Medication management at home: medication risk factor prevalence and inter-relationships

Background and objective: Patients can have medication-related risk factors associated with poor health outcomes that become evident through visiting them in their homes. These medication-related risk factors may not be apparent in pharmacy and general practitioner (GP) records. The aim was to determine the prevalence and inter-relationships of medication-related risk factors for poor patient health outcomes identifiable through 'in-home' observations. Methods: The design was a cross-sectional study of 204 general practice patients living in their own homes and at risk of medication-related poor health outcomes. Medication-related risk factors were identified in the patients' homes by community pharmacists and GPs. Results and discussion: The prevalence of risk factors varied from 8.3% (multiple medication storage locations) to 55.9% (confused by generic and trade names). There were many relationships observed between the medication-related risk factors, with expired medication having the most relationships with other risk factors followed by therapeutic duplication and poor adherence (9, 6 and 6 relationships respectively). Conclusion: Visiting patients' homes may identify medication-related risk factors not otherwise apparent through patient visits to the health practitioner when medications may be brought for review (i.e. 'brown bag' reviews).

Periocular and Orbital Amyloidosis. Clinical Characteristics, Management, and Outcome

Objective: To present the clinical features and management outcome in a large series of patients with periocular and orbital amyloidosis. Design: Retrospective, noncomparative, interventional case series. Patients: All patients diagnosed with periocular and orbital amyloidosis in 6 oculoplastic and orbital units. Methods: Clinical records of all patients were reviewed. Main Outcome Measures: Clinical presentation, radiological and histological findings, treatment modalities, and outcome. Results. The study included 24 patients (15 female, 9 male) with a mean age of 57 17 years. Nineteen cases were unilateral, and 5 were bilateral. Clinical signs and symptoms included a visible or palpable periocular mass or tissue infiltration (95.8%), ptosis (54.2%), periocular discomfort or pain (25%), proptosis or globe displacement (21%), limitations in ocular motility (16.7%), recurrent periocular subcutaneous hemorrhages (12.5%), and diplopia (8.3%). Seven cases had orbital involvement, and 17 were periocular. Immunohistochemistry in 7 patients showed B cells or plasma cells producing monoclonal immunoglobulin chains that were deposited as amyloid light chains. Only 1 patient was diagnosed with systemic amyloid light chain amyloidosis. Treatment modalities were mainly observation and surgical debulking. During a mean follow-up period of 39 months, 21% showed significant progression after treatment, whereas 79% were stable or showed no recurrence after treatment. Conclusion: Periocular and orbital amyloidosis may present with a wide spectrum of clinical findings and result in significant ocular morbidity. Complete surgical excision is not feasible in many cases, and the goal of treatment is to preserve function and to prevent sight-threatening complications.

A configuration framework of manufacturing strategy paradigm in state owned enterprises within China's petrochemical industry:building context-embedded configurations for the paradigm of strategic manufacturing management from exploratory case studies

