Off-label prescription of drugs at hospital

Objectives: To develop a procedure for management of off-label medications, and to analyze the treatments, indications, and hospital units which will request them more frequently, as well as which variables will have an impact on the authorization decision, and its economic impact. Methods: A procedure was designed where clinicians would complete request forms and the Hospital Unit would prepare reports assessing their efficacy, safety, convenience, and cost. The request forms for the past five years were analyzed. Results: A total of 834 applications were received, and 88.1% of these were accepted. The authorization rates were higher for Paediatric Units (95.7% vs. 86.6%; p<0.05). The reasons for considering prescriptions as off-label were: different indication (73.2%), different combination (10.2%), different line of treatment (8.6%) and different age (8%). A 73.4% of requests were for antineoplastic drugs, and the most frequently prescribed were rituximab (120) and bevacizumab (103). The quality of evidence supporting the prescriptions was moderate-low, though no direct relationship with the likelihood of approval was demonstrated (p = 0.413). The cost of the approved medications was 8,567,537 €, and the theoretical savings for those drugs rejected was of 2,268,642 €. There was a statistically significant decrease in the authorization rate (p < 0.05, Student's t test) when spending increased. Conclusions: The responsibility for assessing off-label prescriptions has fallen on the Pharmacy Unit. It has not been demonstrated that the quality of evidence represents a decisive variable for approval of treatment; on the other hand, age and cost have demonstrated a significant impact.

Use of closed systems in the Hospital Pharmacy

Objective: In the setting of the increasing use of closed systems for reconstitution and preparation of these drugs, we intend to analyze the correct use of these systems in the Hospital Pharmacy, with the objective to minimize the risks of exposure not only for those professionals directly involved, but also for all the staff in the unit, taking also into account efficiency criteria. Method: Since some systems protect against aerosol formation but not from vapours, we decided to review which cytostatics should be prepared using an awl with an air inlet valve, in order to implement a new working procedure. We reviewed the formulations available in our hospital, with the following criteria: method of administration, excipients, and potential hazard for the staff handling them. We measured the diameters of the vials. We selected drugs with Level 1 Risk and also those including alcohol-based excipients, which could generate vapours. Outcomes: Out of the 66 reviewed formulations, we concluded that 11 drugs should be reconstituted with this type of awl: busulfan, cabazitaxel, carmustine, cyclophosphamide, eribulin, etoposide, fotemustine, melphalan, paclitaxel, temsirolimus and thiotepa; these represented an 18% of the total volume of formulations. Conclusions: The selection of healthcare products must be done at the Hospital Pharmacy, because the use of a system with an air valve inlet only for those drugs selected led to an outcome of savings and a more efficient use of materials. In our experience, we confirmed that the use of the needle could only be avoided when the awl could adapt to the different formulations of cytostatics, and this is only possible when different types of awls are available. Besides, connections were only really closed when a single awl was used for each vial. The change in working methodology when handling these drugs, as a result of this study, will allow us to start different studies about environmental contamination as a future line of work.

The effects of permeable bed on waves setup

Generally the flow properties of rivers, estuaries and coastal seas are highly dependent on the bed morphology. These include mainly three flow parameters, as bed shear stress, velocity profile and turbulent fluctuations. Here we investigate the effects of permeate of the bed on these flow properties We consider the effects of suction (W0) injection (W0) on these flow properties particularly the bottom stress. Four types of bottom permeability with different size of sand have been tested. The results indicate a substantial reduction and enhancement of the bed stress under respectively injection and suction as has been observed by others on wave motion in shallow seas. We consider 5 waves to shore with this rang of wave steepness ( 0/015 < so < 0/05 ) . Cr Calculated used of mansard method (1980). We search the stream line of current in bed with a video camera and looking this. Near the surface and the deep of bed and consider V=W (in or su)/ U(ru or rd) and bottom stress for 6 period of this study with Canly and Inman studies (1994). All these results are shown by curves with the effects of permeable bed.

