The evolution and assessment of pharmaceutical care: Structure, processes, and outcomes

The evolution of pharmaceutical care is identified through a complete review of the literature published in the American Journal of Health-System Pharmacy, the sole comprehensive publication of institutional pharmacy practice. The evolution is categorized according to characteristics of structure (organizational structure, the role of the pharmacist), process (drug delivery systems, formulary management, acquiring drug products, methods to impact drug therapy decisions), and outcomes (cost of drug delivery, cost of drug acquisition and use, improved safety, improved health outcomes) recorded from the 1950s through the 1990s. While significant progress has been made in implementing basic drug distribution systems, levels of pharmacy involvement with direct patient care is still limited.^ A new practice framework suggests enhanced direct patient care involvement through increase in the efficiency and effectiveness of traditional pharmacy services. Recommendations advance internal and external organizational structure relationships that position pharmacists to fully use their unique skills and knowledge to impact drug therapy decisions and outcomes. Specific strategies facilitate expansion of the breadth and scope of each process component in order to expand the depth of integration of pharmacy and pharmaceutical care within the broad healthcare environment. Economic evaluation methods formally evaluate the impact of both operational and clinical interventions.^ Outcome measurements include specific recommendations and methods to increase efficiency of drug acquisition, emphasizing pharmacists' roles that impact physician prescribing decisions. Effectiveness measures include those that improve safety of drug distribution systems, decrease the potential of adverse drug therapy events, and demonstrate that pharmaceutical care can significantly contribute to improvement in overall health status.^ The implementation of the new framework is modeled on a case study at the M.D. Anderson Cancer Center. The implementation of several new drug distribution methods facilitated the redeployment of personnel from distributive functions to direct patient care activities with significant personnel and drug cost reduction. A cost-benefit analysis illustrates that framework process enhancements produced a benefit-to-cost ratio of 7.9. In addition, measures of effectiveness demonstrated significant levels of safety and enhanced drug therapy outcomes. ^

Clonal Evolution and Blast Crisis Correlate with Enhanced Proteolytic Activity of Separase in BCR-ABL b3a2 Fusion Type CML under Imatinib Therapy.

Unbalanced (major route) additional cytogenetic aberrations (ACA) at diagnosis of chronic myeloid leukemia (CML) indicate an increased risk of progression and shorter survival. Moreover, newly arising ACA under imatinib treatment and clonal evolution are considered features of acceleration and define failure of therapy according to the European LeukemiaNet (ELN) recommendations. On the basis of 1151 Philadelphia chromosome positive chronic phase patients of the randomized CML-study IV, we examined the incidence of newly arising ACA under imatinib treatment with regard to the p210BCR-ABL breakpoint variants b2a2 and b3a2. We found a preferential acquisition of unbalanced ACA in patients with b3a2 vs. b2a2 fusion type (ratio: 6.3 vs. 1.6, p = 0.0246) concurring with a faster progress to blast crisis for b3a2 patients (p = 0.0124). ESPL1/Separase, a cysteine endopeptidase, is a key player in chromosomal segregation during mitosis. Separase overexpression and/or hyperactivity has been reported from a wide range of cancers and cause defective mitotic spindles, chromosome missegregation and aneuploidy. We investigated the influence of p210BCR-ABL breakpoint variants and imatinib treatment on expression and proteolytic activity of Separase as measured with a specific fluorogenic assay on CML cell lines (b2a2: KCL-22, BV-173; b3a2: K562, LAMA-84). Despite a drop in Separase protein levels an up to 5.4-fold increase of Separase activity under imatinib treatment was observed exclusively in b3a2 but not in b2a2 cell lines. Mimicking the influence of imatinib on BV-173 and LAMA-84 cells by ESPL1 silencing stimulated Separase proteolytic activity in both b3a2 and b2a2 cell lines. Our data suggest the existence of a fusion type-related feedback mechanism that posttranslationally stimulates Separase proteolytic activity after therapy-induced decreases in Separase protein levels. This could render b3a2 CML cells more prone to aneuploidy and clonal evolution than b2a2 progenitors and may therefore explain the cytogenetic results of CML patients.