The role of the production system as a key determinant of competitive performance of business operations- has long been the subject of industrial organization research, even predating the .explicit conceptua1isation of manufacturing, strategy in the literature. Particular emergent production issues such as the globalisation of production, global supply chain management, management of integrated manufacturing and a growing e~busjness environment are expected to critically influence the overall competitive performance and therefore the strategic success of the organization. More than ever, there is a critical need to configure and improve production system and operations competence in a strategic way so as to contribute to the long-term competitiveness of the organization. In order to operate competitively and profitably, manufacturing companies, no matter how well managed, all need a long-term 'strategic direction' for the development of operations competence in order to consistently produce more market value with less cost towards a leadership position. As to the long-term competitiveness, it is more important to establish a dynamic 'strategic perspective' for continuous operational improvements in pursuit of this direction, as well as ongoing reviews of the direction in relation to the overall operating context. However, it also clear that the 'existing paradigm of manufacturing strategy development' is incapable of adequately responding to the increasing complexities and variations of contemporary business operations. This has been factually reflected as many manufacturing companies are finding that methodologies advocated in the existing paradigm for developing manufacturing strategy have very limited scale and scope for contextual contingency in empirical application. More importantly, there has also emerged a deficiency in the multidimensional and integrative profile from a theoretical perspective when operationalising the underlying concept of strategic manufacturing management established in the literature. The point of departure for this study was a recognition of such contextual and unitary limitations in the existing paradigm of manufacturing strategy development when applied to contemporary industrial organizations in general, and Chinese State Owned Enterprises (SOEs) in particular. As China gradually becomes integrated into the world economy, the relevance of Western management theory and its paradigm becomes a practical matter as much as a theoretical issue. Since China markedly differs from Western countries in terms of culture, society, and political and economic systems, it presents promising grounds to test and refine existing management theories and paradigms with greater contextual contingency and wider theoretical perspective. Under China's ongoing programmes of SOE reform, there has been an increased recognition that strategy development is the very essence of the management task for managers of manufacturing companies in the same way as it is for their counterparts in Western economies. However, the Western paradigm often displays a rather naive and unitary perspective of the nature of strategic management decision-making, one which largely overlooks context-embedded factors and social/political influences on the development of manufacturing strategy. This thesis studies the successful experiences of developing manufacturing strategy from five high-performing large-scale SOEs within China’s petrochemical industry. China’s petrochemical industry constitutes a basic heavy industrial sector, which has always been a strategic focus for reform and development by the Chinese government. Using a confirmation approach, the study has focused on exploring and conceptualising the empirical paradigm of manufacturing strategy development practiced by management. That is examining the ‘empirical specifics’ and surfacing the ‘managerial perceptions’ of content configuration, context of consideration, and process organization for developing a manufacturing strategy during the practice. The research investigation adopts a qualitative exploratory case study methodology with a semi-structural front-end research design. Data collection follows a longitudinal and multiple-case design and triangulates case evidence from sources including qualitative interviews, direct observation, and a search of documentations and archival records. Data analysis follows an investigative progression from a within-case preliminary interpretation of facts to a cross-case search for patterns through theoretical comparison and analytical generalization. The underlying conceptions in both the literature of manufacturing strategy and related studies in business strategy were used to develop theoretical framework and analytical templates applied during data collection and analysis. The thesis makes both empirical and theoretical contributions to our understanding of 'contemporary management paradigm of manufacturing strategy development'. First, it provides a valuable contextual contingency of the 'subject' using the business setting of China's SOEs in petrochemical industry. This has been unpacked into empirical configurations developed for its context of consideration, its content and process respectively. Of special note, a lean paradigm of business operations and production management discovered at case companies has significant implications as an emerging alternative for high-volume capital intensive state manufacturing in China. Second, it provides a multidimensional and integrative theoretical profile of the 'subject' based upon managerial perspectives conceptualised at case companies when operationalising manufacturing strategy. This has been unpacked into conceptual frameworks developed for its context of consideration, its content constructs, and its process patterns respectively. Notably, a synergies perspective towards the operating context, competitive priorities and competence development of business operations and production management has significant implications for implementing a lean manufacturing paradigm. As a whole, in so doing, the thesis established a theoretical platform for future refinement and development of context-specific methodologies for developing manufacturing strategy.

River basin surveillance using remotely sensed data: a water resources information management system

This thesis describes the development of an operational river basin water resources information management system. The river or drainage basin is the fundamental unit of the system; in both the modelling and prediction of hydrological processes, and in the monitoring of the effect of catchment management policies. A primary concern of the study is the collection of sufficient and sufficiently accurate information to model hydrological processes. Remote sensing, in combination with conventional point source measurement, can be a valuable source of information, but is often overlooked by hydrologists, due to the cost of acquisition and processing. This thesis describes a number of cost effective methods of acquiring remotely sensed imagery, from airborne video survey to real time ingestion of meteorological satellite data. Inexpensive micro-computer systems and peripherals are used throughout to process and manipulate the data. Spatial information systems provide a means of integrating these data with topographic and thematic cartographic data, and historical records. For the system to have any real potential the data must be stored in a readily accessible format and be easily manipulated within the database. The design of efficient man-machine interfaces and the use of software enginering methodologies are therefore included in this thesis as a major part of the design of the system. The use of low cost technologies, from micro-computers to video cameras, enables the introduction of water resources information management systems into developing countries where the potential benefits are greatest.