The 1998 BFA Graduating Class: Department of Visual Arts

The exhibition of works by Sir Wilfred Grenfell College's graduating Class in visual arts constitutes the culmination of four years of intensive study and practice. our students are trained in the fundamentals of their craft and exposed tio a variety of media and styles ranging from the traditional to the avant garde. But their education has more to do with the exploration and development of their creativity, the enlargement of their capacity to see, and their mastery of the vocabulary of sight, enabling them to discover, uncover and represent. Each of the students ha sustained and nurtured an individual and unique quest over the four years of this rigorous programme.

Profile of Washington & Fayette streets, Georgetown, D.C. /

Washington Street profile covers 30th Street between Q and R streets N.W. Fayette Street profile covers 35th Street between Volta Place and Wisconsin Avenue N.W.

Two-State Thermodynamics of Supercooled Water

Water has been called the “most studied and least understood” of all liquids, and upon supercooling its behavior becomes even more anomalous. One particularly fruitful hypothesis posits a liquid-liquid critical point terminating a line of liquid-liquid phase transitions that lies just beyond the reach of experiment. Underlying this hypothesis is the conjecture that there is a competition between two distinct hydrogen-bonding structures of liquid water, one associated with high density and entropy and the other with low density and entropy. The competition between these structures is hypothesized to lead at very low temperatures to a phase transition between a phase rich in the high-density structure and one rich in the low-density structure. Equations of state based on this conjecture have given an excellent account of the thermodynamic properties of supercooled water. In this thesis, I extend that line of research. I treat supercooled aqueous solutions and anomalous behavior of the thermal conductivity of supercooled water. I also address supercooled water at negative pressures, leading to a framework for a coherent understanding of the thermodynamics of water at low temperatures. I supplement analysis of experimental results with data from the TIP4P/2005 model of water, and include an extensive analysis of the thermodynamics of this model.

‘Failure to maintain’: care rationing and the clinical and financial burden of nurse sensitive hospital-acquired complications in complex older patients