Industry evolution and cross-sectoral skill transfers:a comparative analysis of the video game industry in Japan, the United States, and the United Kingdom

In this paper we explore the interrelationship between technological progress and the formation of industry-specific skills by analysing the evolution of the video-game industry in three countries: Japan, the United States, and the United Kingdom. We argue that the cross-sectoral transfer of skills occurs differently depending on national contexts, such as the social legitimacy and strength of preexisting industries, the socioeconomic status of entrepreneurs or pioneer firms in an emerging industry, and the sociocultural cohesiveness between the preexisting and emerging industries. Each country draws on a different set of creative resources, which results in a unique trajectory. Whereas Japan's video-game industry emerged out of corporate sponsorships in arcades, toys, and consumer electronics industries and drew skills from the comic book and animated-film sectors, the video-game industry in the United States evolved from arcades and personal computers. In the United Kingdom the video-game industry developed bottom-up, through a process of skills formation in the youth culture of 'bedroom coders' that nurtured self-taught programmers in their teens throughout the country.

Evolution and change in industrial clusters : an analysis of Hsinchu and Sophia Antipolis

The aim of this paper is to advance understandings of the processes of cluster-building and evolution, or transformative and adaptive change, through the conscious design and reflective activities of private and public actors. A model of transformation is developed which illustrates the importance of actors becoming exposed to new ideas and visions for industrial change by political entrepreneurs and external networks. Further, actors must be guided in their decision-making and action by the new vision, and this requires that they are persuaded of its viability through the provision of test cases and supportive resources and institutions. In order for new ideas to become guiding models, actors must be convinced of their desirability through the portrayal of models as a means of confronting competitive challenges and serving the economic interests of the city/region. Subsequent adaptive change is iterative and reflexive, involving a process of strategic learning amongst key industrial and political actors.

Design Optimisation of UAVs Systems achieved on a Framework Environment via Evolution and Game Theory

Over recent years, Unmanned Air Vehicles or UAVs have become a powerful tool for reconnaissance and surveillance tasks. These vehicles are now available in a broad size and capability range and are intended to fly in regions where the presence of onboard human pilots is either too risky or unnecessary. This paper describes the formulation and application of a design framework that supports the complex task of multidisciplinary design optimisation of UAVs systems via evolutionary computation. The framework includes a Graphical User Interface (GUI), a robust Evolutionary Algorithm optimiser named HAPEA, several design modules, mesh generators and post-processing capabilities in an integrated platform. These population –based algorithms such as EAs are good for cases problems where the search space can be multi-modal, non-convex or discontinuous, with multiple local minima and with noise, and also problems where we look for multiple solutions via Game Theory, namely a Nash equilibrium point or a Pareto set of non-dominated solutions. The application of the methodology is illustrated on conceptual and detailed multi-criteria and multidisciplinary shape design problems. Results indicate the practicality and robustness of the framework to find optimal shapes and trade—offs between the disciplinary analyses and to produce a set of non dominated solutions of an optimal Pareto front to the designer.

Assessing and learning in internships: Reflecting on pedagogy and progress

An elective internship unit as part of a work integrated learning program in a business faculty is presented as a case study. In the unit, students complete a minimum of 120 hours work placement over the course of a 13 week semester. The students are majoring in advertising, marketing, or public relations and are placed in corporations, government agencies, and not for profit organisations. To support and scaffold the students’ learning in the work environment, a range of classroom and online learning activities are part of the unit. Classroom activities include an introductory workshop to prepare students for placement, an industry panel, and interview workshop. These are delivered as three workshops across the semester. Prior to commencing their placement, students complete a suite of online learning modules. The Work Placement Preparation Program assists students in securing obtaining a placement and make a successful transition to the work environment. It provides an opportunity for students to source possible work placement sites, prepare competitive applications, develop and rehearse interview skills, deal with workplace issues, and use a student ePortfolio to reflect on their skills and achievements. Students contribute to a reflective blog throughout their placement, with feedback from academic supervisors throughout the placement. The completion of the online learning modules and contribution to a reflective blog are assessed as part of the unit. Other assessment tools include a internship plan and learning contract between the student, industry supervisor, and academic supervisor; job application including responses to selection criteria; and presentation to peers, academics and industry representatives at a poster session. The paper discusses the development of the internship unit over three years, particularly learning activities and assessment. The reflection and refinement of the unit is informed by a pedagogical framework, and the development of processes to best manage placement for all stakeholders. A model of best practice is proposed, that can be adapted to a variety of discipline areas.