Budgeting, budgetary control and management information in the highways departments

The need for an adequate information system for the Highways Departments in the United Kingdom has been recognised by the report of a committee presented to the Minister of Transport in 1970, (The Marshall Report). This research aims to present a comprehensive information system on a sound theoretical basis which should enable the different levels of management to execute their work adequately. The suggested system presented in this research covers the different functions of the Highways Department, and presents a suggested solution for problems which may occur during the planning and controlling of work in the different locations of the Highways Department. The information system consists of:- 1. A coding system covering the cost units, cost centres and cost elements. 2. Cost accounting records for the cost units and cost centres. 3. A budgeting and budgetary control system covering, the different planning methods and procedures which are required for preparing the capital expenditure budget, the improvement and maintenance operation flexible budgets and programme of work, the plant budget, the administration budget, and the purchasing budget. 4. A reporting system which ensures that the different levels of management are receiving relevant and timely information. 5. The flow of documents which covers the relationship between the prime documents, the cost accounting records, budgets, reports and their relation to the different sections and offices within the department. A comprehensive cost units, cost centres, and cost elements codes together with a number of examples demonstrating the results of the survey, and examples of the application and procedures of the suggested information system have been illustrated separately as appendices. The emphasis is on the information required for internal control by management personnel within the County Council.

Examining the relationship between risk assessment and risk management in mental health

Risk assessment is crucial for developing risk management plans to prevent or minimize mental health patients' risks that will impede their recovery. Risk assessments and risk management plans should be closely linked. Their content and the extent to which they are linked within one Trust is explored. There is a great deal of variability in the amount and detail of risk information collected by nurses and how this is used to develop risk management plans. Keeping risk assessment information in one place rather than scattered throughout patient records is important for ensuring it can be accessed easily and linked properly to risk management plans. Strengthening the link between risk assessment and management will help ensure interventions and care is tailored to the specific needs of individual patients, thus promoting their safety and well-being. Thorough risk assessment helps in developing risk management plans that minimize risks that can impede mental health patients' recovery. Department of Health policy states that risk assessments and risk management plans should be inextricably linked. This paper examines their content and linkage within one Trust. Four inpatient wards for working age adults (18-65 years) in a large mental health Trust in England were included in the study. Completed risk assessment forms, for all patients in each inpatient ward were examined (n= 43), followed by an examination of notes for the same patients. Semi-structured interviews took place with ward nurses (n= 17). Findings show much variability in the amount and detail of risk information collected by nurses, which may be distributed in several places. Gaps in the risk assessment and risk management process are evident, and a disassociation between risk information and risk management plans is often present. Risk information should have a single location so that it can be easily found and updated. Overall, a more integrated approach to risk assessment and management is required, to help patients receive timely and appropriate interventions that can reduce risks such as suicide or harm to others. © 2011 Blackwell Publishing.

Estimation and prediction of average vehicle occupancies using traffic accident records

As congestion management strategies begin to put more emphasis on person trips than vehicle trips, the need for vehicle occupancy data has become more critical. The traditional methods of collecting these data include the roadside windshield method and the carousel method. These methods are labor-intensive and expensive. An alternative to these traditional methods is to make use of the vehicle occupancy information in traffic accident records. This method is cost effective and may provide better spatial and temporal coverage than the traditional methods. However, this method is subject to potential biases resulting from under- and over-involvement of certain population sectors and certain types of accidents in traffic accident records. In this dissertation, three such potential biases, i.e., accident severity, driver’s age, and driver’s gender, were investigated and the corresponding bias factors were developed as needed. The results show that although multi-occupant vehicles are involved in higher percentages of severe accidents than are single-occupant vehicles, multi-occupant vehicles in the whole accident vehicle population were not overrepresented in the accident database. On the other hand, a significant difference was found between the distributions of the ages and genders of drivers involved in accidents and those of the general driving population. An information system that incorporates adjustments for the potential biases was developed to estimate the average vehicle occupancies (AVOs) for different types of roadways on the Florida state roadway system. A reasonableness check of the results from the system shows AVO estimates that are highly consistent with expectations. In addition, comparisons of AVOs from accident data with the field estimates show that the two data sources produce relatively consistent results. While accident records can be used to obtain the historical AVO trends and field data can be used to estimate the current AVOs, no known methods have been developed to project future AVOs. Four regression models for the purpose of predicting weekday AVOs on different levels of geographic areas and roadway types were developed as part of this dissertation. The models show that such socioeconomic factors as income, vehicle ownership, and employment have a significant impact on AVOs.