Background: The ageing population, with concomitant increase in chronic conditions, is increasing the presence of older people with complex needs in hospital. People with dementia are one of these complex populations and are particularly vulnerable to complications in hospital. Registered nurses can offer simultaneous assessment and intervention to prevent or mitigate hospital-acquired complications through their skilled brokerage between patient needs and hospital functions. A range of patient outcome measures that are sensitive to nursing care has been tested in nursing work environments across the world. However, none of these measures have focused on hospitalised older patients. Method: This thesis explores nursing-sensitive complications for older patients with and without dementia using an internationally recognised, risk-adjusted patient outcome approach. Specifically explored are: the differences between rates of complications; the costs of complications; and cost comparisons of patient complexity. A retrospective cohort study of an Australian state’s 2006–07 public hospital discharge data was utilised to identify patient episodes for people over age 50 (N=222,440) where dementia was identified as a primary or secondary diagnosis (N=44,422). Extra costs for patient episodes were estimated based on length of stay (LOS) above the average for each patient’s Diagnosis Related Group (DRG) (N=157,178) and were modelled using linear regression analysis to establish the strongest patient complexity predictors of cost. Results: Hospitalised patients with a primary or secondary diagnosis of dementia had higher rates of complications than did their same-age peers. The highest rates and relative risk for people with dementia were found in four key complications: urinary tract infections; pressure injuries; pneumonia, and delirium. While 21.9% of dementia patients (9,751/44,488, p<0.0001) suffered a complication, only 8.8% of non-dementia patients did so (33,501/381,788, p<0.0001), giving dementia patients a 2.5 relative risk of acquiring a complication (p<0.0001). These four key complications in patients over 50 both with and without dementia were associated with an eightfold increase in length of stay (813%, or 3.6 days/0.4 days) and double the increased estimated mean episode cost (199%, or A$16,403/ A$8,240). These four complications were associated with 24.7% of the estimated cost of additional days spent in hospital in 2006–07 in NSW (A$226million/A$914million). Dementia patients accounted for 22.0% of these costs (A$49million/A$226million) even though they were only 10.4% of the population (44,488/426,276 episodes). Hospital-acquired complications, particularly for people with a comorbidity of dementia, cost more than other kinds of inpatient complexity but admission severity was a better predictor of excess cost. Discussion: Four key complications occur more often in older patients with dementia and the high rate of these complications makes them expensive. These complications are potentially preventable. However, the care that can prevent them (such as mobility, hydration, nutrition and communication) is known to be rationed or left unfinished by nurses. Older hospitalised people who have complex needs, such as those with dementia, are more likely to experience care rationing as their care tends to take longer, be less predictable and less curative in nature. This thesis offers the theoretical proposition that evidence-based nursing practices are rationed for complex older patients and that this rationed care contributes to functional and cognitive decline during hospitalisation. This, in turn, contributes to the high rates of complications observed. Thus four key complications can be seen as a ‘Failure to Maintain’ complex older people in hospital. ‘Failure to Maintain’ is the inadequate delivery of essential functional and cognitive care for a complex older person in hospital resulting in a complication, and is recommended as a useful indicator for hospital quality. Conclusions: When examining extra length of stay in hospital, complications and comorbid dementia are costly. Complications are potentially preventable, and dementia care in hospitals can be improved. Hospitals and governments looking to decrease costs can engage in risk-reduction strategies for common nurse sensitive complications such as healthy nursing work environments that minimise nurses’ rationing of functional and cognitive care. The conceptualisation of complex older patients as ‘business as usual’ rather than a ‘burden’ is likely necessary for sustainable health care services of the future. The use of the ‘Failure to Maintain’ indicators at institution and state levels may aid in embedding this approach for complex older patients into health organisations. Ongoing investigation is warranted into the relationships between the largest health services expense (hospitals), the largest hospital population (complex older patients), and the largest hospital expense (nurses). The ‘Failure to Maintain’ quality indicator makes a useful and substantive contribution to further clinical, administrative and research developments.

Análisis de posicionamiento en el sector de servicios de hosterías en el Valle de Yunguilla y propuesta de diseño de un plan estratégico de marketing para la hostería “Los Cisnes” en el periodo 2015-2018

El proyecto está enfocado al desarrollo de un Plan Estratégico aplicado a Hostería “Los Cisnes”. Tiene como objetivo contribuir con el desarrollo organizacional de la empresa, hacer frente a la competencia con la finalidad de prestar un servicio de calidad.Para la consecución de lo mencionado anteriormente se realizó un esquema que contempla lo siguiente: Se Expone conceptos y definiciones básicos de marketing que se necesitarán a lo largo del desarrollo del proyecto para el entendimiento del mismo.Se realizó el estudio del sector mediante encuestas y entrevistas aplicadas a personas que hacen uso del servicio de hostería y a los administradores de estos establecimientos. Para la obtención de resultados se utilizó el programa SPSS donde se emplearon variables e indicadores. Se estableció un ranking de acuerdo al catastro de establecimientos otorgado por el Ministerio de Turismo, encontrándose Hostería Los Cisnes en el tercer lugar, esto de acuerdo a la encuesta aplicada por las autoras del trabajo de titulación. Se desarrolló la situación actual de la empresa mediante herramientas como: análisis del micro-entrono y macro-entorno, análisis FODA, matriz EFI, matriz EFE, matriz BCG. Se desarrolló el Plan Estratégico de Marketing que contempla: misión, visión, objetivos, implementación de estrategias, planes de acción y presupuestos, es decir, está formado por todos los recursos necesarios para posicionamiento de la empresa.Finalmente se presenta las conclusiones y recomendaciones que fortalezcan la realización de las estrategias planteadas y que a la vez determinen resultados óptimos para la hostería.