Influence of historical landscapes, drainage evolution and ecological traits on patterns of genetic diversity in Southeast Asian freshwater snakehead fishes

Snakehead fishes in the family Channidae are obligate freshwater fishes represented by two extant genera, the African Parachannna and the Asian Channa. These species prefer still or slow flowing water bodies, where they are top predators that exercise high levels of parental care, have the ability to breathe air, can tolerate poor water quality, and interestingly, can aestivate or traverse terrestrial habitat in response to seasonal changes in freshwater habitat availability. These attributes suggest that snakehead fishes may possess high dispersal potential, irrespective of the terrestrial barriers that would otherwise constrain the distribution of most freshwater fishes. A number of biogeographical hypotheses have been developed to account for the modern distributions of snakehead fishes across two continents, including ancient vicariance during Gondwanan break-up, or recent colonisation tracking the formation of suitable climatic conditions. Taxonomic uncertainty also surrounds some members of the Channa genus, as geographical distributions for some taxa across southern and Southeast (SE) Asia are very large, and in one case is highly disjunct. The current study adopted a molecular genetics approach to gain an understanding of the evolution of this group of fishes, and in particular how the phylogeography of two Asian species may have been influenced by contemporary versus historical levels of dispersal and vicariance. First, a molecular phylogeny was constructed based on multiple DNA loci and calibrated with fossil evidence to provide a dated chronology of divergence events among extant species, and also within species with widespread geographical distributions. The data provide strong evidence that trans-continental distribution of the Channidae arose as a result of dispersal out of Asia and into Africa in the mid–Eocene. Among Asian Channa, deep divergence among lineages indicates that the Oligocene-Miocene boundary was a time of significant species radiation, potentially associated with historical changes in climate and drainage geomorphology. Mid-Miocene divergence among lineages suggests that a taxonomic revision is warranted for two taxa. Deep intra-specific divergence (~8Mya) was also detected between C. striata lineages that occur sympatrically in the Mekong River Basin. The study then examined the phylogeography and population structure of two major taxa, Channa striata (the chevron snakehead) and the C. micropeltes (the giant snakehead), across SE Asia. Species specific microsatellite loci were developed and used in addition to a mitochondrial DNA marker (Cyt b) to screen neutral genetic variation within and among wild populations. C. striata individuals were sampled across SE Asia (n=988), with the major focus being the Mekong Basin, which is the largest drainage basin in the region. The distributions of two divergent lineages were identified and admixture analysis showed that where they co-occur they are interbreeding, indicating that after long periods of evolution in isolation, divergence has not resulted in reproductive isolation. One lineage is predominantly confined to upland areas of northern Lao PDR to the north of the Khorat Plateau, while the other, which is more closely related to individuals from southern India, has a widespread distribution across mainland SE Asian and Sumatra. The phylogeographical pattern recovered is associated with past river networks, and high diversity and divergence among all populations sampled reveal that contemporary dispersal is very low for this taxon, even where populations occur in contiguous freshwater habitats. C. micropeltes (n=280) were also sampled from across the Mekong River Basin, focusing on the lower basin where it constitutes an important wild fishery resource. In comparison with C. striata, allelic diversity and genetic divergence among populations were extremely low, suggesting very recent colonisation of the greater Mekong region. Populations were significantly structured into at least three discrete populations in the lower Mekong. Results of this study have implications for establishing effective conservation plans for managing both species, that represent economically important wild fishery resources for the region. For C. micropeltes, it is likely that a single fisheries stock in the Tonle Sap Great Lake is being exploited by multiple fisheries operations, and future management initiatives for this species in this region will need to account for this. For C. striata, conservation of natural levels of genetic variation will require management initiatives designed to promote population persistence at very localised spatial scales, as the high level of population structuring uncovered for this species indicates that significant unique diversity is present at this fine spatial scale.