Diversity of Hymenoptera, cultivated plants and management practices in home garden agroecosystems, Kyrgyz Republic

Pollination-dependent fruit trees grown in home gardens play an important role in the agricultural based economy of Central Asian countries, yet little is known about the status of pollinator communities, the cultivated plant composition or the factors that influence management practices in Kyrgyz home garden agroecosystems. As agricultural systems are human created and managed, a logical approach to their study blends anthropological and ecological methods, an ethnoecological approach. Over three years, I investigated how species richness and abundance of Hymenoptera, cultivated plants, and home garden management were related using quantitative and qualitative methods in the Issyk-kul Man and Biosphere reserve. Structured surveys were undertaken with heads of households using a random sample stratified by village. Gardens were then mapped with participation of household members to inventory edible species in gardens, most of which are pollinator-dependent, and to compare home garden diversity as reported by respondents during interviews. Apple diversity was studied to the variety level to understand respondents’ classification system in the context of in situ agrobiodiversity conservation. Household members identified 52 edible plant species when mapping the garden, compared with 32 reported when interviewed. The proportion of plant species received from others through exchange and the number of plots cultivated significantly explained the variation in edible plant diversity among gardens. Insects were sampled in gardens and orchards to determine potential pollinator community composition and the effect of different management practices on Hymenoptera richness and abundance. I collected 756 Hymenoptera individuals (56 bee; 12 wasp species); 12 species were new records for Kyrgyzstan or within Kyrgyzstan. Economic pressures to intensify cultivation could impact management practices that currently promote diversity. A home garden development initiative was undertaken to study management practice improvement. Participants in the initiative had higher adoption rates than controls of management practices that improve long-term yield, ecological sustainability and stability of home gardens. Home gardens, as currently managed, support abundant and diverse pollinator communities and have high cultivated plant diversity with few differences in community composition between garden management types.

Process of privatization: Benefits of *reform in management of public housing

The study of the private management of public housing is an important topic to be critically analyzed as the government search for ways to increase efficiency in providing housing for the poor. Public Housing Authorities must address the cost for repairing or replacing the deteriorating housing stock, the increase in the need for affordable housing, and the lack of supply. There is growing pressure on efficient use of public funds that has heightened the need for profound structural reform. An important strategy for carrying out such reform is through privatization. Although privatization does not work in every case, the majority position in the traditional privatization literature is that reliance on private organizations normally, but not always, results in cost savings. ^ The primary purpose of this dissertation is to determine whether a consensus exist among decision-makers on the efficiency of privatizing the management of public housing. A secondary purpose is to review the techniques (best practices) used by the private sector that results in cost-efficiencies in the management of public housing. The study employs the use of a triangulated research design utilizing cross-sectional survey methodology that included use of a survey instrument to solicit responses from the private managers. The study consists of qualitative methods using interviews from key informants of private-sector management firms and public housing agencies, case studies, focus groups, archival records and housing authorities documents. ^ Results indicated that important decision-makers perceive that private managers made a positive contribution to cost-efficiencies in the management of public housing. The performance of private contractors served as a yardstick for comparison of efficiency of services that are produced in-house. The study concluded that private managers made the benefits of their management techniques well known creating a sense of competition between public and private managers. Competition from private contractors spurred municipal worker and management productivity improvements creating better management results for the public housing authorities. The study results are in concert with a review of recent research and studies that also concluded private managers have some distinct advantages to controlling costs in the management of public housing. ^

Estimation and Prediction of Average Vehicle Occupancies using Traffic Accident Records