Design, construction, and applications of a high-resolution terahertz time-domain spectrometer

This thesis reports on the design, construction, and initial applications of a high-resolution terahertz time-domain ASOPS spectrometer. The instrument employs asynchronous optical sampling (ASOPS) between two Ti:sapphire ultrafast lasers operating at a repetition rate of approximately 80 MHz, and we thus demonstrate a THz frequency resolution approaching the limit of that repetition rate. This is an order of magnitude improvement in resolution over typical THz time-domain spectrometers. The improved resolution is important for our primary effort of collecting THz spectra for far-infrared astronomy. We report on various spectroscopic applications including the THz rotational spectrum of water, where we achieve a mean frequency error, relative to established line centers, of 27.0 MHz. We also demonstrate application of the THz system to the long-duration observation of a coherent magnon mode in a anti-ferromagnetic yttrium iron oxide (YFeO3) crystal. Furthermore, we apply the all-optical virtual delay line of ASOPS to a transient thermoreflectance experiment for quickly measuring the thermal conductivity of semiconductors.

Smart and sustainable public transport systems through improving level and quality of service

Buses are considered a slow, low comfort and low reliability transport system, thus its negative and por image. In the framework of the 3iBS project (2012), several examples of innovative and/or effective solutions regarding the Level of Service (LoS) were analysed aiming to provide operators, practitioners and policy makers with a set of Good Practice Guidelines to strengthen the competitiveness of the bus in the urban environment. The identification of the key indicators regarding vehicles, infrastructure and operation was possible through the analysis of a set of case studies -among which Barcelona (Spain), Cagliari (Italy), London (United Kingdom), Paris and Nantes (France). A cross comparison between the case studies was carried out for contrasting the level of achievement of the different criteria considered. The information provided on Regulatory, Financial and Technical issues allows the identification of a number of specific factors influencing the implementation of a high quality transport scheme, and set the basis for the elaboration of a set of Guidelines for the implementation of an intelligent, innovative and integrated bus system, including the main barriers to be tackled.

O efeito do stresse no julgamento moral: um estudo experimental

Dissertação de Mestrado, Psicologia Clínica e da Saúde, Faculdade de Ciências Humanas e Sociais, Universidade do Algarve, 2015

Toxicological impact of JWH-018 and its phase I metabolite N-(3-hydroxypentyl) on human cell lines

"The emergence and abuse of synthetic cannabinoids has been increasing as an alternative to cannabis, mainly among youth. As their appearance on the drug market has been recent, the pharmacological and toxicological profiles of these psychoactive substances are poorly understood. Current studies suggest that they have stronger effects compared to their natural alternatives and their metabolites retain affinity towards CB1 receptors in CNS. Since studies on its toxicological properties are scarce, the effects of the drug in human derived cell lines were investigated. The present study was designed to explore the toxicological impact of parent drug versus phase I metabolites of synthetic cannabinoids on human cells with and without CB1 receptor. The human cell line of neuroblastoma SH-SY5Y and human kidney cell line HEK-293T were exposed to JWH-018 and to its N-(3-hydroxypentyl) metabolite. Cell toxicity was evaluated using the MTT and LDH assay. Additionally, a dual staining methodology with fluorescent Annexin V-FITC and propidium iodide was performed to address the question of whether JWH-018 N-(3-hydroxypentyl) metabolite is inducing cell death through apoptosis or necrosis, in HEK293T and SH-SY5Y cell lines. The obtained results show that JWH-018 does not cause a statistically significant decrease in cell viability, in contrast to its N-(3-hydroxypentyl) metabolite, which at ≥25μM causes a significant decrease in cell viability. Both cell lines are affected by JWH-018 metabolite. Our results point to higher toxicity of JWH-018 metabolite when compared to its parent drug, suggesting a non-CB1 receptor mediated toxicological mechanism. Comparing the results from Annexin V/PI with MTT and LDH assays of SH-SY5Y and HEK293T in the presence of the synthetic cannabinoid metabolite, emerges the picture that cellular viability decreases and associated death is occurring through necrosis."