Preparing for Research Assessment: Co-evolution and Gamesmanship

In this paper we adopt a complex systems perspective to examine the perturbations caused by the introduction of the Research Quality Framework (RQF) at a research-intensive Australian university. This case is instructive as it 1) presents a Federal policy initiative that attempted to fundamentally alter the recognition and reward mechanism within a regulated funding environment, 2) analyses the strategies of an institution and its research groups as they sought to not only comply with the implementation of the RQF but to maximise their outcome,and 3) it reveals the ways that some actors used this perturbation to advance their own interests. In short, this case represents an instrumental study into the dynamics of how information systems, organisations, and individuals co-evolve in practice as they seek to navigate a complex problem scenario.

Cerclage, evolution and potential of a Cinderella Technology : an overview with reference to periprosthetic fractures

Periprosthetic fractures are increasingly frequent. The fracture may be located over the shaft of the prosthesis, at its tip or below (21). The treatment of explosion fractures is difficult because the shaft blocks the application of implants, like screws, which need to penetrate the medullary cavity. The cerclage, as a simple periosteal loop, made of wire or more recently cable, does not only avoid the medullary cavity. Its centripetal mode of action is well suited for reducing and maintaining radially displaced fractures. Furthermore, the cerclage lends itself well for minimally invasive internal fixation. New insight challenges the disrepute of which the cerclage technology suffered for decades. The outcome of cerclage fixation benefits from an improved understanding of its technology, mechano-biology and periosteal blood supply. Preconceived and generally accepted opinions like "strangulation of blood supply" need to be re-examined. Recent mechanical evaluations (22) demonstrate that the wire application may be improved but cable is superior in hand- ling, maintenance of tension and strength. Beside the classical concepts of absolute and relative stability a defined stability condition needs consideration. It is typical for cerclage. Called "loose-lock stability" it specifies the situation where a loosened implant allows first unimpeded displacement changing abruptly into a locked fixation preventing further dislocation.

Complexity, evolution, and the structure of demand

This chapter argues that evolutionary economics should be founded upon complex systems theory rather than neo-Darwinian analogies concerning natural selection, which focus on supply side considerations and competition amongst firms and technologies. It suggests that conceptions such as production and consumption functions should be replaced by network representations, in which the preferences or, more correctly, the aspirations of consumers are fundamental and, as such, the primary drivers of economic growth. Technological innovation is viewed as a process that is intermediate between these aspirational networks, and the organizational networks in which goods and services are produced. Consumer knowledge becomes at least as important as producer knowledge in determining how economic value is generated. It becomes clear that the stability afforded by connective systems of rules is essential for economic flexibility to exist, but that too many rules result in inert and structurally unstable states. In contrast, too few rules result in a more stable state, but at a low level of ordered complexity. Economic evolution from this perspective is explored using random and scale free network representations of complex systems.

Evolution and innovation in guardianship laws: Assisted decision-making

Guardianship laws in most Western societies provide decision-making mechanisms for adults with impaired capacity. Since the inception of these laws, the principle of autonomy and recognition of human rights for those coming within guardianship regimes has gained prominence. A new legal model has emerged, which seeks to incorporate ‘assisted decision-making’ models into guardianship laws. Such models legally recognise that an adult’s capacity may be maintained through assistance or support provided by another person, and provide formal recognition of the person in that ‘assisting’ role. This article situates this latest legal innovation within a historical context, examining the social and legal evolution of guardianship laws and determining whether modern assisted decision-making models remain consistent with guardianship reform thus far. It identifies and critically analyses the different assisted decision-making models which exist internationally. Finally, it discusses a number of conceptual, legal and practical concerns that remain unresolved. These issues require serious consideration before assisted decisionmaking models are adopted in guardianship regimes in Australia.