As congestion management strategies begin to put more emphasis on person trips than vehicle trips, the need for vehicle occupancy data has become more critical. The traditional methods of collecting these data include the roadside windshield method and the carousel method. These methods are labor-intensive and expensive. An alternative to these traditional methods is to make use of the vehicle occupancy information in traffic accident records. This method is cost effective and may provide better spatial and temporal coverage than the traditional methods. However, this method is subject to potential biases resulting from under- and over-involvement of certain population sectors and certain types of accidents in traffic accident records. In this dissertation, three such potential biases, i.e., accident severity, driver¡¯s age, and driver¡¯s gender, were investigated and the corresponding bias factors were developed as needed. The results show that although multi-occupant vehicles are involved in higher percentages of severe accidents than are single-occupant vehicles, multi-occupant vehicles in the whole accident vehicle population were not overrepresented in the accident database. On the other hand, a significant difference was found between the distributions of the ages and genders of drivers involved in accidents and those of the general driving population. An information system that incorporates adjustments for the potential biases was developed to estimate the average vehicle occupancies (AVOs) for different types of roadways on the Florida state roadway system. A reasonableness check of the results from the system shows AVO estimates that are highly consistent with expectations. In addition, comparisons of AVOs from accident data with the field estimates show that the two data sources produce relatively consistent results. While accident records can be used to obtain the historical AVO trends and field data can be used to estimate the current AVOs, no known methods have been developed to project future AVOs. Four regression models for the purpose of predicting weekday AVOs on different levels of geographic areas and roadway types were developed as part of this dissertation. The models show that such socioeconomic factors as income, vehicle ownership, and employment have a significant impact on AVOs.

Diversity of Hymenoptera, Cultivated Plants and Management Practices in Home Garden Agroecosystems, Kyrgyz Republic

Pollination-dependent fruit trees grown in home gardens play an important role in the agricultural based economy of Central Asian countries, yet little is known about the status of pollinator communities, the cultivated plant composition or the factors that influence management practices in Kyrgyz home garden agroecosystems. As agricultural systems are human created and managed, a logical approach to their study blends anthropological and ecological methods, an ethnoecological approach. Over three years, I investigated how species richness and abundance of Hymenoptera, cultivated plants, and home garden management were related using quantitative and qualitative methods in the Issyk-kul Man and Biosphere reserve. Structured surveys were undertaken with heads of households using a random sample stratified by village. Gardens were then mapped with participation of household members to inventory edible species in gardens, most of which are pollinator-dependent, and to compare home garden diversity as reported by respondents during interviews. Apple diversity was studied to the variety level to understand respondents’ classification system in the context of in situ agrobiodiversity conservation. Household members identified 52 edible plant species when mapping the garden, compared with 32 reported when interviewed. The proportion of plant species received from others through exchange and the number of plots cultivated significantly explained the variation in edible plant diversity among gardens. Insects were sampled in gardens and orchards to determine potential pollinator community composition and the effect of different management practices on Hymenoptera richness and abundance. I collected 756 Hymenoptera individuals (56 bee; 12 wasp species); 12 species were new records for Kyrgyzstan or within Kyrgyzstan. Economic pressures to intensify cultivation could impact management practices that currently promote diversity. A home garden development initiative was undertaken to study management practice improvement. Participants in the initiative had higher adoption rates than controls of management practices that improve long-term yield, ecological sustainability and stability of home gardens. Home gardens, as currently managed, support abundant and diverse pollinator communities and have high cultivated plant diversity with few differences in community composition between garden management types.

Land Use and Climate Change Impacts on the Hydrology of the Upper Mara River Basin, Kenya: Results of a Modeling Study to Support Better Resource Management