Lições Aprendidas (Lessons Learned) no Exército Português

As Lições Aprendidas em contexto militar permite reduzir o risco operacional e, simultaneamente, aumentar o grau de sucesso das operações. Desde a década de cinquenta, o Exército português demostrou querer aprender com a experiência, nomeadamente com os Franceses na Argélia e Indochina e com os Ingleses no Quénia e Malásia. Na década de sessenta e início dos anos setenta, durante a denominada Guerra de África, acentuou-se esta necessidade. O Exército Português, desde 2012, dispõe de uma capacidade de Lições Aprendidas, constituída por um processo, estrutura e ferramentas, que tem como principal objetivo, precisamente, facilitar o desiderato de se tornar uma organização aprendente. Neste sentido, é pertinente estudar e comparar estes dois sistema, para melhor perceber o fenómeno no passado e evidenciar a capacidade de hoje em dia. Para isso é necessário descreve-los segundo certos parâmetros ou indicadores. Estes indicadores estão evidentes no modelo criado pela Organização Tratado Atlântico Norte para uma capacidade de Lições Aprendidas. Na Investigação foi utilizado uma abordagem Dedutiva, como procedimentos podemos já depreender que foram utilizados o Histórico e Comparativo, as técnicas de recolha de dados foram as Entrevistas e Análise Documental. O estudo proporcionou a materialização do processo, a perceção da estrutura dedicada, das ferramentas, a influência da mentalidade, liderança, e difusão de informação feitas na guerra de África. Na atualidade, muitos dos indicadores de análise estão descritos em diretivas e doutrina de referência, no entanto é pertinente perceber como é que funcionam e criam melhorias hoje em dia. Conclui-se que o modelo criado pela Organização Tratado Atlântico Norte, que valida uma capacidade de Lições Aprendidas nas organizações militares é intemporal, pois depreende-se, que a lógica que a sustenta em tudo se aplica à guerra de África Portuguesa e à atualidade, o que demostra que esta capacidade é fundamental para tornar o Exército Português mais eficaz e eficiente nas suas atividades e missões futuras.

Evaluación al sistema de control interno del departamento de producción del Centro Gráfico Salesiano de la Editorial Don Bosco

El trabajo que hemos desarrollado es una Evaluación al Sistema de Control Interno del Centro Grafico Salesiano de la Editorial Don Bosco. Esta investigación se desarrolló por la importancia que el Departamento de Producción tiene dentro de la Editorial; esto nos permitirá exponer las falencias, y dar sugerencias para mejorar su funcionamiento. Este estudio se enfoca en los procesos, procedimientos y tareas a cumplir por parte del personal, con productos de calidad, tiempos apropiados, sin desperdicio de materias primas, reducción de tiempos muertos y de costos de producción. En el CAPITULO I, se desarrollaron los conceptos del COSO 1, que serán útiles para nuestro estudio que describe las generalidades de cada uno de sus componentes y métodos de evaluación. En el CAPITULO II, realizamos una breve descripción de los aspectos generales de la empresa, para tener un mayor conocimiento del entorno. En el CAPITULO III realizamos la evaluación, del SCI al departamento productivo, utilizado técnicas de evaluación como las del flujograma, cuestionarios, y con la información obtenida realizamos un diagnóstico y emitimos un informe con conclusiones y recomendaciones. En el CAPITULO IV se finaliza con un planteamiento de conclusiones y recomendaciones que ayuden a mejorar el control de las actividades dentro del departamento de producción. Este estudio no solo servirá como fuente de observación por parte de la Editorial Don Bosco, sino también a empresas del mismo giro comercial, siendo capaz de dar lineamientos de observación de producción.