is being established. As the vast majority of children with a hearing loss are born into hearing families with no prior history of deafness, parents generally have had little exposure to childhood hearing loss and often experience acute emotional vulnerability as they respond to the diagnosis. The researcher conducted in-depth interviews primarily with parents (and to a lesser extent with professionals), as well as a follow-up postal questionnaire for parents. Through a grounded theory analysis of data, the researcher subsequently fashioned a four-stage model depicting the parental journey of receiving and coping with a diagnosis. The four stages (entitled Anticipating, Confirming, Adjusting and Normalising) are differentiated by the chronology of service intervention and defined by the overarching parental experience. Far from representing a homogenous trajectory, this four-stage model is multifaceted and captures a wide diversity of parental experiences ranging from acute distress to resilient hopefulness

THE EFFECT OF A PROGRAM OF PORTABLE ELECTRONIC PIANO KEYBOARD EXPERIENCE ON THE ACQUISITION OF SIGHT-SINGING SKILL IN THE NOVICE HIGH SCHOOL CHORUS

The problem was to determine whether a method of aural and visual vocal training that included a program of portable electronic piano keyboard experience would be more effective in teaching sight-singing skills to novice high school chorus students than a method that included only aural and visual vocal training. A sub-problem was to determine whether novice chorus students enjoyed playing electronic keyboards in chorus as a reinforcement experience in sight-singing training. Students were randomly assigned to two treatment groups, tested with the Musical Aptitude Profile, Tonal Imagery, part A, and then trained separately. The experimental group sang repetitions of melodic patterns and utilized techniques associated with the Kodály Method while simultaneously playing keyboard. The comparison group received a similar treatment without using keyboards. The students were pre- and post-tested in sight-singing using the Vocal Sight-Reading Inventory. Results of the Analysis of Covariance using MAP scores as the covariate revealed no significant difference (p<.05) between post-test scores of the two groups. Improvement was noted in 96% of students from pre-test to post-test regardless of grouping. The repeated measures ANOVA revealed a significant relationship (p<.006) between aptitude group and post-test score. High aptitude students in both groups were found to benefit more from the training than low aptitude students. High aptitude keyboard group students achieved an average gain score that was 8.67 points higher than the comparison group. Of the total experimental group, 92% enjoyed playing keyboards in chorus. It is recommended that future research be undertaken to study the use of keyboards with advanced high school choruses and with uncertain singers in the high school chorus. Research is also needed to develop graded, valid, and reliable sight-singing tests for use in high school chorus. Techniques of the Kodály Method should be further investigated for use in high school sight-singing training.

Ritualizing Barong and Rangda: Repercussions of a Collaborative Field Experience in Kerambitan, Bali.

The dance-drama called Barong and Rangda a ritual, is one of the vital events that breathes life in the small village, Banjar Tista, and extends beyond the boundaries of its "performance" area. In this thesis, I depend on Ronald Grimes' concept of "ritualizing" as a continuum in the context of my fieldwork in Bali, Indonesia. The ritual cycle and the collaborative fieldwork process are analyzed through the impressions of each fieldworker. Barong and Rangda is a well-documented dance-drama and part of the longer Calonarang story. This dance-drama is a mythological battle between the lion, Barong, and the witch, Rangda, and is performed authentically to create spiritual balance and cleanse its community members of evil. This ritual performance reaches beyond the time and place in which the performance originates and creates a ripple affect on the village members, those in trance, musicians and cultural outsiders alike.

High School Choral Students' Perceptions of Choral Music Experience

The purpose of this study is to explore high school students' perceptions of their choral experiences, providing an understanding of students' ongoing perspectives of choral experience. Specifically, how have these experiences influenced the formation of their musical identities as members of a choral ensemble? The researcher collected data from the three participants during a full school year. The participants were current students in the researcher's advanced choral ensemble. Through axial coding, three themes emerged: musical interpretation, attitude, and group efficacy. The study revealed that experienced choral students have well-informed musical perspectives that influence their choral experiences. Implications for music education include using students' perspectives for creating rehearsal strategies, planning and programming performances, and fostering a nurturing learning atmosphere. Suggestions for further research include comparing experienced students to non-experienced students, comparing ensembles with student-chosen repertoire to those with director-chosen repertoire, and further examining the impact of choral experience on musical identity.

Emotional intensity predicts autobiographical memory experience.