Some of the most valued natural and cultural landscapes on Earth lie in river basins that are poorly gauged and have incomplete historical climate and runoff records. The Mara River Basin of East Africa is such a basin. It hosts the internationally renowned Mara-Serengeti landscape as well as a rich mixture of indigenous cultures. The Mara River is the sole source of surface water to the landscape during the dry season and periods of drought. During recent years, the flow of the Mara River has become increasingly erratic, especially in the upper reaches, and resource managers are hampered by a lack of understanding of the relative influence of different sources of flow alteration. Uncertainties about the impacts of future climate change compound the challenges. We applied the Soil Water Assessment Tool (SWAT) to investigate the response of the headwater hydrology of the Mara River to scenarios of continued land use change and projected climate change. Under the data-scarce conditions of the basin, model performance was improved using satellite-based estimated rainfall data, which may also improve the usefulness of runoff models in other parts of East Africa. The results of the analysis indicate that any further conversion of forests to agriculture and grassland in the basin headwaters is likely to reduce dry season flows and increase peak flows, leading to greater water scarcity at critical times of the year and exacerbating erosion on hillslopes. Most climate change projections for the region call for modest and seasonally variable increases in precipitation (5–10 %) accompanied by increases in temperature (2.5–3.5 °C). Simulated runoff responses to climate change scenarios were non-linear and suggest the basin is highly vulnerable under low (−3 %) and high (+25 %) extremes of projected precipitation changes, but under median projections (+7 %) there is little impact on annual water yields or mean discharge. Modest increases in precipitation are partitioned largely to increased evapotranspiration. Overall, model results support the existing efforts of Mara water resource managers to protect headwater forests and indicate that additional emphasis should be placed on improving land management practices that enhance infiltration and aquifer recharge as part of a wider program of climate change adaptation.

Electronic health records: essential tools in integrating substance abuse treatment with primary care.

While substance use problems are considered to be common in medical settings, they are not systematically assessed and diagnosed for treatment management. Research data suggest that the majority of individuals with a substance use disorder either do not use treatment or delay treatment-seeking for over a decade. The separation of substance abuse services from mainstream medical care and a lack of preventive services for substance abuse in primary care can contribute to under-detection of substance use problems. When fully enacted in 2014, the Patient Protection and Affordable Care Act 2010 will address these barriers by supporting preventive services for substance abuse (screening, counseling) and integration of substance abuse care with primary care. One key factor that can help to achieve this goal is to incorporate the standardized screeners or common data elements for substance use and related disorders into the electronic health records (EHR) system in the health care setting. Incentives for care providers to adopt an EHR system for meaningful use are part of the Health Information Technology for Economic and Clinical Health Act 2009. This commentary focuses on recent evidence about routine screening and intervention for alcohol/drug use and related disorders in primary care. Federal efforts in developing common data elements for use as screeners for substance use and related disorders are described. A pressing need for empirical data on screening, brief intervention, and referral to treatment (SBIRT) for drug-related disorders to inform SBIRT and related EHR efforts is highlighted.

Building a Rockfall Database Using Remote Sensing: Techniques for Hazard Management in Canadian Rail Corridors

The section of CN railway between Vancouver and Kamloops runs along the base of many hazardous slopes, including the White Canyon, which is located just outside the town of Lytton, BC. The slope has a history of frequent rockfall activity, which presents a hazard to the railway below. Rockfall inventories can be used to understand the frequency-magnitude relationship of events on hazardous slopes, however it can be difficult to consistently and accurately identify rockfall source zones and volumes on large slopes with frequent activity, leaving many inventories incomplete. We have studied this slope as a part of the Canadian Railway Ground Hazard Research Program and have collected remote sensing data, including terrestrial laser scanning (TLS), photographs, and photogrammetry data since 2012, and used change detection to identify rockfalls on the slope. The objective of this thesis is to use a subset of this data to understand how rockfalls identified from TLS data could be used to understand the frequency-magnitude relationship of rockfalls on the slope. This includes incorporating both new and existing methods to develop a semi-automated workflow to extract rockfall events from the TLS data. We show that these methods can be used to identify events as small as 0.01 m3 and that the duration between scans can have an effect on the frequency-magnitude relationship of the rockfalls. We also show that by incorporating photogrammetry data into our analysis, we can create a 3D geological model of the slope and use this to classify rockfalls by lithology, to further understand the rockfall failure patterns. When relating the rockfall activity to triggering factors, we found that the amount of precipitation occurring over the winter has an effect on the overall rockfall frequency for the remainder of the year. These results can provide the railways with a more complete inventory of events compared to records created through track inspection, or rockfall monitoring systems that are installed on the slope. In addition, we can use the database to understand the spatial and temporal distribution of events. The results can also be used as an input to rockfall modelling programs.