College students generated autobiographical memories from distinct emotional categories that varied in valence (positive vs. negative) and intensity (high vs. low). They then rated various perceptual, cognitive, and emotional properties for each memory. The distribution of these emotional memories favored a vector model over a circumplex model. For memories of all specific emotions, intensity accounted for significantly more variance in autobiographical memory characteristics than did valence or age of the memory. In two additional experiments, we examined multiple memories of emotions of high intensity and positive or negative valence and of positive valence and high or low intensity. Intensity was a more consistent predictor of autobiographical memory properties than was valence or the age of the memory in these experiments as well. The general effects of emotion on autobiographical memory properties are due primarily to intensity differences in emotional experience, not to benefits or detriments associated with a specific valence.

Preliminary experience of ovarian tissue cryopreservation procedure: alternatives, perspectives and feasibility

Chemotherapy and radiotherapy induce premature ovarian failure in many patients treated for oncological or benign diseases. The present paper reviews the risk of developing premature ovarian failure according to the type of treatment and the different options to preserve fertility, focusing on the cryopreservation of ovarian tissue. This technique constitutes a promising approach to preserve the fertility of young patients and offers the advantage of storing a large number of follicles that could be subsequently transplanted or cultured in vitro to obtain mature oocytes. Based on 34 requests, from which 19 were performed, the feasibility of the ovarian cryopreservation procedure is evaluated. The medical and ethical approaches of this protocol are also discussed. Cryopreservation of ovarian tissue constitutes new hope for many patients, but must still be kept for selected cases, with a significant risk of premature ovarian failure after treatments such as bone marrow transplantation.

A framework for revising preservice curriculum for nonphysician clinicians: The mozambique experience.

Mozambique, with approximately 0.4 physicians and 4.1 nurses per 10,000 people, has one of the lowest ratios of health care providers to population in the world. To rapidly scale up health care coverage, the Mozambique Ministry of Health has pushed for greater investment in training nonphysician clinicians, Tιcnicos de Medicina (TM). Based on identified gaps in TM clinical performance, the Ministry of Health requested technical assistance from the International Training and Education Center for Health (I-TECH) to revise the two-and-a-half-year preservice curriculum. A six-step process was used to revise the curriculum: (i) Conducting a task analysis, (ii) defining a new curriculum approach and selecting an integrated model of subject and competency-based education, (iii) revising and restructuring the 30-month course schedule to emphasize clinical skills, (iv) developing a detailed syllabus for each course, (v) developing content for each lesson, and (vi) evaluating implementation and integrating feedback for ongoing improvement. In May 2010, the Mozambique Minister of Health approved the revised curriculum, which is currently being implemented in 10 training institutions around the country. Key lessons learned: (i) Detailed assessment of training institutions' strengths and weaknesses should inform curriculum revision. (ii) Establishing a Technical Working Group with respected and motivated clinicians is key to promoting local buy-in and ownership. (iii) Providing ready-to-use didactic material helps to address some challenges commonly found in resource-limited settings. (iv) Comprehensive curriculum revision is an important first step toward improving the quality of training provided to health care providers in developing countries. Other aspects of implementation at training institutions and health care facilities must also be addressed to ensure that providers are adequately trained and equipped to provide quality health care services. This approach to curriculum revision and implementation teaches several key lessons, which may be applicable to preservice training programs in other less developed countries.

SELECTED ICONIC CHAMBER MUSIC WORKS WITH PIANO FROM THE NINETEENTH AND TWENTIETH CENTURIES

Chamber music repertoire featuring the piano blossomed from the mid-nineteenth through the early twentieth century. The quantity of works increased greatly during this time and the quality of these works reached the highest level. Among the many symbolic works that were composed were sonatas for a single string instrument with piano, piano trios, quartets: and quintets as well as two-piano works and four-hand duets. Being able to study and perform many of these iconic works before I graduated was one of the major goals I set for myself as a collaborative pianist. The abundance of repertoire has made it easy to choose works considered "iconic" for my dissertation's three recitals. Iconic is defined as "very famous or popular, especially being considered to represent particular opinions or a particular time" in the online Cambridge Advanced Leamer's Dictionary & Thesaurus © Cambridge University. The compositions featured in the recitals were composed from 1842 through 1941, including works by Schumann, Brahms, Faure, Rachmaninoff, Ravel, and Lutoslawski. Choosing the repertoire with my fellow performers in mind was an important part of this dissertation. In addition to trying to make balanced programs which include variety, working with different instruments and performers is one of the most fulfilling parts of the musical experience for me as a collaborative pianist. Joining me for the concerts were members of the Aeolus String Quartet (violinist Nicholas Tavani, violinist Rachel Shapiro, violist Greg Luce, and cellist Alan Richardson), pianist Hsiao-Ying Lin (a doctoral student from the Peabody Conservatory), and my colleagues from the Peabody Institute Preparatory Division (faculty violinist Dr. Christian Tremblay and cellist Alicia Ward), and Derek Smith, Associate Principal violist of the Annapolis Symphony Orchestras). The three recitals were performed in the Gildenhom and Ulrich Recital Halls at the University of Maryland, College Park, Maryland. They are recorded on CD and available on compact discs, which can be found in the Digital Repository at the University of Maryland (DRUM).

Resources, experience and perseverance in entrepreneurs' perceived likelihood of success in an emerging economy

This paper introduces new results obtained from a statistical investigation into a 3071-observation data set collected from a Vietnamese nationwide entrepreneurship survey. From established relationships, such factors as preparedness, financial resources and participation in social networks are confirmed to have significant effects on entrepreneurial decisions. Entrepreneurs, both financially constrained and unconstrained, who have a business plan tend to start their entrepreneurial ventures earlier. Also, financial constraints have a profound impact on the entrepreneurial decisions. When perceiving the likelihood of success to be high, an entrepreneur shows the tendency for prompt action on business ideas. But when seeing the risk of prolonging the waiting time to first revenue, a prospective entrepreneur would be more likely to wait for more favorable conditions despite the vagueness of "favorable". Additionally, empirical computations indicate that there is a 41.3% probability that an extant entrepreneur who is generating revenue sees high chance of success. Past work and entrepreneurial experiences also have positive impacts on both the entrepreneurial decisions and perceived chance of success.

Doctoral programs and academic research: Mathematics education in the Spanish university

We have shown a description of the changes and innovations happened in Spain concerning the research on Mathematics Education during the last 25 years, highlighting specially the fast development of the last 10 years. Neither of these great and striking changes would have taken place if there was not been an evolution within the Spanish society, and particularly, within its educational system. Thanks to this, we have found the appropriate conditions for research development.

The Experience of Security in Mathematics

In this paper, we report some findings from an investigation of a topic related to affect and mathematics which is not well-represented in the literature. For some mathematicians, mathematics itself is a source of security in an uncertain world, and we investigated this feeling and experience in the case of 19 adult mathematicians working in universities and schools in Greece. The focus reported here is on ways that a relationship with mathematics offers a sense of permanence and stability on the one hand, and an assurance of novelty and progress on the other.

AASK - Aircraft accident statistics and knowledge: A database of human experience in evacuation, derived from aviation accident reports

Computer based mathematical models describing the aircraft evacuation process have a vital role to play in aviation safety. However such models have a heavy dependency on real evacuation data in order to (a) identify the key processes and factors associated with evacuation, (b) quantify variables and parameters associated with the identified factors/processes and finally (c) validate the models. The Fire Safety Engineering Group of the University of Greenwich is undertaking a large data extraction exercise from three major data sources in order to address these issues. This paper describes the extraction and application of data from one of these sources - aviation accident reports. To aid in the storage and analysis of the raw data, a computer database known as AASK (aircraft accident statistics and knowledge) is under development. AASK is being developed to store human observational and anecdotal data contained in accident reports and interview transcripts. AASK comprises four component sub-databases. These consist of the ACCIDENT (crash details), FLIGHT ATTENDANT (observations and actions of the flight attendants), FATALS (details concerning passenger fatalities) and PAX (observations and accounts from individual passengers) databases. AASK currently contains information from 25 survivable aviation accidents covering the period 4 April 1977 to 6 August 1995, involving some 2415 passengers, 2210 survivors, 205 fatalities and accounts from 669 people. In addition to aiding the development of aircraft evacuation models, AASK is also being used to challenge some of the myths which proliferate in the aviation safety industry such as, passenger exit selection during evacuation, nature and frequency of seat jumping, speed of passenger response and group dynamics. AASK can also be used to aid in the development of a more comprehensive approach to conducting post accident interviews, and will eventually be used to store the data directly.

An aircraft accident database of human experience in evacuation derived from aviation accident reports

Computer based mathematical models describing the aircraft evacuation process have a vital role to play in aviation safety. However, such models have a heavy dependency on real evacuation data. The Fire Safety Engineering Group of the University of Greenwich is undertaking a large data extraction exercise in order to address this issue. This paper describes the extraction and application of data from aviation accident reports. To aid in the storage and analysis of the raw data, a computer database known as AASK (Aircraft Accident Statistics and Knowledge) is under development. AASK is being developed to store human observational and anecdotal data contained in accident reports and interview transcripts. AASK currently contains information from 25 survivable aviation accidents covering the period 04/04/77 to 06/08/95, involving some 2415 passengers, 2210 survivors, 205 fatalities and accounts from 669 people. Copyright © 1999 John Wiley & Sons, Ltd.